Saturday, June 16, 2012

ELDERLY ISSUES-National Policy on Older Persons




As late as 1999, more than 50 years after gaining Independence, the Government of India for the first time unveiled a comprehensive and coherent plan to improve the quality of life of the country's elderly: the National Policy on Older Persons (NPOP). It was announced with fanfare and covered the gamut - financial security, healthcare, safety, shelter. Overdue by several decades, it was therefore very welcome.

However, the first five years of the policy had little to show. Before its second term - 2004-2009 - the Ministry of Social Justice and Empowerment, the nodal ministry for welfare of the elderly, met NGOs and experts to review the document. After much debate and consequent recommendations of various working groups, it drew up a Suggested Action Plan for 2005-07. Unfortunately, even this has not resulted in adequate action. Even standardisation of the age of a senior citizen for eligibility to benefit from various schemes - a point debated for the Action Plan for 2005-07, but eventually not included - has not been achieved.

Officials of the Ministry of Social Justice and Empowerment admit that NPOP has progressed in fits and starts. With this in mind, Harmony for Silvers Foundation decided to review its progress. This document reveals the present state of the policy, voices the need for its urgent implementation, and seeks to offer practical solutions. While the measure of the policy's success is a commentary on specific developments in modernising services for older people, the need to make the elderly central to the progress of the policy is imperative. After all, nearly 22 per cent of the population that casts a ballot is over 60.

We at Harmony for Silvers Foundation believe the elderly in India, whom we refer to as 'Silvers', need to be aware of their rights, and the power they wield. We want to translate this largely latent force into concrete action. Indeed, this document could in some ways be treated as a blueprint for real-time change.

- Meeta Bhatti
January 2007


Every society has a social contract to fulfil to its Silvers. Our elders have helped us become the people, and country, we are. We owe them at least a basic level of financial security and healthcare, shelter, security in their neighbourhoods, barrier-free movement, and an enabling social environment where they can fulfil their potential.

With this in mind, in February 2005 Harmony for Silvers Foundation handed its Silver Manifesto to Finance Minister P Chidambaram with a list of our recommendations on what needed to be done - across the board - for elderly in India. An important part of that list was the need to energise the National Policy on Older Persons (NPOP), a policy that was introduced in 1999 with much fanfare, but resulted in more sound than substance. For us, a fledgling organisation working for elderly, our Silver Manifesto was an important first step in our mission to make ourselves heard.

The release of this document is a defining moment. A product of research, interviews and analysis on part of the Harmony team, our review of NPOP is exhaustive and our recommendations a blueprint for action. In our continuous effort to improve the lives of Silvers across India, we will ensure it reaches every ministry and department of government relevant to Silvers (at the Centre and in states), policymakers and practitioners, NGOs, researchers and analysts studying ageing-related issues, and international organisations.

Today, the Indian economy is booming. As we continue to build roads, ports, railways, airports, we must also invest the money in our coffers to bolster social infrastructure to make the country inclusive and elder-friendly. And rather than dismissing Silvers as has-beens in need of handouts, we must co-opt their skills and use them productively. Silvers are a powerful market segment that companies cannot afford to ignore and a vote bank that politicians must respect.

But first, government needs to go beyond mere good intentions and act decisively to implement all the provisions of NPOP in letter and intent. The Silvers of India cannot be ignored any longer.

- Tina Ambani
Chairperson, Harmony for Silvers Foundation


In India, the issue of social security first became significant with the submission of the Adarkar Commission Report in 1944, which laid the basis for various retirement pension schemes and other social welfare programmes after Independence. In March 1943, the Government of India appointed Professor B P Adarkar, special officer, to prepare a health insurance scheme for industrial workers. He focused on workers not covered by any kind of insurance working in three major groups of industries - textiles, engineering, and minerals and metals. Adarkar submitted his report to government in August 1944.

The Adarkar Report and suggestions of experts of the International Labour Organisation finally emerged as the Workmen's State Insurance Bill 1946, passed in April 1948 as Employees' State Insurance Act 1948. It provided medical cover (not included in the Adarkar Report) and maternity benefit, and replaced lump sum payments with pensions for long-term benefits in the event of employment disability. The Act placed the responsibility for administration of the scheme and liability for benefit claims on a statutory organisation: the Employees' State Insurance Corporation. The Act has been amended thrice - first in 1951, then in 1966 and recently in 1975 - with a view to extend coverage and bring about simplification of procedures.


Soon after Independence, the government also wanted to highlight the well being of the elderly as the responsibility of the Centre. This was fulfilled with various constitutional provisions and Acts. India being a federal government, the subject of ageing is on a Concurrent List, where both the Centre and the states can plan and develop programmes. Yet, for almost five decades after Independence, the government failed to understand the impact of population ageing and therefore, did not accept it as a subject for formulating policy. The factors that led to this short sightedness included the relatively insignificant elderly population compared to total population, and traditional Indian value system that emphasised that the youth must care for their elders. However, statistics were changing fast - and so were attitudes.

The advent of industrialisation, urbanisation and modernisation led to improved medical technologies and, therefore, longevity. Today, the rapidly escalating population of senior citizens in India stands at about 80 million, and is expected to rise to about 100 million in 2016 and 177 million by 2025. Until the early 1980s, population ageing was perceived as an issue that concerned only developed countries. But when the parallel trend of increasing life expectancy hit developing countries, there was a collective awareness of a range of issues that would soon confront India's elderly population1, such as alienation from family and society, and diversity in terms of age, gender, income, and work participation.

Recognising this, several social welfare policies and government interventions have identified older people as a priority group2. The major focus of attention has been in the areas of financial security, recognition of voluntary organisations, and provision and promotion of measures to improve the quality of life of elderly. In 1983-84, the Ministry of Welfare began to provide grant assistance to NGOs to build old age homes and non-institutional services such as day care centres - the number of such NGOs grew rapidly from 134 in 1992-93 (Financial Year: March-April) to 218 in 1993-94 and 346 during 1994-95. In 1991-92, age-related concerns were first included under Five-Year Plan allocations: a separate allocation of Rs 15 million was made to provide assistance to voluntary organisations for welfare programmes for the elderly. The annual plan allocation for the welfare of the elderly was increased to Rs 30 million in 1993-94, Rs 52.7 million in 1994- 95, Rs 60 million in 1995-96 and Rs 100 million in 1996-97.


Though progress was slow, India was officially committed to develop elderly-oriented policies. Following the First World Assembly on Ageing held in Vienna in 1982, India, along with 123 other countries, adopted the United Nations First International Plan of Action on Ageing. One of the salient features of the 'priorities and recommendations' for participating countries as outlined by the Plan was, "National machinery should be established or strengthened to ensure that humanitarian needs and developmental potential of the aged are appropriately addressed."3 The participation of various countries in the First World Assembly on Ageing was accompanied by the understanding that formulation and implementation of policies on ageing are the sovereign right and responsibility of each State, and would be carried out on the basis of specific national needs and objectives. Further, the 1991 UN General Assembly resolution on 'Principals of Older Persons', the 1992 General Assembly proclamation on 'Ageing and Global Targets on Ageing for 2001', and the World Bank study conducted in 1994 on economic security of older persons in developing countries all contributed to national debate on India's elders.

Earlier, care of elderly, especially the poor, had received the attention of several committees constituted by various ministries from time to time4. For instance, the Study Group on Income and Wages (1978) recognised that the needs of the elderly were not covered by pensions or other retirement benefits and suggested the adoption of some standard criteria by states for old age pension. However, India actively began to establish the framework for evolving a policy on older persons only in 1990.

The Ministry of Welfare (currently called the Ministry of Social Justice and Empowerment, and hereafter referred to as MSJE) was declared the nodal agency for the welfare of the elderly. The Ministry initiated the process of consulting state governments, voluntary organisations, research institutions, and academicians for a thorough review of earlier programmes and to globally benchmark India. Based on feedback and recommendations, a policy document was prepared. In 1997-98, the final draft was discussed in different regions at meetings, mainly convened by HelpAge India, Indian Federation on Ageing and other advocacy groups, before arriving in Parliament5.

The result was the National Policy on Older Persons (NPOP). MSJE was declared the lead agency coordinating all matters pertaining to the implementation of NPOP. The announcement of India's NPOP coincided with the marking of 1999 as the International Year of the Older Persons by the UN. The following year was declared as National Year of Older Persons by the Government of India.


Article 41
The State shall, within the limits of its economic capacity and development, make effective provision for... old age, sickness and disablement, and in other cases of undeserved want

Entry 24 in List III of Schedule VII
Welfare of labour including conditions of work, provident funds... invalidity and old age pensions

Item 9 of the State list and Items 20, 23 and 24 of the Concurrent List
List II - State List
Relief of the disabled and unemployable

List III - Concurrent List
20. Economic and social planning

23. Social security and social insurance; employment and unemployment

24. Welfare of labour including conditions of work, provident funds... invalidity and old age pensions

The Employees' Provident Fund and Miscellaneous Provisions Act, 1952

Compulsory contributory fund for the future of an employee after his retirement or for his dependents in case of early death
Extends to the whole of India, except the State of Jammu and Kashmir and is applicable to every factory engaged in any industry specified in Schedule 1 in which 20 or more persons are employed; every other establishment employing 20 or more persons or class of such establishments, which the Central Government may notify; or any other establishment so notified by the Central Government even if employing less than 20 persons
The Hindu Adoptions and Maintenance Act, 1956 (Maintenance of children and aged parents)

Subject to the provisions of this Section, a Hindu is bound, during his or her lifetime, to maintain his or her legitimate or illegitimate children and his or her aged or infirm parents
A legitimate or illegitimate child may claim maintenance from his or her father or mother so long as the child is a minor
The obligation of a person to maintain his or her aged or infirm parent or daughter who is unmarried extends in so far as the parent or the unmarried daughter, as the case may be, is unable to maintain himself or herself out of his or her own earnings or other property
The Hindu Succession Act, 1956
Lays down general rules of succession and distribution of property after a person's death

National Old Age Pension Scheme
The National Old Age Pension Scheme is a direct monthly transfer of income to the aged poor over the age of 65 years of age and below the poverty line. In some states like Delhi, the age has been revised to 60 years. The Ministry of Rural Development uses a set of calculations to determine the poorer among the poor and arrive at the number of people eligible for pensions. The financial assistance under the Scheme till 2005-06 was Rs 75 per person per month. Some states such as Delhi, Maharashtra and Sikkim make a significant additional contribution to this amount but as many as 18 states and union territories have been paying Rs 100 or less per month. In the Budget for 2006-07, the Central Government has raised its contribution from Rs 75 per month per pensioner to Rs 200.

Family Pension Program, 1971
The Family Pension Programme facilitates long-term protection for the family of the worker who dies in service. Mandatory for the members of the Employees' Provident Fund, it is financed by transferring a portion of the employee's share of the Provident Fund (1.6 per cent of salary) and matched by both employer and the Central Government. The programme offers a family survivor pension, life insurance, and retirement income with withdrawal privileges.

If the worker dies during service before the age of 60, a pension is paid to a surviving family member. A retirement benefit for those aged 60, who contributed at least one year to the family pension fund, is also based on the member's monthly salary. If the worker dies after retirement, a pension is paid to one family member for seven years or up to the date at which the member would have reached 65 years of age, whichever is shorter.

Income Tax Rebate (Section 88B of Finance Act, 1992)
This provision provides income tax rebate to senior citizens. The rebate is available in the case of a resident individual who has attained the age of 65 years at any time during the relevant previous year. From assessment year 1998-99, tax rebate under Section 88B is the amount of income tax before giving any rebate under Sections 88, 88B and 89(1); or Rs 10,000 or 40 per cent, whichever is less. The rebate is available from assessment year 1998-99, even if gross total income is above Rs 120,000.

Payment of Gratuity Act, 1972
Objectives: To provide for payment of gratuity on ceasing to hold office

Coverage: Factories, mines, oil fields, plantations, railways, companies, shops, and other establishments to which the law is extended

Eligibility: Five years' continuous service is required for payment of gratuity

Benefits: Fifteen days' wages for every completed year of service, or part thereof in excess of six months, subject to a maximum of Rs 100,000. Seasonal employees are entitled to gratuity at a rate of seven days' wages for each season.

Section 125 of the Code of Criminal Procedure
Orders maintenance of wives, children and parents who can't maintain themselves. Upon proof of such neglect, a Magistrate can order the offender to pay the victim a monthly allowance. If anyone fails without sufficient cause to comply with the order, the Magistrate may, for every breach of the order, levy fine or sentence such person to imprisonment for a term which may extend to one month or until payment.


NPOP aims to be a comprehensive document to ensure the well being of the elderly by strengthening their legitimate place in society and recognising the need for affirmative action in their favour. The policy promises an array of state interventions - from financial security through viable investment avenues and second careers to good health with systematic geriatric care, safety with the support of community and state, and mobility facilitated by a barrier-free environment. The policy articulates the need for an age-integrated society with development of formal as well as informal support systems so that the capacity of families to take care of their elderly is strengthened. Too, empowering older people is an important part of the policy. It lays emphasis on their participation in decision-making on issues that affect them. The policy recognises concerns of the elderly as national, and considers them a huge reserve of human resource. It calls for an integrated programme for older persons, with the objective to promote a society for all ages.


Encourage families to take care of their older members
Enable and support voluntary and non-government organisations (NGOs) to supplement care provided by the family
Provide care and protection to vulnerable elderly
Provide healthcare facilities to the elderly
Promote research and training facilities to train geriatric caregivers and organisers of services for the elderly
Encourage individuals to make provisions for their own and their spouse's old age
Create general awareness about elderly persons and enable them to become independent citizens
The policy suggests specific action in several areas and even undertakes to help pursue many recommendations to fruition.


Financial Security

Priority to security of income in old age
Old age pension schemes
Avoid administrative lapses and consequent hardship while settling pension, provident fund and gratuity
Pension schemes both in the private and public sector for self-employed and salaried persons in non-government employment, with provision for employers to contribute
Higher standard deduction and a standard annual medical rebate while calculating income tax
Income tax concessions for caregivers
Long-term saving instruments in active working years
Remove age-related discrimination, also known as 'ageism', in the workplace and elsewhere
Strengthen Section 125 of the Criminal Procedure Code, which provides the right to support from their children for parents without means
Healthcare and Nutrition

Strengthen the primary healthcare system and orient its services to older people; and expand and strengthen geriatric care facilities provided at secondary and tertiary levels
Provide educational material on the concept of healthy ageing, nutritional needs of elderly, importance of a balanced diet, physical exercise, regular habits, stress management, regular medical checkups, allocation of time for leisure, and recreation and pursuit of hobbies
Discounted health insurance catering to lower income groups
Promote charitable societies and voluntary agencies by way of grants and tax relief to provide free beds, medicines and treatment to very poor elderly
Direct hospitals to set up geriatric wards
Expand and strengthen mental health services for older persons

Earmark about 10 per cent of government housing schemes for allotment to older persons
Elder-friendly layouts for residential developments, multipurpose centres, group housing comprising accommodation with common service facilities, and easy access to various public utilities
Special consideration for older persons in dealing with matters related to transfer of property mutation, property tax, etc.

Meet the educational, training and information needs of older persons
Dispel negative images, myths and stereotypes
Develop inter-generational bonds and a mutually supporting relationship between the young and elderly

Prioritise the needs of vulnerable older persons (the poor, disabled, chronically sick, and those without family support)
Encourage non-institutional services by voluntary organisations to strengthen the capacity of older persons and their families to cope
Promises assistance to voluntary organisations in the construction and maintenance of old age homes, organisation of services such as day care and multi-service centres, outreach services, supply of disability-related aids and appliances and assistance to the elderly to learn to use them, short-term stay services, protective services, help line services, legal aid and friendly home visits by social workers
Protection of Life and Property

Protect older persons from physical, emotional and financial abuse at home
Direct police to keep a friendly vigil on older couples or old single persons living alone, promote mechanisms of interaction between the police and neighbourhood associations, and provide precautionary measures to be taken by elderly with regard to the protection of their life and property
Other Areas of Action

Promises support needed for issuing identity cards, concessions in all modes of transport, preference in reservation of seats, earmarking seats in local public transport, modifications in designs of public transport, priority in gas and telephone connections and fault repairs
Speedy disposal of complaints
Non-Government Organisations

Networking among NGOs, mainly to exchange information and facilitate better interaction
Recognise formation of self-help groups and associations of older persons for advancement of the rights of the elderly and utilising their skills and experience
Active collaboration and cooperation within the government and between government and non-government agencies
Realising the Potential of the Elderly

Recognise the need for active and productive involvement of older persons
Efforts to make the family and others appreciate and respect the contribution of older persons

Recognise the importance of strengthening family support
Promotion of family values, and increasing awareness of the necessity and desirability of intergenerational bonding among the young
Strengthen counselling services to resolve intra-family stress
Research and Training

Strengthen research and training activities related to ageing
Recognise the need to establish a national institute of research, training and documentation and resource centres in different parts of the country

Involve mass media as well as informal and traditional channels of communication with issues related to ageing


NPOP is an ambitious document. It also has a clear-cut plan of action, which, as the inbuilt protocol demanded, was reviewed after its five-year term in July 2005. However, as Harmony sees it, MSJE, to begin with, couldn't even push the 22 other ministries assigned to share the implementation of the policy, let alone the other highlights of the original Action Plan. Moreover, the review ended up adding new areas to the plan. Now, the 2005-07 Draft Action Plan, as it was called, is coming to a close and most of its promises will remain unfulfilled before MSJE meets again - it will be soon as most NGOs are urgently demanding action.
Here is Harmony's status sheet of what has been done and what has not:

Identify roles of various ministries
Facilitate setting up a National Association of Older Persons
Identify a nodal department of state governments to coordinate and monitor implementation of the policy
Promote voluntary organisations in the field of ageing
Establish a Senior Citizens' Welfare Fund at the Centre
Develop instruments to provide old age social and income security for workers from the unorganised sector - India's largest labour segment
Promote the concept of active ageing
Promote non-institutional forms of care for strengthening the family's contribution
Assist panchayats - village-level administrative units - to serve older persons
Facilitate training and orientation of workers and volunteers in organisations providing services to the elderly
Promote research on ageing issues
Requisition state governments to issue a multipurpose identity card to the elderly
Expand legal aid to older persons
Provide relief and rehabilitation of older persons in the existing relief code
Provision for special attention by the police for the security of life and property of older persons
Promote and assist pre-retirement counselling programmes
Assist organisations to provide career guidance, training, placement and support services to older persons
Include course materials on older persons in curriculum and different stages of education

Segmentation of elderly
Assess the needs of elderly of different age groups and finalise schemes and programmes for them
Establish universal coverage of National Social Assistance Programme for special groups like rural poor, widows, Dalits
Economic security
Enhance the number of NSAP beneficiaries
Reduce the eligibility age to 60 years and increase the amount given under NSAP per beneficiary
Facilitate savings and investments for secure income in old age, professional management of pension funds and insurance of returns by adopting regulatory system and flexible operations
Allocate separate funds for elderly women in all major poverty alleviation programmes
Establish credit cooperatives in rural areas and urban slums
Ensure food security for poor elderly, particularly for women
Health security
Ensure all medical colleges at least have a post-graduate programme in geriatrics
Develop training facilities for paramedical staff and caregivers in each state capital
Develop short-term residential care facilities for elderly in all metros
Provide universal access to mental health services and add a mental health component in all healthcare programmes
Change private insurance schemes to include benefits like chronic ambulatory care
Persuade private and public insurance companies to make elder-friendly health insurance policies
Form a regulatory body to review and regulate the quality of services available and money charged by various private-sector institutions
Public-private partnership for age care
Encourage private sector to contribute to age care by providing tax benefits to enable it to undertake healthcare and emotional care activities for elderly, especially those living in rural and backward areas
Temper filial affection with economic logic, like tax concessions to young relatives taking care of elderly
Create a network of organisations that work for the cause of caring for disadvantaged elderly by setting up a National Coordinating Committee to identify organisations and a national federation of such organisations


Why is the situation so bad? The problem, say experts, is not the document but its implementation. The original framework of NPOP envisaged four mechanisms - National Bureau of Older Persons, National Council for Older Persons, an Inter-Ministerial Committee to coordinate the functioning of NPOP's proposals by 22 different ministries, and a National Association of Older Persons. While the Bureau was intended as a working secretariat, the Council was set up as an advisory body. The Inter-Ministerial Committee was set up for monitoring the policy. And the Association was meant to be an advocacy group to be created by way of the policy - it still hasn't taken off.

For its part, the Council - comprising well-known and well-regarded individuals representing NGOs, citizens' groups, retired persons' associations, and from the field of law, social welfare and security, research and medicine - was first constituted in 1999 and reconstituted in August 2005. MSJE conceived the Council as a representative of the collective opinion of senior citizens, which could suggest steps and measures for productive ageing to government. Originally comprising 39 members, the Council now has 37 members - most of them don't agree with the way NPOP is being treated by MSJE and other ministries.

Until 2004, when the 2005-07 Action Plan was drafted, the Inter-Ministerial Committee had met only twice. Mathew Cherian, chief executive of HelpAge India, which helped draft the original NPOP and then convened the meeting for the 2004 review, calls it a "clear failure". The policy, he says, was conceived with the best intentions, but the sum total of it doesn't work. It's not just Cherian. Most NGOs call MSJE the 'softer Ministry' with not enough clout to convene inter-ministerial meetings. "And when such meetings happen, people only express their views and there's very little implementation," adds Cherian.


"The elderly are clearly not a priority for government," insists Himanshu Rath, convenor of Delhi-based Agewell Foundation, an NGO that was appointed the secretariat for the Council in December 1999. Called Aadhar, the organisation was intended to answer grievances addressed to MSJE. Then secretary Asha Das appointed Rath consultant in the Ministry. Aadhar's job was to console letter writers, take up their problem on behalf of the Ministry and follow up with related departments or ministries. Realising that a local problem could be dealt with locally, Aadhar suggested appointing people at the district-level as Zila Aadhar members to take up problems with district collectors or superintendents of polices. This was implemented effectively. However, in April 2002, Agewell Foundation snapped links with the Ministry because of lack of funding from MSJE. It continues to run Aadhar with external funding.

Rath's contention is that the Ministry would rather take the easy way out by merely funding mobile medical vans (that it runs with HelpAge India) and old age homes. K R Gangadharan, director of Heritage Geriatric Hospital in Hyderabad and member of the Council, agrees. "Each time I visit the Ministry, I am told they don't have manpower to carry on implementation, he says. "Empowering and enabling the elderly isn't their priority and hence they haven't allocated manpower for the job." Gangadharan, who is fighting for intensive training of caregivers in India, feels funding isn't a problem either as every year MSJE returns funds allocated for welfare of seniors. For example, in 2005-06, MSJE didn't use Rs 40 million of the allocated Rs 280 million. Of the rest, Rs 55.3 million was given to 289 NGOs for running 223 old age homes, 151 day care centres, 31 mobile medical units and one non-institutional service, and Rs 12.5 million to Panchayati Raj institutions. The unutilised amount was returned to the Centre.

Not surprisingly, representatives of the government are quick to deflect any criticism. A P Singh, director, Ministry of Health and Family Welfare, who was part of the committee that drafted NPOP, feels implementation is a continuous, evolving process for any policy. "Seven years is not a long time," he contends. "Also, NPOP was never envisaged as a government policy but as a national policy. The nation is not equal to the government, it's much larger." Singh insists NPOP hasn't been forgotten. Instead, he believes it has acquired visibility over the years and its message has been disseminated inside and outside government among relevant groups - ministries, NGOs, civil society and older people themselves. "This is a document people can fall back on in terms of making demands on the legislature," he says. "I think this is the best way to use the policy, as wherever the policy has gathered momentum it hasn't been through government action." Singh and his successors in MSJE feel it is the people who need to galvanise action.

According to him, small beginnings - in seven years - include the incorporation of inter-generational bonding in school education (almost every school has a token activity like Grandparents' Day), concessions in rail and air fare, and a railway ticketing system that has been programmed to allot senior citizens lower berths. "In my time, NPOP was one of my many responsibilities," says Singh. "Now, MSJE has a joint secretary dedicated to it." This recent change needs to be reflected in state capitals as the same people are assigned to look at drug abuse, disability and many other issues.


One thing everyone agrees on is the need to constitute the National Association of Older Persons as the first step to implementing NPOP. Envisaged as an association comprising the elderly themselves, it should work as a steering group with officers, researchers and policy advisers. The Association should be empowered to find 'key areas of action' for policymakers, researchers, society at large and Silvers themselves. "Unless senior citizens as a group push the government, the policy will not move," says Cherian of HelpAge India.
Harmony for Silvers Foundation agrees entirely. We believe it's time for the elderly to push the policy. The ball is in the court of the beneficiaries - India's Silvers - who are not neglected children, but people of substance, of acquired experience who know how to realise their own potential. Currently, only some NGOs are pursuing the implementation of the policy. However, they can first act as facilitators. Only people with common interests can act as real pressure groups. Apart from presenting this critical review of NPOP to policymakers, researchers and NGOs, Harmony for Silvers Foundation is engaged in generating awareness about their rights among Silvers and is in the process of creating pressure groups to make NPOP effective.
To review promises fulfilled, and unfulfilled, Harmony for Silvers Foundation next takes up every category detailed in NPOP individually and analyses the effectiveness of various provisions, schemes and plans devised over the past seven years. The subjects we cover are finance; health; shelter; safety; protection of life and property; other areas of action such as travel discounts, fast-track justice and mobility; non-government organisations; second careers; and research on ageing-related issues. The results - backed by statistics, case studies and commentary by experts - are accompanied by Harmony's proposals.

Like most other developing countries, India does not have a social security system to protect the elderly against economic deprivation.

Persistently high rates of poverty and unemployment act as a deterrent to institute a state pension for every citizen attaining old age7. There are two main types of pension schemes - a defined benefit pension scheme only for civil servants, and one for those in the fold of Employees' Provident Fund Organisation, which is available to civil servants and workers in the organised sector. Both appear to be unsustainable in their present form.
While the defined benefit scheme is financed directly by the Centre (the government's pension bill in 2000 was more than 1 per cent of the GDP, or 15 per cent of revenues), the Employees' Provident Fund is supported by employer-employee participation. The Employees' Provident
Fund is the world's largest pension fund in terms of number of participants. It has evolved to extend from five to 179 industries since 1952 but its coverage of the labour force has barely risen from 1 per cent to 5 per cent8. The resultant financial burden on the employer and government is rising with every passing year. Also, high rates of withdrawal from account balances, fixed retirement age and returns below income growth combine to produce inadequate balances at retirement.
As late as the Budget for 2004-05 (though envisaged in the Budget for 2001-02), partial pension reforms led to the announcement of the New Pension Scheme. Designed for new entrants to government service, the Scheme is a hybrid one combining defined contribution from employees and a matching contribution from the Centre. In the long run, experts hope it will ease the pressure of supporting an ever-increasing workforce of civil servants.
The New Pension Scheme also offers a guide to state government employees, middle-class self-employed people and those in the lower income bracket from the unorganised sector. This, however, is voluntary and without the employer's contribution. The extension of the New Pension Scheme to the unorganised sector has stemmed from OASIS (Old Age Social and Income Security), drafted by MSJE, under former minister of social justice and empowerment Maneka Gandhi, in January 2000. OASIS recommended an old age scheme based on individual retirement accounts to be opened at modest contributions (starting at a minimum of Rs 500 per annum and calibrated to reach Rs 200,000 by the age of 60) through a person's working life. Served by banks and post offices, it was proposed that there would be a depository for centralised record keeping, fund managers to manage funds, and annuity providers to provide benefits after the age of 60. An Indian Pension Authority was recommended as regulatory body. However, it was eventually implemented as a simple pension fund as part of the New Pension Scheme.
Government and experts continue to put their heads together to assess safety net measures provided to the working population as it ages but are yet to arrive at a consensus. The most debatable proposal is whether to adopt a mutual fund framework for the pension fund and divert savings of employees to the equity market. This is being widely criticised, and is still mired in controversy. Two of the many questions raised: Should the reformed system create individual accounts or should it remain a single collective fund with a defined-benefit formula? And, if individual accounts are adopted, should the reformed system move toward private and decentralised collection of contributions, management of investments, and payment of annuities, or should these be administered by a public agency? Associated problems in case of private management could include intermediation costs, and costs to administer the plan9.
But before we debate the implementation of pension reforms, government needs to address the lack of any kind of formal, structured and universal pension plan as the world knows it. Urban elderly may be aware of their need to plan for retirement but there are no instruments in place. And any time government is criticised for the lack of a system to take care of citizens in their old age, the argument is that almost all countries face a pension crisis in terms of under-funding of the system.

What did the Budget for 2006-07 bring for Silvers? No changes in the tax quotient of seniors - tax-free income remained the same, at Rs 185,000. But, from 2006, senior citizens whose gross income is below the tax threshold (before deductions) needn't bother with the annual ritual of filing a tax return. Earlier, according to the One-by-Six Scheme, anyone who owned residential or commercial property, a vehicle, a telephone, travelled abroad or held a credit card had to file a return. The good news: this amendment was made retroactively effective from financial year 2005-06 and not 2006-07.
The other change: Section 80C benefit is given to fixed deposits of five years and more with all banks. That means seniors can invest up to Rs 100,000 and get up to 20 per cent rebate on actual tax. Earlier in 2004, the Budget brought just the Senior Citizens' Savings Scheme, which came into effect from the first week of August 2004. Initially available through post-offices, it is now also available through private banks that can also handle the Public Provident Fund Scheme. Some tangential benefits to the elderly from the Ministry of Finance are mentioned in its 2005-06 Annual Report. Representation of ex-servicemen in 19 nationalised banks is one of them. According to the report, 44,656 ex-servicemen were rehired as officers, clerks, sub-staff and sweepers in banks like State Bank of India, Reserve Bank of India, Industrial Development Bank of India, National Bank for Agriculture and Rural Development, Export Import Bank of India, National Housing Bank and Small Industries Development Bank of India as on 31 December 2005. Such independent provisions by the Ministry of Finance - not led or influenced by NPOP - are few and far between.
Some other aspects that appear sketchily in the Ministry of Finance's Annual Report include claims of processing all pension cases at the Central Pension Accounting Office within the prescribed time frame; the implementation of the New Pension Scheme and the facility of micro-credit for women - but with no specific facilities for older women. One of the few banks that offers cooperative loans to senior citizens is in the most backward district of Tamil Nadu. In Dharmapuri, the Cooperative Bank offers loan between Rs 2,000 and Rs 5,000 to senior citizens to start an income-generating project. While providing cooperative loans to seniors, particularly low-income groups, is quite rare, several NGOs extend the facility as micro loans for entrepreneurial business beyond the age of 55 to 60 years.
"I ran around for a petty sum of Rs 150" Ram Milan Lodhi, a 71 year-old former peon in Unnao Government School, Lucknow, retired with savings of Rs 70,000 in 1995. Soon after, his wife suffered serious burn injuries and Lodhi exhausted his entire savings for her care. But the treatment could not save her and Lodhi was left to fend for himself with no money to fall back on. With a strained relationship with his son and daughter-inlaw, Lodhi decided to live alone and apply for old age pension. The experience revealed to him a whole new world of extortion (by middlemen) and indifference (by government officials in the pension office).
"In the name of old age pension, they act like they are giving alms to greedy, well-off beggars," laments Lodhi as he recalls his experience. "For a petty amount of Rs 150, you have to fix a cut at every level of the Department of Social Welfare. By the time the file is cleared, the applicant does not even get enough money to cover his conveyance expense."
The application form was the first stumbling block. "There were so many columns to be filled that it took me more than a day," recalls Lodhi. "I had to be extra cautious as a single blank space could get my case rejected. Some information was asked for twice. But that was just the beginning of the procedure." He submitted the complete form to a clerk sitting in the section office. It was accepted, but the clerk demanded 10 per cent commission to forward the form. Lodhi refused to oblige and his form was returned to him. "After spending a lifetime in an education institution, I was accustomed to being treated with respect and dignity so the clerk's behaviour offended me," he says. "But at home, caustic comments from my daughter-in-law were equally hurtful. So I went to the section office again the next day."
This time, the clerk was willing to move his file for a tip of Rs 50 and the file finally reached the section officer's table - but only to collect dust there. He demanded 20 per cent share of the pension to process Lodhi's file. Once more, Lodhi was tempted to drop the whole thing but urged himself to go on. He promised to give the officer the share after getting the promised pension money and the file moved to the table of the section officer in-charge. Here, too, he promised a 30 per cent cut. The file was forwarded to the district magistrate's office. Again fresh demands for cuts and commissions by middlemen and officers in charge began. Finally, Lodhi decided to give up any hope of getting old age pension, or even a part of it. "I was so tired of running for three months for a petty sum of Rs 150 a month that I decided to live without it," he says. "My file is still gathering dust at some indifferent government official's desk and it will remain there." As will the files of hundreds of poor elderly suffering corruption and apathy in the name of social welfare.

- Harmony team in Lucknow
OLD AGE PENSION As part of National Social Assistance Programme - a social assistance programme for poor households in the case of old age, death of a breadwinner and maternity - the Centre funds the National Old Age Pension Scheme. Different states look at the quantum of old age pension differently. From 1 April 2006, government increased monthly pension from Rs 75 to Rs 200 for elderly living below the poverty line (BPL). In September 2006, the Tamil Nadu government increased it from Rs 200 to Rs 400. In some districts of Karnataka, it's only Rs 100. In Assam, it's still Rs 75 per month - in addition, from 2004-05, the state social welfare department gives Rs 700 per annum to poor elderly under its healthcare scheme.
Old age pension apart, states have their own system of distributing clothes and rice free of cost or at a discounted rate of Rs 3 per kg. However, less than 7 per cent of the elderly in poor districts receive old age pension as it calls for making a BPL card, with the applicant - s age certified by a doctor at a primary healthcare centre. NGOs working for the elderly feel that making a BPL card is an abnormal multi-step process. It even includes attaching three passport-size photos with the form that a poor person, especially an older person, finds hard to fill in. And if there's no BPL card, there's no old age pension.
Evaluation studies10,11 carried out on the functioning of programmes for the care of elderly have revealed some important findings. Several distortions have been observed in the implementation of the old age pension scheme, right from the initial submission of an application to the receipt of amount. These include cumbersome procedures in submitting the application; inappropriate eligibility criteria; unusual delays in processing the application; and irregular payments. Administrative hurdles and procedural problems are also observed in the implementation of the National Old Age Pension Scheme, which needs urgent attention.
Some organisations also feel that giving out old age pension is a way to buy votes. With a few hundred every month to one person in the family, you get the votes of everyone in that family, they allege. While this is clearly a cynical view, ad-hocism and knee-jerk policymaking lend credence to such criticism.

After the Reserve Bank of India announced its credit policy in 2001, several banks launched special deposit schemes that help seniors earn higher interest than other depositors. Some of them are Andhra Pradesh State Cooperative Bank Limited, Tamil Nadu Mercantile Bank, United Bank of India, Centurion Bank of India, UCO Bank, Bharat Overseas Bank Limited, and Punjab National Bank, to name a few. Insiders feel this had something to do with fulfilling certain responsibilities to NPOP.
In February 2005, Harmony had written to Finance Minister P Chidambaram with some suggestions that would benefit Silver citizens. We add to the list in this document:
  • Pension reforms adopted by government have been largely borrowed from western industrialised countries. Given that a majority of India's workforce is in the unorganised sector (90 per cent) and not covered under any of the existing programmes12, there is a need to re-examine and modify existing social security schemes.

  • In addition, given consistent increase in life expectancy and proportional increase in postretirement years, there is a significant increase in pension amounts and corresponding 'pension burden' to the state exchequer. The situation calls for formulating appropriate and effective pension policies.13 As it is, pension for retirees is declining in real terms. They need assured saving returns, especially in old age.

  • There should be direct tax incentives to ensure that seniors remain in a position to retain a minimum level of tax-free income.

  • There should be direct tax incentives to corporations, the business community and society at large to encourage them to contribute to welfare schemes for seniors.

  • We need direct tax incentives for people on whom seniors are financially dependent.

  • Apart from the Senior Citizens' Savings Scheme - a welcome measure - there should be more tax-friendly investment avenues that offer better market returns to the elderly.

  • The rate of interest gained on the Senior Citizens' Saving Scheme should be non-taxable.

  • Medical expenses and house rent for senior citizens could be completely tax-deductible.

  • There should be no ceiling on investment in policies that give good returns.

  • The Reserve Bank has directed public and private-sector banks to constitute a Customer Service Committee dedicated to maintaining the quality of customer service. Still a grey area, it can be explored further by including senior citizens in these committees.
Letter to magazine, January 2007
The Income Tax Department has started a new avenue for self-employment called the 'Income Tax Preparer'. He will prepare tax returns of individuals, families, small-scale organisations and whoever else may need his services. The department has made arrangements with NIIT to train 5,000 graduates from the age of 21 to 35 for this. Working from home, they will get a remuneration of either 3 per cent of the assessed tax amount or Rs 250. Retired Silvers who are graduates or professionally qualified and are fit to work from home should also be permitted to work as income tax preparers, after a short period of training if required. Many Silvers may welcome this opportunity to work at their own pace and supplement their income. The government should consider this option for the benefit of senior citizens.
- Arun Chandra Mukhopadhyay, Kolkata
The need for pension reforms Financial security for senior citizens is a worldwide concern, but more so in India as one out of every nine elderly citizens in this world is an Indian. In sheer numbers, the elderly in India exceed 80 million. With improving life expectancy in recent decades, seniors have to fend for themselves for at least 20-25 years. Of these, barely about 15 per cent are covered under a pension or retirement plan of some kind through government or their employers. The majority, about 68 million, have no effective social security to provide them financial support in their non-earning years.

Given the economic profile of the population, most of the elderly range from being poor to very poor. The Central Government has a pension for destitute senior citizens amounting to Rs 200 per month. This figure comes after a recent hike in July 2006 when the government had increased the pension amount under the National Old Age Pension Scheme (NOAPS) from Rs 75 per month for people above 65 years of age.
The government has allocated an additional Rs 14.3 billion in the Budget for 2006-07 for the scheme. It is easy to see that the scheme is grossly inadequate. Assuming a senior citizen can fend for himself with Rs 2,500 per month, the amount needed to provide pension to 50 million senior citizens would translate to an annual bill of Rs 1,500 billion. Clearly, what the government has been doing is inadequate.
The policy framework in India is also grossly inequitable. While the government has no effective solution for the informal sector, it foots a bill in the region of Rs 1,000 billion for pensions of central and state government employees put together. Therefore, the vast majority of the elderly in India have to fend for themselves with no access to retirement benefits from government or their employers.
The situation arises from the way Indian labour markets are structured. The Indian Retirement Earning and Savings (IRES) survey of over 40,000 earners located across India revealed that out of 358 million workers, only some 16 per cent (about 57 million) were salaried. Of this 57 million, 55 per cent (31.5 million) are in the private sector and the other 25.5 million are in the government sector. The rest of the labour market (about 300 million) has no access to formal retirement benefit or social security. They will have no pension coming their way once they grow old and stop earning.
In recent years, the government has realised the enormity of the task and its inability to provide effective pension to the old and those who will retire in future. While the government cannot bear the financial burden of providing pension to everybody, it is in a position to develop a framework that will facilitate savings of citizens towards income security in old age. To this end, the government framed the New Pension System (NPS), which would enable all citizens to invest regularly. The money would be invested according to the choice of the member in different investment options. The options would cater to different risk profiles of various members. As safety of funds is of prime concern, management of funds would be regulated by a separate regulator, called the Pension Fund Regulatory and Development Authority (PFRDA). The schemes would allow individuals to save in easy-to-understand schemes with low charges.
This initiative has unfortunately become mired in politics. The Left parties see the scheme as one where members could lose their hard-earned money. The fact is, by not investing in equity, one is already resigned to an inadequate pension. The other argument could be that the government should fund the pension. They are, therefore, demanding a guaranteed return on investments. As discussed earlier, the government is already saddled with a huge pension bill for government employees and cannot afford it, much less take on a similar burden for the informal sector.

The other aspect of income security relates to insurance. In the past six years, the insurance market has been opened to the private sector and more and more people have been buying insurance. Contrary to perception, life insurance can be cheap. In a standard-term insurance plan for seven years, a monthly premium of about Rs 500 gets you a cover of Rs 1 million. For every additional one rupee in premium, you can add an accidental cover of Rs 1,000. This is without considering the tax benefits. However, of the estimated 358 million workers with regular income, 75.4 per cent comprise rural people. And nearly 79 per cent of the above total workforce has never invested in life insurance.
Of the urban population, while more than ever people can buy affordable insurance today, they would need about 60-70 per cent of their annual income to live in reasonable comfort after retirement. Blame it on inflation. Historically, only property or stock markets have managed to beat inflation in a significant manner. While property markets are too opaque to become a realistic asset class for pension funds in India, stock markets are too risky for most. So what are the other options? Nowhere in the world does any pension fund investing in fixed-income securities offer such high replacement rates. They won't get you within sniffing distance, at best offering 2 per cent premium over inflation over the long term. Pension reforms will not solve the social security needs of those who are already old but could go a long way in ensuring that future generations have an effective mechanism to build their own social security.
Ashish Aggarwal is associate director - pension policy, Invest India Economic Foundation, based in Noida, which assists in financial policy analysis and formulation through research and education


Health is not only about treating illness. It is a much broader term and calls for free and fair access to healthcare services to not only prevent ill health, but also promote good individual and public health. While maintaining good health is the responsibility of every individual, society and the state need to provide an environment that facilitates it. Currently, in India, there is no strategy in place to develop such an environment for the care of the elderly. Despite impressive gains in longevity, we still have some of the worst statistics on the global human development index.
As detailed earlier, the original NPOP document called for "a judicious mix of public health services, health insurance, health services provided by not-for-profit organisations including trusts and charities, and private medical care". Other promises included a strengthened primary healthcare system, strengthening and expanding mental health services, research, programmes for long-term management of illness, training in nursing care to include geriatric care, orientation opportunities for private general practitioners, geriatric wards in hospitals and mobile health services, and health insurance packages catering to lower income groups.
While MSJE funds mobile medical vans, largely through HelpAge India, the realisation of the other proposals is the responsibility of the Ministry of Health and Family Welfare. However, action is diffused as 'health' is a 'state subject' (with actual implementation largely to be effected at district level), and the Ministry of Health can only suggest and advise.

The concept of primary healthcare evolves from the WHO's 1st International Conference on Primary Healthcare, held in Alma Ata in 1978, where countries, including India, declared that they would achieve "health care for all by 2000". This is defined as "essential healthcare based on scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community, through their full participation and at a low cost that the community and country can afford to maintain at every stage of their development, in a spirit of self-reliance and self determination"14.
It's 2007 and India still has a long way to go. Studies across the country have revealed that most people mistrust and are displeased with government health centres. Among the small percentage of users of these services, a majority are dissatisfied because of non-availability of medicines or impersonal behaviour of health functionaries15. HelpAge India, a NGO working for the welfare of the rural elderly, reports an utter lack of basic healthcare in poor regions. According to HelpAge project leaders, primary healthcare centres are either closed or used "for playing cards". Even if most remain open, doctors or nurses often don't turn up to attend to patients. As for medicines, even basic drugs like Paracetamol are not available and people have to travel at least 20 km to the nearest hospital for which they have no bus fare - most villagers go on foot, or take bullock carts.
A recent article in Outlook magazine (25 December 2006) highlighted the contribution of a handful of good doctors who have turned their back on high-paying jobs in India and the West to work in rural areas, offering low-cost, high-quality healthcare. They have even trained local workers to become competent medical workers. There are examples from Ganiyari district of Chhattisgarh (where they are called Ganiyari doctors), Haryana, Maharashtra and Uttaranchal. Well-known among them are Abhay and Rani Bang, who were featured in Harmony magazine (January 2006) as one of the 15 'Silver' achievers of 2005. Disappointed with the dwindling number of medics ready to join them, the Bangs and other doctors like them - who are the main reference points for India's health indicators - point out that the rural poor are the worst prone to communicable and lifestyle diseases.
While government officials myopically deny that primary healthcare centres are languishing, they are forced to admit there isn't enough medical staff to take care of these centres. According to Minister of State for Health and Family Welfare P Lakshmi, "Seventeen per cent of posts of doctors in rural areas are lying vacant." As against 24,476 sanctioned posts of doctors, there were 20,308 doctors in place in 23,236 primary healthcare centres in India in September 2005. And there were 3,550 specialists posted at community health centres as against the sanctioned number of 7,582. All this is on paper.
According to the minister, these posts are lying vacant because of non-availability of doctors, delay in recruitment, inappropriate personnel policy of states, and lack of basic amenities and incentives for specialists to work in rural areas. Each state promises to take the initiative to overcome the problem, but all they do is make these postings compulsory for admission to post-graduate courses or as prerequisites for promotion, foreign assignments or training abroad. Some states have introduced contractual appointment of doctors, which is still not enough.
Though special cataract operation drives, as part of the National Programme for Control of Blindness (especially in the Northeast, as indicated in the 2005-06 Annual Report of the Ministry of Health), have achieved considerable success in rural areas, no credit for this goes to NPOP. "I don't think the policy has translated into any action in the health sector," admits A P Singh, director, Ministry of Health and Family Welfare. Then he goes on to argue, "But healthcare of older people is not stagnant or in a state of decline. Though it's not happening at a galloping pace, today's senior generation is fitter, enjoying life more than the preceding generation."
While this is largely true only for urban middleclass elderly, for rural areas, Singh cites the launch of ASHA (Accredited Social Health Activity), in April 2005, as part of the National Rural Health Mission. Here, a woman from the target village is appointed to spread awareness in the village on health (birth, contraception), hygiene, and nutrition. She needs to be married or widowed - someone who has lived life - and have studied at least until Class VIII. She will also have to undergo training every year. As only the first 20-day training capsule has been conducted so far, it's too early to gauge the success of ASHA. The Ministry of Health feels the project will gradually pick up and be able to include problems like menopause.
"My medicines for just 10 days cost over Rs 200" Near Amritsar, a narrow lane winds off Grand Trunk Road. It leads to a dusty slum called Maqboolpura. It is infamously dubbed the 'Locality of Widows' - a term first coined by newspaper The Tribune, which has consistently highlighted the high incidence of male deaths in the area in the past decade. Largely populated by truck drivers who have fallen prey to morphine addiction, a result of unchecked drug trafficking in Haryana and Punjab, Maqboolpura has lost one man in almost every family.
A bricked lane lined with open drains ends in a small two-roomed house with a sunny courtyard. This is where Mangal Kaur, wife of truck-driver Gyan Singh, lives. Mangal, 55, suffers from angina, an irregular heartbeat, and related heart disorders. "It started five years ago," she recalls. "I experienced shooting pain in my chest accompanied by a blinding headache. My heart was beating so fast, I thought it would burst." Mangal was taken in a rickshaw to the government hospital where the apathy of the doctors frightened her. "They just wouldn't attend to any patient, even those lying on the floor; and they were so rude," she says. "It was as if I didn't exist. They wouldn't reply to my questions." The next day, despite the expenses involved, Mangal's husband shifted her to Bhatia Heart Care Centre, a private nursing home.
After initial tests, the doctor advised surgery, but she opted out. "Where was the money?" she asks. With no relief from government or any NGO, Mangal's family has a hand-to-mouth existence with no savings to fall back on. "My medicines for just 10 days cost over Rs 200," she says with a sigh. "Even the rickshaw fare to the nursing home is Rs 30. But the doctor is very kind; he charges me half his normal fee of Rs 100."
Today, Mangal is unable to do even simple household chores. "My heart starts beating really fast when I exert myself," she says. And she's finding it increasingly difficult to make ends meet, as her healthcare expenses are eating into her husband's meagre monthly earnings of Rs 1,300. "I have to spend about Rs 800 on medicines, which is more than half of what my husband brings in," she says. "But the doctor says that I must have them everyday, whether I eat my food or not."
Mangal's two elder sons work as daily wagers in a factory. "They are married, and have separate kitchens, so they don't contribute to the expenses," she explains. Her youngest son Balwinder is still unmarried, and gives her about Rs 700 every month. This helps her pull through. She wonders what will happen when he gets married too.
Mangal has never heard of health insurance. Explain the concept to her and she wryly asks, "Where will we get the money to pay the insurance company?" She does not have access to any geriatric care, as none of the four government hospitals in Amritsar have any special facilities or wards for the elderly. She has never seen or heard of any educational material on geriatric care. "Those things are for the rich, not for us."
NPOP is alien to Mangal - in fact, no one in Maqboolpura has heard of the policy. They know about old age pension though. "Our neighbours get regular pension of Rs 200 every month as they are 'well off'," she says cynically. "They have the right contacts. We have to go to the municipal office to get it started, but nobody knows us there. End of story." On rare occasions that government officials come to Maqboolpura, they cancel pension of the really poor and give it out to those who can grease palms, she alleges. So, Mangal Kaur, like countless others, bears the burden of poverty and a chronic ailment, alone.

- Payal Khurana


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The government launched the National Mental Health Programme during the 10th Five Year Plan (2002-07). In 2004-05, 50 new districts were inducted into the District Mental Health Programme, taking the number up to 94. (India has over 600 districts.) Though a mental healthcare component-as recommended by MSJE's 2005-07 Action Plan for NPOP-has been added to all health programmes for the general population, there is no access to mental health services exclusively for the elderly. The Ministry of Health, however, informs Harmony that a dozen working groups engaged in making recommendations for the 11th Five Year Plan (2007-12) are talking about incorporating mental health, including Alzheimer's, among other priorities. "The 11th Plan will have more geriatrics and gerontology than preceding plans," promises Singh.
But why is 'geriatrics' discounted as only a short paragraph (without any budgetary allocation) in the 2005-06 Annual Report of his ministry? Under the header of Indian Council of Medical Research (ICMR), the report merely says: "The Council has initiated a task force on determinants of the functional status of Indian older persons at two centres in Delhi. The information, like physical, psychological and social factors/barriers influencing health in old age, is being obtained."
When questioned by Harmony, ICMR says the study is a prospective cross-sectional, community-based study for which 1,000 residents of Delhi aged 60 and above will be chosen. Subjects are being evaluated for their personal details, education and access to social support systems. Detailed clinical evaluation is being done to find out their functional status and health problems. Psychological evaluation includes self-rated physical and mental health, functional status for social health, life satisfaction, coping strategies and leisure activities using standardised tools. A detailed report and findings will be available on the completion of the study, say officials of ICMR.
While NGOs argue the scope and relevance of this piece of research, A P Singh of the Ministry of Health and Family Welfare says that though there is no lack of funding, research hasn't developed as a discipline in India. "Pharmaceutical research is fairly recent and is a larger part of the change sweeping India," he adds.

Training is one area that desperately needs attention but it has eluded policymakers. Geriatrics is based on the premise that problems of the aged are unique, and best dealt with by a multidisciplinary team of specialists and nurses-termed caregivers-trained to be sensitive to the needs of senior citizens. Essentially, the focus needs to be on healthy living, and prevention and treatment of chronic disease and disability in later life. Comprehensive programmes need to be chalked out on physical medicine, remedial exercise, counselling, occupational therapy and recreation with typical ailments like Alzheimer's, arthritis, Parkinson's and heart disease being factored in.
Gerontology or research on these aspects of the elderly in countries like the US is extensive with the result that geriatrics as a practice has picked up considerably. According to a recent study, there are about 20,000 geriatric-related professionals, including 9,000 super specialists, practising in the US alone. Several countries have introduced a multidisciplinary approach to geriatric care, as one specialist alone cannot offer necessary care. Besides the doctor, a social worker, physiotherapist, psychologist, speech therapist, and trained nurse constitute an appropriate team to care for elderly patients. However, in India, such a set-up is rare, with geriatric-only hospitals being rarer still. As things stand, some government hospitals in India do boast separate facilities for senior citizens-and, of late, geriatric wards in major hospitals in big cities-but they are often confined to holding weekly clinics for checkups and prescribing medicines.
Hospitals need to see geriatric care as an opportunity, not a burden. K R Gangadharan, Director of Heritage Geriatric Hospital in Hyderabad, maintains it is very important to train professionals in geriatric care. "It's as important as setting up mother-and-child hospitals," he says. "While you see these in every district, there are hardly any trained geriatricians around. As a result, Silvers are queuing up for specialists who over-drug their patients," he adds, insisting that he discourages over-drugging at his hospital, as does Dr V S Natarajan, Director of Madras Medical Hospital in Chennai.
Madras Medical College was the first hospital to introduce an MD in Geriatric Medicine in 1997. However, the Medical Council of India only recognised it in 2005, after the insistence of several experts and organisations, including Harmony for Silvers Foundation-it was part of the Silver Manifesto that Harmony presented to the government in February 2005 to urge it to implement NPOP.
Recently, Amrita Mai Institute of Medical Sciences in Kochi (formerly Cochin) also started an MD in Geriatric Medicine. Basic courses in geriatric medicine and nursing are offered at the Madras Medical College, Indira Gandhi National Open University (IGNOU) in Delhi, Kochi-based Alzheimer's and Related Disorders Society of India, and other organisations. The National Institute of Social Defence, established by MSJE, conducts various 'caregiver' and 'care-manager' programmes; the first diploma course kicked off in 2003, and an MSc in Geriatrics is planned.
From 2001-04, WHO helped trained internal medicine experts from New Delhi's All India Institute of Medical Sciences (AIIMS) in geriatrics-unfortunately, all of them were close to retirement age and no longer practice full-time. As for caregivers, there aren't many in India as lucrative jobs in the Middle East lure the trained ones. However, in the next five years, according to experts, every medical college could have a geriatric medicine department, with trained personnel. Until then, Gangadhran advises Silvers to identify one general practitioner (GP) in their neighbourhood and stick to him. And visit a specialist only when referred by the GP.

Getting health insurance for Silvers in India is a difficult proposition. Forget discounted health insurance for lower income groups, even urban elderly are now being charged 100 per cent more than the average. Oriental Insurance, following a green signal from the Insurance Regulatory and Development Authority, hiked the premium for a cover of Rs 200,000 from Rs 10,000 to Rs 13,000 for 70-plus proposers (those who buy a policy). What's worse, both public and private-sector companies are offering a plethora of options for the young and healthy, but are not ready to insure the elderly. Predictably, no organisation admits to charges of discrimination despite being pressed by Harmony.
Insurers admit they cannot refuse cover to anyone, provided certain criteria are fulfilled. All customers must pass stringent medical tests. If they do, insurers accept the proposal, but exclude almost all chronic diseases like diabetes and heart disease. Others, like cancer, are covered for the first time, but excluded on renewal. Most insurers exclude 'pre-existing' diseases. However, you can get medical cover if the disease develops after three years of holding a policy.
The most common medical problem that plagues Silvers in India is diabetes. WHO estimates there are 35 million diabetics in India, with the possibility of the number rising to 52 million by 2010. Of these, 95 per cent are Type II diabetics (they do not produce enough insulin), with the rest being Type I diabetics (who do not produce any insulin). Type I diabetics face a bigger problem as insurers don't cover them at all. However, ICICI Prudential Life Insurance and Bajaj Allianz General Insurance now cover Type II diabetics. Launched in November 2006, their schemes charge extra over the normal premium. ICICI goes a step further and encourages the proposer to control the condition by including three free blood sugar checks a year and reduces the premium by 20 per cent if the problem is controlled. Type II diabetes can cause heart attacks, decreased vision or blindness (retinopathy), damage to kidneys (nephropathy) and gangrene.
Several other private-sector companies are not coy about admitting that insuring the elderly is bad business, plain and simple. Their client profile reflects this wariness, with the proportion of young to elderly being 60:40. "All insurance companies have started adopting an extremely cautious approach towards health insurance," Ravi Mutani, relationship manager at Iffco Tokio, Mumbai, recently told Harmony magazine ("Searching for Cover", November 2006). "We are making heavy losses owing to high claim ratios. If we collect Rs 100 as premium a year, we are paying out Rs 120 as claims. Thus, we pref...

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