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.
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.
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
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:
THE HIGHLIGHTS OF THE POLICY ARE:
Financial Security
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:
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...
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...
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
MumbaiJanuary 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
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, 1956Lays 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...
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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).
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.
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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