Ageing in India: Some Social Challenges to Elderly Care

Ageing in India is exponentially increasing due to the impressive gains that society has made in terms of increased life expectancy. With the rise in elderly population, the demand for holistic care tends to grow. By 2025, the geriatric population is expected to be 840 million in the developing countries [1]. It is projected that the proportion of Indians aged 60 and older will rise from 7.5% in 2010 to 11.1% in 2025 [2]. In 2010, India had more than 91.6 million elderly and the number of elderly in India is projected to reach 158.7 million in 2025 [2]. An aging population puts an increased burden on the resources of a country and has raised concerns at many levels for the government in India. The aging population is both medical and sociological problem. The elderly population suffers high rates of morbidity and mortality due to infectious diseases. The demographic transition in India shows unevenness and complexities within different states. This has been attributed to the different levels of socio-economic development, cultural norms, and political contexts. Hence it will be a herculean task for policy makers to address the geriatric care that will take into account all these determinants. Care for the elderly is fast emerging as a critical element of both the public and private concern.


Introduction
Ageing in India is exponentially increasing due to the impressive gains that society has made in terms of increased life expectancy. With the rise in elderly population, the demand for holistic care tends to grow. By 2025, the geriatric population is expected to be 840 million in the developing countries [1]. It is projected that the proportion of Indians aged 60 and older will rise from 7.5% in 2010 to 11.1% in 2025 [2]. In 2010, India had more than 91.6 million elderly and the number of elderly in India is projected to reach 158.7 million in 2025 [2]. An aging population puts an increased burden on the resources of a country and has raised concerns at many levels for the government in India. The aging population is both medical and sociological problem. The elderly population suffers high rates of morbidity and mortality due to infectious diseases. The demographic transition in India shows unevenness and complexities within different states. This has been attributed to the different levels of socio-economic development, cultural norms, and political contexts. Hence it will be a herculean task for policy makers to address the geriatric care that will take into account all these determinants. Care for the elderly is fast emerging as a critical element of both the public and private concern.
The apparent success of the medical science is invariably accompanied by several social, economic and psychological problems in older persons, in addition to the medical problems. It needs to be understood that many of these problems require lifelong drug therapy, physical therapy and long-term rehabilitation [3]. The elderly tend to be cared for in a variety of settings: home, nursing home, day-care centre, geriatric out-patient department, medical units or intensive care unit depending on the nature of the clinical problem. Care of elderly necessitates addressing several social issues. The needs and problems of the elderly vary significantly according to their age, socioeconomic status, health, living status and other such background characteristics. Their social rights are neglected and they are profusely abused which goes unreported.

Lack of Infrastructure
With increasing longevity and debilitating chronic diseases, many elder citizens will need better access to physical infrastructure in the coming years. Lack of physical infrastructure is a major deterrent to providing comfort to the aged. Many elder citizens need better access to physical infrastructure, both in their own homes and in public spaces. Unattended chronic disease, unaffordable medicines and treatment and malnutrition are part of old age life in India as there is no system of affordable health care. Emphasis on geriatrics in the public health system is limited with few dedicated geriatric services. The other issues of the public health system are lack of infrastructure, limited manpower, poor quality of care and overcrowding of facilities due to insufficient focus on elderly care [4].

Changing Family Structure
The traditional Indian society with an age-old joint family system has been instrumental in safeguarding the social and economic security of the elderly people. The traditional norms and values of Indian society also laid stress on showing respect and providing care for the elderly. However with the emerging prevalence of nuclear family set-ups in recent years, the elderly are likely to be exposed to emotional, physical and financial insecurity in the years to come. There is an upward trend in the living arrangement pattern of elderly staying alone or with spouse only from 9.0% in 1992 to 18.7% in 2006 [5]. Family care of the elderly seems likely to decrease in the future with the economic development of the nation and modernization.

Lack of Social Support
The elderly in India are much more vulnerable because of the less government spending on social security system. The elderly in urban area rely primarily on hired domestic help to meet their basic needs in an increasingly-chaotic and crowded city. Social isolation and loneliness has increased [6]. Insurance cover that is elderly sensitive is virtually non-existent in India. In addition, the preexisting illnesses are usually not covered making insurance policies unviable for the elders. Pension and social security is also restricted to those who have worked in the public sector or the organized sector of industry. In a study by Lena et al. [7], almost half of the respondents felt neglected and sad and felt that people had an indifferent attitude towards the elderly. It was also found that 47% felt unhappy in life and 36.2% felt they were a burden to the family.

Social Inequality
Elderly are a heterogeneous section with an urban and rural divide. They are less vulnerable in rural areas as compared to their urban counterparts, due to the still holding values of the joint family system. All the elderly are not seen in the same view as the needs and problems of elderly are rejected to a vast extent as government classifies these people based on caste and other socio cultural dimensions. In a case study, it was found that a major proportion of the elderly women were poorer; received the lowest income per person; had the greatest percentage of primary level education; recorded the highest negative affective psychological conditions; were the least likely to have health insurance coverage and they recorded the lowest consumption expenditure [8].
Availability, Accessibility and Affordability of Health Care children who find themselves responsible for their parents' well-being. Managing home care for the elderly is a massive challenge as multiple service providers -nursing agencies, physiotherapists and medical suppliers -are small, unorganized players who extend sub-optimal care. In India, health insurance coverage is essentially limited to hospitalization. The concept of geriatric care has remained a neglected area of medicine in the country. Despite an aging population, geriatric care is relatively new in many developing countries like India with many practicing physicians having little knowledge of the clinical and functional implications of aging [9][10][11]. Not many institutes offer the geriatrics course, and even takers are few. Most of the government facilities such as day care centres, old age residential homes, counselling and recreational facilities are urban based. The geriatric outpatient department services are mostly available at tertiary care hospitals [12]. Reaching to 75% of the elderly that reside in rural areas with geriatric care will be challenging. Dhar [13] has pointed out the relative neglect in provision of facilities for patient care as well as training and development in geriatrics in the Indian context. As pointed by Dey et al. [14], the key challenges to access and affordability for elderly population include reduced mobility, social and structural barriers, wage loss, familial dependencies, and declining social engagement. The stigma of aging is another social barrier to access of health in addition to the health and social conditions the elderly commonly face such as dementia, depression, incontinence and widowhood [15].

Economic Dependency
As per the 52nd round of National Sample Survey Organization, nearly half of the elderly are fully dependent on others, while another 20 percent are partially dependent for their economic needs [16]. About 85% of the aged had to depend on others for their day to day maintenance. The situation was even worse for elderly females [17]. The elders living with their families are largely contingent on the economic capacity of the family unit for their economic security and well being. Elderly often do not have financial protection such as sufficient pension and other form of social security in India. The single most pressing challenge to the welfare of older person is poverty, which is a multiplier of risk for abuse [18]. Also due to their financial dependence, elderly persons though are most vulnerable to infections have low priority for own health. Migration of younger generation, lack of proper care in the family, insufficient housing, economic hardship and break-up of joint family have made the old age homes seem more relevant even in the Indian context [19].
It is important to understand the social aspects concerning aged in the country as they go through the process of ageing. Increased life expectancy, rapid urbanization and lifestyle changes have led to an emergence of varied problems for the elderly in India. It must be remembered that comprehensive care to the elderly is possible only with the involvement and collaboration of family, community and the Government. India should prepare to meet the growing challenge of caring for its elderly population. All social service institutions in the country need to address the social challenges to elderly care in order to improve their quality of life. There is a need to initiate requisite and more appropriate social welfare programmes to ensure life with dignity for the elderly. In addition, there is also a need to develop an integrated and responsive system to meet the care needs and challenges of elderly in India.