NATIONAL POLICY ON OLDER PERSONS: TAKING IT FORWARD
CONTENTS
PREFACE
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
Mumbai
January 2007
FOREWORD
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
BACKGROUND
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.
TIME TO ACT
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.
FOLLOWING THE WORLD
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.
CONSTITUTIONAL PROVISIONS AND ACTS
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.
CONTENT OF NPOP
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.
NPOP WAS ANNOUNCED6
WITH THE FOLLOWING OBJECTIVES:
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.
THE HIGHLIGHTS OF THE POLICY ARE:
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
Shelter
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.
Education
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
Welfare
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
Family
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
Media
Involve mass media as well as informal and traditional channels of communication with issues related to ageing
PLAN OF ACTION
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:
No.
|
FIRST ACTION PLAN (1999)
|
Status
|
1
|
Identify roles of various ministries
|
DONE
|
2
|
Facilitate setting up a National Association of Older Persons
|
NOT DONE
|
3
|
Identify a nodal department of state governments to coordinate and monitor implementation of the policy
|
DONE
|
4
|
Promote voluntary organisations in the field of ageing
|
INADEQUATE
|
5
|
Establish a Senior Citizens' Welfare Fund at the Centre
|
NOT DONE
|
6
|
Develop instruments
to provide old age social and income security for workers from the
unorganised sector - India's largest labour segment
|
NOT DONE
|
7
|
Promote the concept of active ageing
|
NOT DONE
|
8
|
Promote non-institutional forms of care for strengthening the family's contribution
|
NOT DONE
|
9
|
Assist panchayats - village-level administrative units - to serve older persons
|
PARTLY DONE
|
10
|
Facilitate training and orientation of workers and volunteers in organisations providing services to the elderly
|
NOT DONE
|
11
|
Promote research on ageing issues
|
PARTLY DONE
|
12
|
Requisition state governments to issue a multipurpose identity card to the elderly
|
DONE
|
13
|
Expand legal aid to older persons
|
PARTLY DONE
|
14
|
Provide relief and rehabilitation of older persons in the existing relief code
|
DONE
|
15
|
Provision for special attention by the police for the security of life and property of older persons
|
DONE
|
16
|
Promote and assist pre-retirement counselling programmes
|
NOT DONE
|
17
|
Assist organisations to provide career guidance, training, placement and support services to older persons
|
NOT DONE
|
18
|
Include course materials on older persons in curriculum and different stages of education
|
NOT DONE
|
No.
|
SECOND ACTION PLAN (2005-07)
|
Status
|
A
|
Segmentation of elderly
|
|
1
|
Assess the needs of elderly of different age groups and finalise schemes and programmes for them
|
NOT DONE
|
2
|
Establish universal coverage of National Social Assistance Programme for special groups like rural poor, widows, Dalits
|
PARTLY DONE
|
B
|
Economic security
|
|
1
|
Enhance the number of NSAP beneficiaries
|
NOT DONE
|
2
|
Reduce the eligibility age to 60 years and increase the amount given under NSAP per beneficiary
|
NOT DONE
|
3
|
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
|
NOT DONE
|
4
|
Allocate separate funds for elderly women in all major poverty alleviation programmes
|
NOT DONE
|
5
|
Establish credit cooperatives in rural areas and urban slums
|
PARTLY DONE
|
6
|
Ensure food security for poor elderly, particularly for women
|
NOT DONE
|
C
|
Health security
|
|
1
|
Ensure all medical colleges at least have a post-graduate programme in geriatrics
|
NOT DONE
|
2
|
Develop training facilities for paramedical staff and caregivers in each state capital
|
NOT DONE
|
3
|
Develop short-term residential care facilities for elderly in all metros
|
NOT DONE
|
4
|
Provide universal access to mental health services and add a mental health component in all healthcare programmes
|
NOT DONE
|
5
|
Change private insurance schemes to include benefits like chronic ambulatory care
|
NOT DONE
|
6
|
Persuade private and public insurance companies to make elder-friendly health insurance policies
|
NOT DONE
|
7
|
Form a regulatory
body to review and regulate the quality of services available and
money charged by various private-sector institutions
|
NOT DONE
|
D
|
Public-private partnership for age care
|
|
1
|
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
|
NOT DONE
|
2
|
Temper filial affection with economic logic, like tax concessions to young relatives taking care of elderly
|
NOT DONE
|
3
|
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
|
NOT DONE
|
THEN, AND NOW
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.
ON THE BACKBURNER
"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.
More...
TAKING CONTROL
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.
IMPLEMENTATION OF NPOP
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.
FINANCE
Like most other developing countries, India does not have a social
security system to protect the elderly against economic deprivation.
PENSION SCHEMES
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.
BUDGETARY PROVISIONS
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.
RAM MILAN LODHI, 71, LUCKNOW
"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.
SAVING SCHEMES
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.
HARMONY'S PROPOSALS
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
COMMENT by ASHISH AGARWAL
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
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.
PRIMARY HEALTHCARE
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.
MANGAL KAUR, 55, AMRITSAR
"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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MENTAL HEALTH
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.
RESEARCH
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 DOCTORS, NURSES AND CAREGIVERS
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.
MEDICAL INSURANCE
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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