AGEING IN INDIA IN THE 21ST CENTURY: A RESEARCH
AGENDA
(Priority Areas and Methodological Issues)
PREFACE
Ageing in India in the 21st Century: A Research Agenda is a country-specific report
with special focus on priority areas and methodological issues. It is prepared on the
lines of the research agenda framed by the United Nations Office on Ageing and the
International Association of Gerontology in 2002.
The main aim of this report is to focus on the emerging ageing issues in India in the
coming decades and to suggest alternative methodological approaches to study these
issues in a more comprehensive way.
My sincere thanks and deepest gratitude to Tina A Ambani for her constant
encouragement and valuable suggestions during the preparation of the report. I
sincerely thank S Rangarajan for his continual assistance in finalising the report. I
would also like to thank Prof C P Prakasam, Head, Computer Centre, International
Institute for Population Sciences, Mumbai, for analysing the demographic data on
ageing.
— Dr S Siva Raju
Mumbai
February 2006
FOREWORD
Many seniors in India lead healthy, dignified, and satisfying lives. They work
through the day or part-time. Many live off well-planned savings. They travel,
increase acquaintance with computers and other empowering gadgets, and are secure
as owners of their homes. But there are many more who retire without a pension,
provident fund or modest savings. They lack access to even the most basic
healthcare, and suffer abuse and neglect from the younger generation — and in
many cases, the state. This is unacceptable, and simply cannot be permitted to
continue.
The Harmony Initiative was born of a dream to touch the lives of every elder person
across India, irrespective of gender, class or region. Our aim is a national movement
to improve the quality of life of these ‘silver’ citizens, to ensure that society and
government cannot ignore them any longer, and equally, spur them into greater selfreliance.
The need is unquestionable. India is home to one out of 10 senior citizens in the
world. This population, estimated to be over 80 million at present, is projected to
grow to 137 million by 2021.
There is strength in these numbers. We firmly believe that the elderly are not a spent
force. Indeed, silver citizens are active and proud. As marketers and researchers fete
Generation X, our commitment is to Generation A — people with a wealth of
experience, expertise and wisdom to share.
The Harmony Initiative, launched in 2004, has three main facets: Harmony, the
magazine, the Harmony Interactive Centre and the website www.harmonyindia.org.
All three work towards urging Silvers to live life to the fullest and reinforcing the
spirit of Harmony: Celebrate age.
Over the past two years, we have realised that we need to learn more about Silvers if
we are to make a real difference to their lives. That is how Harmony’s Research
Division took shape. We believe it is imperative that voluntary organisations, selfhelp groups and other agencies streamline their efforts in the areas of research,
teaching, training and advocacy, and join hands with government to evolve policies
and programmes that work on the ground.
This can only be achieved with appropriate research, the first building block in the
process of enabling and empowerment. It’s time to ask some important questions:
Have existing statistics helped us understand the conditions of our elderly living in
different socio-economic situations? Have studies enabled government to frame
effective policies and programmes? Given the high population growth among this
segment of the population and wide variety and change in their profiles, do we need
alternative approaches in research? We need to consider these questions, as we
urgently need accurate answers.
Through this monograph, Dr S Siva Raju, Vice-President (Research & Training),
Harmony, attempts to set the agenda on future research in the field of ageing in
India. This report is not just an interesting and stimulating read, but has practical
application for Silvers across India. Through it, our aim is to reach out to a wide
audience of students, researchers, teachers, policy makers and practitioners, as well
as those with a general interest in issues related to ageing. We also hope it spurs
government and non-government agencies to consider the issues presented here as
priority areas for commissioning projects.
In 1989, sociologist and demographer Alfred Sauvy predicted, “The 21st century
will be the century of the ageing of mankind.” He couldn’t have been more right.
But to make this century worthwhile, we need to fill the gap between policy and
reality. Let us come together to create a society where age is just an irrelevant
number, where elders stand side by side with the younger generation, Silver,
shining, and proud.
— Tina Anil Ambani
AGEING IN INDIA IN THE 21ST CENTURY: A RESEARCH
AGENDA
(Priority Areas and Methodological Issues)
EXECUTIVE SUMMARY
The rapid growth of the elderly population, the wide diversity in their profiles
and the varied inter-related environmental influences need significant
consideration of researchers, policy planners and service providers.
The research agenda on ageing in the 21st century developed by the United
Nations Programme on Ageing and the International Association of
Gerontology aimed to contribute to clarifying and implementing public
policies on ageing, and influence the direction and priorities for scientific
gerontology.
As the second most populous country in the world, India needs to prioritise
issues for future research on ageing and refine methodologies to undertake
such studies. This report is an effort in that direction.
Earlier studies on ageing have enabled us to understand issues concerning the
elderly, especially their problems. However, besides being exploratory,
descriptive and localised, most of the studies focused on urban, male
retirees/pensioners, who were viewed as passive receivers of care.
Profiles of the elderly population are undergoing a change. Today, the
proportion that intends leading active lives of fulfilment for themselves, their
family and the community is on an increase.
These changes affect their quality of life both directly and indirectly.
Consequently, it is imperative to prioritise research efforts and evolve
alternative methodologies for the study of ageing issues.
Areas for research on ageing include:
• Female elderly
• The very old (80-plus years)
• Rural elderly
• Inter-generational bonds
• Community-based support programmes
• Life span approaches
• Impact of health problems like HIV/AIDS
• Nutritional status
• Geriatric issues
• Elder abuse
• Family relations
• Social networks
• Determinants of successful ageing
• Network of organisations for the care of the elderly
Methodological aspects that require attention to study these emerging issues
include:
• Multi and inter-disciplinary perspectives
• Promotion of explanatory studies
• National-level studies covering different geographical regions
• Stratification of the elderly population
• Conceptual issues related to quality of life
Harmony advocates greater interaction as well as dissemination of information
among researchers, policy planners, community workers and service
providers associated with ageing issues.
AGEING IN INDIA IN THE 21ST CENTURY: A RESEARCH
AGENDA
(Priority Areas and Methodological Issues)
“Viewed as a whole, the problem of ageing is no problem at all. It is only
the pessimistic way of looking at a great triumph of civilization.” –
Notestein, 1954
BACKGROUND
Across the world, countries are experiencing population ageing. The growth rate of
the elderly population is more rapid in developing countries like India than
developed countries. Apart from demographic transitions, socio-economic and
political changes together with increased individualism have altered living
conditions of the elderly.
Today, the elderly demand that society should not only ensure independence and
participation, but also provide care, fulfilment and dignity. Limited understanding of
factors influencing their quality of life is largely responsible for the elderly being
denied a dignified existence. After all, the last stage of life holds as much potential
for growth and development as earlier stages. The diversity among the elderly and
varied inter-related influencing aspects from their environment need significant
consideration of researchers and policy planners.
“There is a need to assess the ‘state of the art’ of existing knowledge, as it
varies across countries and regions, and to identify priority gaps in
information necessary for policy development.” – UN, 2002
The United Nations Office on Ageing and the International Association of
Gerontology jointly developed the Research Agenda on Ageing for the 21st Century.
Initiated mainly to support the implementation of the International Plan for Action
on Ageing, the research agenda was adopted by the Second World Assembly on
Ageing at Madrid, Spain, in 2002. It aimed to elaborate and implement public
policies on ageing and influence the direction and priorities for scientific
gerontology in the coming decades. This was built on the substantial body of
knowledge and expertise regarding gerontology and related fields accumulated over
time.
However, wide variations exist in its accessibility and relevance depending on socioeconomic conditions of different countries. Hence, a country with substantially
fewer resources for conducting research needs to carry out a stock taking exercise at
regular intervals. This assists in understanding various ageing issues and in
modifying or seeking new methodologies for their study.
Until recently, ageing was not a priority issue in India for research,
planning and programs of social security provisions and services.
Though the scientific study of ageing issues in India was attempted as early as the
1960s, the World Assembly on Ageing held in 1982 gave significant impetus to
gerontological research; this has recently gained importance. Further,
announcements of policies like National Health Policy, National Population Policy
and National Policy on Older Persons have also created far more awareness and
consciousness among researchers, policy makers and others, resulting in an
increased focus on age-related issues.
As the second most populous country in the world, it is important for us to assess the
status of research on ageing in our country and identify existing gaps. This requires
the attention of researchers as well as policy makers and others associated with
issues of ageing. Such exercises help us to prioritise issues for future research and
refine methodologies to undertake such studies. This is the content in which this
report attempts to assess the status of research on ageing. It analyses the focus,
approaches and study areas, and lists out priority areas and methodological
approaches for future research.
The studies on ageing conducted so far may be broadly categorised as:
Demography of ageing
Attitudes and stereotyped perceptions
Ageing differentials
Ageing in specific locations
Cross cultural comparisons of ageing
Development and health in old age
Livelihood issues
Care of older persons
Family relations and social networks
Quality of life
Preparedness for death
Policies and services
Alternative approaches or methodologies are required for comprehensive
research to further our knowledge of ageing issues.
SCENARIO
Elderly issues are multi-dimensional in nature. They may be broadly categorised as
demographic, social, psychological, economic and health.
(i) Demographic Issues
Age Pyramid
The elderly population in India is the second largest in the world, next only to
China. This population, which was 77 million according to the 2001 census (7.5% of
the total population), is projected by the UN to increase to 137 million by 2021.
Three-fourth of the elderly population live in rural areas. Their annual growth rate is
higher (3%) as compared to the growth rate of the total population (1.9%).
Population projections show that by 2050, the elderly population in India will
surpass the population of children below 14 years.
Growth of elderly population aged 60+, India, 1901-2016
Source: Based on the data presentation by Siva Raju, 2002, in UNFPA
and CBGS, Situation and Voices – The Older Poor and Excluded
in South Africa and India, No. 2
Sex ratio (number of females per 1,000 males) of the elderly population, which was
1,029 in 2001, is projected to become 1,031 by 2016. Life expectancy at the age of
60, which was 9 years in 1901, is currently around 16 years for males and 18 years
for females (Irudaya Rajan, 2005). Widowed elderly females are greater in
proportion (51%) as compared to males (15%).
Some of the major characteristics of ageing in India are: Feminisation of
ageing, the high growth of oldest-old (80+ years) compared to young-old
(60-69 years) and increase in their vulnerability.
The old age dependency ratio (number of 60+ per 100 persons in the 15-59 age
group) is gradually increasing in both rural and urban areas. A majority of the
elderly are supported by their children, and co-residence with their children
increases as they advance in age.
Unfortunately, literacy is 53 per cent among elderly males and only 20 per cent
among elderly females. Elderly males are more economically active as compared to
females.
The situation in India is in favour of continuing the family as a single unit
for performing various activities.
Nearly 90 per cent of the total workforce in India is employed in the unorganised
sector. Consequently, retirement from gainful employment precludes financial
security like pension and other post-retirement benefits. It is estimated that one-third
of the elderly population live below the poverty line.
(ii) Social Issues
“In youth we learn; in age we understand.” – Marie Von EbnerEschenbach
The elderly were the most respected members of the family in traditional Indian
society. Taking care of them was mainly the responsibility of their children.
However, the growth of individualism and materialism among the younger
generation in modern industrial life led to their alienation and isolation from family
and society. Migration from rural areas also resulted in the growth of more nuclear
families in towns and cities.
Despite social problems, the younger generation generally looks after the elderly
relatives. But living conditions and quality of care differ widely in various
communities. Some earlier studies (Nair, 1972; Nair, 1990; Prasad, 1991) focused
on the living conditions of the elderly and found them living only with their
children. In most of these studies, it was noticed that the elderly respondents are
from either extended or joint families, with as many as three to four generations
living together. Over a period of time, there was a noticeable shift in their living
conditions, especially the retirees. According to Sumangala (2003), they enjoyed
living alone with their spouse or with their unmarried children, sometimes even
living separately in the same premises as their married children.
Earlier studies conducted among the rural elderly (Nair, 1980; Nair, 1990) found
that most of them had one or all children living in the same village. Nair (1980)
perceived a close association between the living arrangements with the children and
how the elderly adjusted to fit in. Based on his sample study of the elderly in Kerala,
Cherian (2003) found significant effect of
i)
Living arrangement on emotional adjustment
ii)
Gender on general adjustment; and
iii)
Family life satisfaction on emotional and general adjustment
“In developed countries, population ageing has resulted in a substantial
shift in emphasis between social programs, causing a significant change in
the share of social programs going to older age groups. But in developing
societies like India, these transfers will take place informally and will be
accompanied by high social and psychological costs by way of intra-familial
misunderstandings and strife.” – M.S. Gore, 1993
According to Nandal, Khatri & Kadian (1987), the elderly who handed over their
property to the younger generation and retained no control over the source of
income, lost on their role as decision-makers. Here it was observed that elderly
females suffer the loss of status more than elderly males.
Soodan (1975), Mahajan (1987) and Gangrade (1988) focused on intergenerational
changes and found that most of the elderly population felt that the younger people
did not respect them and anticipated tension in bonding and togetherness. Studying
the elderly in Haryana, Madhu, Vamani & Darshan (2003) noticed that the majority
were involved in less important and non-remunerative roles and felt neglected
during important decision-making in the family.
Many studies have focussed on pensioners and retired persons. In their study of
pensioners in Mumbai, Desai & Nayak (1972) observed that loss of status in the
family was not an important problem for most retirees. Comparing the position of
retirees within the family before and after retirement, Menachery (1987) concluded
that their loss of status is not brought about by retirement per se, but in conjunction
with other intra-familial and personality factors. From his study of retired persons in
Udaipur, Sati (1988) found that on the whole, retirees evaluated the relationship with
their families as good. Also, the number of widowed living with their married
children outnumbered elderly persons who were married.
Elders perceived their social status and respect in the family to be significantly
associated with their education and occupational position. Focus Group Discussions
(HelpAge, 2003) among several groups of the elderly in Bangalore, Mumbai and
Delhi indicated a wide prevalence of mistreatment in urban society.
Day-to-day activities of the urban elderly mainly include assisting the spouse and
other members in household activities, watching television, reading newspapers,
taking morning and evening walks, interacting with friends and assisting
grandchildren in their school work (Siva Raju, 2004). Ladusingh & Bijaya (2004)
observed a similar scenario in Manipur where the elderly (with three or more
children) spent time helping with domestic chores and doing community service
apart from indulging in leisurely activities like watching television, listening to the
radio, reading books, playing cards, visiting friends and relatives. Statistically, this
had a significant negative effect on loneliness.
(iii) Psychological Issues
“Live your life and forget your age.” – Norman Vincent Peale
As changes in cognitive and other abilities surface, the elderly face psychological
problems. Reasoning becomes slower, memory is impaired, enthusiasm decreases,
cautiousness increases, and sleep patterns are altered. Mental illness is also much
higher among old people. Ramamurthi (1978) found that such problems tend to
manifest gradually after the age of 50, resulting in poor adjustment and
dissatisfaction with life. However, after retirement, people gradually adjust — the
index reflecting as positive over a period of time. This continues till the age of 70,
after which the negative effects of ageing become pronounced again.
In his survey of happiness and unhappiness in old age, Sharma (1971) inferred that
happiness, to a great extent, depends on busy life, good health, financial stability and
having a spouse and social contacts. The range of psychological problems was much
wider, and the impact entirely different as compared to that in the ‘unorganised’
sector.
To overcome anxiety, a majority of the elderly read or recite religious books and
hymns (D’Souza, 1982; Jamuna, 1989). According to Dhillon & D’Souza (1992),
females who are less aggressive and experience less frustration while coping are
more socially adjusted and mature, with a greater need for affiliation compared to
males.
From his study of pensioners, Lakshminarayan (1999) noticed that the elderly who
experience deprivation have more adjustment problems. According to Patel (2003),
the institutionalised aged experience a poor sense of psychological well being
compared to the non-institutionalised aged. Chandrika & Anantharaman (1982) also
found that non-institutionalised older people adjusted better than institutionalised
geriatric patients. Factors such as rigidity of attitude, availability of a role to play
and the extent of involvement, communication with the spouse, marital satisfaction,
approach to retirement, attitude regarding one’s future, physical and mental health
(including death) influenced adjustment.
Ramachandran, Sarada Menon & Ramamurthy (1981) reported that family and
living conditions are significant factors affecting the mental health of the elderly.
Mental disorders are attributed to abuse, neglect or lack of care for a parent.
Deshpande, Mathur, Bhatt & Bohra (1998) observed that depression, followed by
dementia, was the most common psychiatric disorder in the older population.
Affective (mood) disorders were identified as the most common psychiatric concern
among the sampled elderly patients in Goa (Yvonneda, Ajoy, Rajesh & John, 2002).
The difference in psychiatric categories and associated physical illnesses was
significantly linked with the gender of the patients. Patel & Prince (2002) perceived
dementia as a normal part of ageing, requiring medical care.
Though the young generation takes care of elders in the modern societies,
their living conditions and quality of care differ widely from community to
community.
Depression levels differed significantly with gender and education. Patil, Gaonkar &
Yadav (2003) noticed lesser depression in a larger proportion of the sample elderly
in Dharwad city. Stress events are specifically more evident in females, those with
low per capita income and those who perceived crises in the family (Niriy &
Jhingan, 2002).
Stressing on the role of social workers in care of the elderly, Indira Jai Prakash
(2000) observes, “There are a large segment of older people who are usually
neglected by health professionals because of the presumed incurability of their
condition. Especially, older persons with cognitive impairment, dependant and frail
elderly are often left to families with very little professional help. The well being of
such people can be significantly improved if social workers can incorporate
principles of behavioural gerontology in their work.”
(iv) Economic Issues
“Opportunities and facilities need to be provided so that they can continue
to contribute more effectively to the family, community and society.”
– NPOP, 1999
Many problems that confront the elderly can be traced to the loss of income
resulting from total or partial withdrawal from occupation, combined with the loss
of social status that they enjoyed while occupied. Nearly 90 per cent of the total
workforce in India is from the unorganised sector. Retiring without any financial
security like pension or other post-retirement benefits (Siva Raju, 2005), a majority
are compelled to continue in some occupation to maintain their families. Studies
conducted in major cities (Mumbai: Desai & Naik, 1972; Lucknow: Soodan, 1975;
Delhi: Jagannathan & Palvia, 1978; Udaipur: Sati, 1988; Siva Raju, 2000) also
confirm that a considerable percentage of retirees take up re-employment mainly
due to financial constraints.
Studies conducted to determine the economic conditions of the elderly (Nair, 1980;
Srivastava, 1983; Nair, 1990; Siva Raju, 1997, 2004) found the majority leads poor
or very poor economic life, and widows suffer the most. Nair (1980) noticed that
while none of the elderly with children received help, many were helping their
children. Ownership of land significantly affected the status of the elderly in family
matters (Otta, 1989).
Other studies conducted on retirees (Desai & Naik, 1972; Mishra, 1987; Reddy,
1989; Sati, 1988) also corroborate that financial issue is the main problem. Based on
data regarding how retirees spent the money received at the time of retirement (Siva
Raju, 2004), it was suggested that there should be a provision for pre-retirement
briefings in public and private sector to enable employees to organise their priorities
and plan a better retired life.
Some studies (Nair, 1980; Mahajan, 1987) focused on the living conditions of
beneficiaries of old-age pension schemes in some states. Assessing the effectiveness
of the scheme in Uttar Pradesh, Soodan (1982) found that most of the pensioners
were females (65%), widows (65%) and those who didn’t have sons (82%). As the
pension amount was quite inadequate, the study established that less than a fifth
(18%) of the pensioners were engaged in some work, while a few were even
begging and living on the pavement. A similar study conducted in Kerala (Nair,
1980) reported that a majority of the pensioners received some kind of assistance in
cash or kind, regularly or intermittently, from their kin or neighbours.
On the other hand, Mahajan (1987) studied the recipients of old-age pension in
Haryana and found that most beneficiaries perceived the scheme as a positive
contribution. More than three-fourth of the beneficiaries said that their lives had
become more comfortable after they started receiving pension. It helped them adjust
better with their family and the community, as they were no longer a financial
burden.
According to the National Policy on Older Persons (Government of India, 1999),
old-age pension schemes covered about 2.76 million persons (until January 1997).
Ultimately, this coverage will be significantly expanded so that the objective of
including all older persons below the poverty line is achieved.
(v) Health Issues
Health facilities exclusively for the elderly are negligible. They have to
compete with the general population to avail them.
The idea that old age is an age of ailments and physical infirmities is deeply rooted
in the Indian psyche. People become increasingly susceptible to chronic diseases,
physical disabilities and mental incapacities, as they grow older. Not surprisingly,
health problems and medical care become major concerns among a majority of the
elderly. Yet many refrain from seeking medical aid due to various impediments.
Some refuse medical attention merely because they have never received such
treatment as a rule.
Multiplicity of diseases is normal among the elderly. The majority often suffer from
chronic bronchitis, anaemia, blood pressure, chest pain, heart attack, kidney
problems, digestive problems, change in vision, diabetes, rheumatism and
depression (Siva Raju, 2000). Disability among the elderly mainly implied difficulty
in walking and standing, partial or complete blindness, partial deafness, difficulty in
moving some joints, indigestion and mild breathlessness. During their survey,
Purohit & Sharma (1972) found that the incidence of diseases was under-reported
and only closer examination revealed some of the serious ailments.
Factors like age, education, economic status, marital status, perception on living,
anxieties and worries, addictions, degree of idleness, type of health centre visited,
and whether the person is on some kind of medication, exert a significant influence
on both the perceived and actual health status of the elderly (Siva Raju, 2002).
Health conditions also vary considerably depending on their gender (Siva Raju,
1997). Joshi (1971) opined that environmental and social factors such as diet,
addictions, education, family and professional life influenced both physical and
mental aspects of differential ageing phenomena.
Comparing the health of retirees before and after retirement in Greater Bombay,
Desai & Naik (1972) observed that retired persons, who keep fit before and
immediately after retirement, continue to be free from illness during the postretirement period. However, if any illness starts before or just after retirement, it
continues during the post-retirement period too. While Bhatia (1983) observed, in
his study of retired public servants in Rajasthan, that a majority enjoyed good health
prior to retirement, Sati (1988) observed a 100 per cent increase of ailments in his
sample of elderly persons during their post-retirement period. Studying retired male
government employees in Chandigarh, Mishra (1987) found a positive correlation
between health condition and adjustment.
Health insurance is limited to only a small section of people in the
organised sector, and covers less than 10% of the total population.
Compared to their male counterparts, functional impairments like malnutrition,
depression, impaired physical performance and urinary incontinence affected elderly
females more significantly (Shan, Sahu, Sahani & Swain, 2003). Venkateswarlu,
Iyer & Rao (2003) found an important association between age, perceived health,
ailments, status and sources of help in times of difficulty. Dilip (2003) found that
with increasing age, diseases are more likely to increase with widowhood, divorce
and economic dependence. Similarly, in his study of elderly rural females in
Rajasthan, Sharma (2003) found that widowhood, economic dependency, lack of
proper food and clothing, fear of the future, lack of caring and progressive decline in
health made coping with health problems difficult. A study conducted among aged
widows in Haryana (Sushma, Vamani & Darshan, 2004) revealed that the majority
had multiple health problems. Elderly widows from poor socio-economic families
had very poor health status. Adequate financial status, good physical and mental
health, active participation in leisure activities, continuation of hobbies, maintenance
of daily schedule, retaining social networks and assuming social roles influenced
healthy ageing positively (Batra, 2004).
Despite the adoption of various policies, the existing medical facilities in India are
quite inadequate, with no clear strategy or schemes for the development of
healthcare for the elderly. Public healthcare utilisation is very low, particularly in
remote, rural areas. Poverty, illiteracy, general backwardness and adherence to
superstitious beliefs for curing illnesses and diseases may be the cause. Analysing
healthcare facilities and its utilisation, Upadhyay had raised doubts as early as 1960
regarding India’s ability to afford health services for the elderly population.
According to Sahni (1982), health policy should be an integral part of health
services for them.
Public health in our country is under the purview of states with supplementary
inputs from the Centre. The healthcare system includes public health facilities like
teaching hospitals, secondary level hospitals, first-level referral hospitals
(community health centres or rural hospitals), dispensaries, primary health centres,
sub-centres, health posts and public facilities for selected occupational groups.
Existing public health infrastructure, such as consumables, equipment and essential
drugs, is far from satisfactory. The presence of medical and paramedical personnel is
often much less than prescribed.
“The National Rural Health Mission document (2005-2012) has articulated
the commitment of the Government to raise public spending on health from
the existing 0.9% to 2-3% of GDP.” – NRHM
Bakshi (1987) felt that geriatric wards, outpatient units and special counters should
be set up in hospitals. Bose (1988) also suggested creating mobile geriatric units and
special counters (or days on which they can be treated) in general hospitals for the
elderly. At present, only one hospital in India has separate facilities for senior
citizens. But it is proposed that all central government hospitals will have an
exclusive outpatients department and general ward for geriatric patients (Times of
India, 2005).
Less than 20 per cent of the population seeking outpatient services and less than 45
per cent seeking indoor treatment avail of services in public hospitals [MOHFW
(Ministry of Health and Family Welfare)]. The private health sector (profit or nonprofit) is more dominant with 50 per cent of the people seeking indoor care and
around 60-70 per cent seeking outpatient or ambulatory care [WHOSEA (World
Health Organisation regional office for South-East Asia)].
While Mehta (1987) suggested a three-pronged approach: i) provision of curative
services ii) legal protection and iii) health education to take care of the medical
problems of the elderly, Siva Raju (1997) stressed the need for medico-social
approaches to study their health issues. Darshan & others (1987) stressed the need
for frequent medical camps for the rural elderly. Commenting on the poor health
facilities existing in rural areas, Gangadharan (2005) observes, “Indian elderly,
especially those in rural areas, have no access to reliable health care, as primary
health centres are not equipped to handle the elderly.”
The disease burden of India’s population is high as 21 per cent of the global disease
burden (WHOSEA). The health needs of the elderly are enormous but,
unfortunately, the financial resources and managerial capacity available to meet
them are inadequate.
POLICY PERSPECTIVES
National Policy on Older Persons (1999) states that, “it will be necessary to
have 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.”
National Population Policy (2000) states that, “promoting old age health
care and support will, over time, also serve to reduce the incentive to have
large families… It has become important to build in geriatric health concerns
in the population policy.”
National Health Policy (2002) expresses the view that, “it is unnecessary to
labour the point that under the umbrella of the macro policy prescriptions in
this document, Governments and private sector program planners will have
to design separate schemes, tailor-made to the health needs of women,
children, geriatrics, tribals and other socio-economically underserved
sections.”
Despite the adoption of various policies, no clear policy or strategy exists
PROBLEMS
Concerted efforts made by researchers have led to a better understanding of ageing
issues. There is more awareness with regard to psycho-social, economic and health
issues of the elderly, profiles of beneficiaries under various programmes and
schemes such as old-age pensions and old-age homes. The diversity that has
emerged in the ageing process necessitates our research efforts to focus on different
ageing issues in society. This will ultimately promote the development of effective
age-related policies and programmes.
(i) Issues
“Age does not matter if the matter does not age.” – Carlos Pena Romulo
A majority of the studies view the elderly as passive receivers of care.
The issues related to the urban male elderly, comprising mostly retirees/
pensioners, are highlighted in the studies conducted so far. In these studies,
the focus on elderly living in rural and tribal communities is inadequate.
The problems of vulnerable elderly like widowed females, disabled, fragile
older persons and those from the unorganised sector are inadequately
covered.
Health problems are mostly assessed on the basis of the subjective
perception of the elderly. Considering their low socio-economic status, high
illiteracy and inadequate knowledge of diseases, medical care and health
issues, health problems perceived by them are mostly underrated and need a
more comprehensive analysis.
The issue of productive ageing, which highlights their contribution in the
family and the community, is grossly neglected in the studies.
Various systems of medicine like Ayurveda, Homeopathy, Naturopathy and
Yoga are under-utilised by people in general and the elderly in particular.
Unfortunately, inadequate effort is made to understand the factors
contributing
to this.
The socio-economic, psychological and health conditions of the elderly are
interlinked with other dimensions of their daily lives. A holistic assessment
of all these dimensions is grossly neglected in assessing their living
conditions.
Attempts are largely made in understanding the socio-economic,
psychological and health status of the elderly. However, there are negligible
efforts to know the determinants.
(ii) Methodologies
Old age should be viewed from the participation of the continuity of roles
and functions than from the perspective of disengagement or withdrawal.
Most earlier studies have limitations in view of their focus on only some specific
segments of the elderly population. A majority of these studies were based on
sample surveys only among particular strata of elderly population because of easy
availability and convenience. In addition, the studies were mostly localised.
Most studies conducted to assess various issues of the elderly are exploratory
and descriptive.
Surveys focused mostly on male retirees/ pensioners, mainly in urban areas.
The elderly residing in rural and tribal areas were inadequately covered in
these studies.
A majority of the surveys used questionnaires/interview schedules to assess
various issues of the elderly. Other types of instruments that could provide
relevant information more comprehensively were not considered adequately.
Health status of elderly was assessed on the basis of their subjective
perception. An objective assessment, based on physical examination by
trained medical professionals was almost non-existent.
The assessment of status of the elderly was mostly based on the data
obtained directly from them. Spouses and other caregivers in the family were
not covered, which led to inadequate understanding of the situation.
A majority of the studies are based on sample surveys, with a small sample
of elderly population residing in a particular geographical location.
Analysis of the data related to elderly issues is mostly through simple
statistical tools and lacks rigorous statistical treatment.
RESEARCHERS’ VIEWS
“Researchers have voiced their views on the current state of research on
ageing studies.” – I J Prakash (Ed, 2005)
“Most research is piece-meal, with hardly any ageing perspective in the
design. Need-based studies that critically analyse the problem and suggest
intervention methods are almost non-existent.” – Indira Jai Prakash (1999)
“It is apparent that many studies have drawbacks of one type or another.
Psychosocial gerontology consists of data collection that uses schedules,
questionnaires or tests. Strict standardisations of these procedures is difficult,
but nevertheless is important.” – P V Ramamurti (2005)
“A review of the studies shows that these researches appear to have been
influenced to a large extent by theoretical perspectives, conceptualisation and
paradigms arising from the works of western scholars. Hardly any efforts
seem to have been towards indigenisation.” – Arun P Bali (2005)
SOLUTIONS
A comprehensive care package that includes promotive, preventive, curative
and rehabilitative services in the area of health needs to be worked out for
holistic promotion of health among the older persons.
The socio-economic profiles of the elderly population are undergoing a change and
many elderly persons want to lead an active life of fulfilment for themselves, their
families and the community. This resource group of people can make valuable
contributions if policies and programmes are developed for their integration into the
development process.
(i) Priority Issues
Following are some of the priority issues for research on ageing:
In recent years, India has undergone enormous changes on account of
increased urbanisation, industrialisation and globalisation. Hence surveys to
assess their impact on the living conditions of the elderly are vital.
Studies are needed on structural analysis of social networks and social
support systems and care of the elderly.
The high vulnerability of elderly females underlines the need to conduct
studies on this growing segment of the population.
The large number of rural elderly with their distinct problems makes
focusing on this segment of the population very important.
The effect of migration of young members on their ability to take care of
their elderly family members needs to be examined.
Research should focus on strengthening inter-generation bonds in order to
enhance the overall quality of life.
Studies should identify feasible and appropriate community-based support
programmes such as day care and interactive centres in the neighbourhood
and community. This would minimise social isolation of the elderly.
The concept of ‘life-span approach’ and its links with socio-economic,
psychological and health status of the elderly needs to be researched
thoroughly.
An understanding of various determinants of the status of the elderly and
variations across different socio-economic settings is essential.
The impact of major health problems like HIV/AIDS, psychiatric disorders,
etc on older people needs to be assessed.
The link between nutritional status and health status of the elderly is a
growing area and research in this area needs to be carried out.
The efficacy of primary healthcare in the context of rural elderly needs to be
explored in greater detail.
The complexity of issues associated with the definition, measurement and
identification of factors contributing to elder abuse necessitate thorough
research.
Social and ecological factors in a society as large and complex as India needs
to be explored to reveal diverse personal adjustments of the elderly. An
assessment of varied determinants of successful ageing should assist in
designing provisions congruent to their specific needs.
The profiles of various organisations associated with care of the elderly in
different geographical locations, along with an assessment of their perceived
strengths and inadequacies need to be studied to initiate a network process.
Elder abuse is a growing problem, the dimensions of which goes beyond
mere physical abuse.
(ii) Methodological Approaches
“The golden age is before us, not behind us.” – St. Simon
Together with the high growth rate of the elderly population, there have been rapid
changes not only in their profiles, but also their personal, familial, neighbourhood
and societal environment. This intensifies the need to evolve alternative approaches
and methodological refinements for studying issues related to ageing.
Following are some of the methodological issues that require the attention of
researchers, policy makers and others involved with ageing issues:
Ageing needs a multi and inter-disciplinary perspective. The development of
social gerontology reveals that disciplines like sociology, demography,
psychology, anthropology, geography, social policy and administration, as
well as varied professional training like social work, nursing and clinical
psychology, focus on various ageing issues. However, no single disciplinary
focus gives a holistic understanding. So approaches to understand these
issues from a multi and inter-disciplinary perspective need to be initiated. A
combination of qualitative and quantitative approaches will also help to
acquire a more comprehensive understanding.
The elderly are a heterogeneous lot. Variations in their living situations need
to be viewed vis-à-vis factors like age, gender, marital status, region,
educational status and occupational status. Considering their heterogeneity,
proper stratification of the elderly is required so that meaningful conclusions
are drawn based on findings emerging from studies on the elderly.
Most studies conducted so far on the elderly in India are exploratory and
descriptive. However, a proper understanding of various explanatory factors
influencing living conditions of the elderly, as well as their perceptions and
attitudes on various issues, require rigorous explanatory studies.
Wide variation in levels of development and socio-economic status of people
living in different geographical regions make national level studies on the
elderly essential. A more realistic countrywide picture can be assessed based
on such studies.
Cohort studies, multi-generational studies and longitudinal studies need
consideration.
The number of economically independent elderly with the ability to
contribute to family and society is growing. Studies on various issues related
to productivity of ageing, with success stories highlighted, are needed.
Family support systems like caregivers and social networks also need to be
emphasised in studies on ageing. Coverage of such support systems and
social networks will help comprehensively to understand ageing issues.
Most ageing issues are closely inter-linked with earlier stages of life. Hence,
studies on perspectives like life-long development are important in
understanding the elderly issues.
A holistic attempt is required in the gerontological research. Our focus on
alternative approaches, change in methodologies, improved definitions,
appropriate tools and sophisticated statistical techniques for analysing data
needs revision.
Quality of life, well-being, healthy ageing, successful ageing, productive
ageing and active ageing are issues of the elderly that require wider links and
greater understanding. For better comprehension, there is a need to visualise
these concepts and to evolve composite indices, with due coverage of the
complex dimensions.
In order to sharpen trends in the findings and draw more meaningful
conclusions, data on ageing issues need to be analysed by controlling factors
like gender, age, class and other relevant characteristics of the elderly.
Consolidation and amalgamation from multiple sources and links of
databases and re-analyses of existing data are necessary. Analyses of both
secondary and primary data need to be attempted, wherever necessary, which
in turn will help to focus on ageing issues, both at macro and micro levels.
Training in the field of geriatrics and gerontology for para-professionals and
other medical staff needs to be framed. This necessitates adequate empirical
database through research.
Understanding various issues of the elderly within the total framework of
their living conditions is important. This will be more satisfying in
understanding their problems.
Areas for collaboration between public and private initiatives for improving
the quality of life of the elderly need to be researched.
MESSAGE FROM HARMONY
Harmony has endeavoured to develop the research agenda for understanding issues
related to our elderly more comprehensively. The following measures have been
suggested for its effective implementation:
Evolve appropriate methodologies in social research to enable creation of a
society where elderly are partners in development.
Adopt alternative and innovative methodologies in health research to make
equitable, affordable and quality healthcare accessible to the elderly
population.
Promote regular and greater interaction among researchers, policy planners,
community workers and service providers associated with ageing issues.
Disseminate the findings of the studies on ageing issues not only among
researchers, policy makers, organisations/associations involved with various
issues of ageing, but also among the wider community. This will ensure that
the importance of research and its findings are appreciated.
“If you carry your childhood with you, you never become older.”
– Abraham Sutzkever
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ABOUT HARMONY
Harmony, founded in 2004, is a social initiative of the Dhirubhai Ambani Memorial
Trust formed by the family of Dhirubhai H Ambani (1932-2002), founder-chairman
of the Reliance Group. Dhirubhai Ambani believed that each individual, irrespective
of age, has an infinite source of energy and, given the proper environment, will
contribute to society. His vision is the foundation on which Harmony has initiated
multi-dimensional activities for senior citizens. Harmony sees India’s elderly as
‘Silver Citizens’, glowing and proud, and seeks to help them retain their dignity and
sustain their sense of pride and self-esteem, with a view to improve their quality of
life.
At present, the Harmony Initiative has three facets:
Harmony, the magazine
The Harmony Interactive Centre for silver citizens, in South Mumbai
www.harmonyindia.org, the portal
The Harmony Interactive Centre, operational since May 2004, provides a unique
opportunity for Silvers to interact with their peers in a space of their own and
experience life anew. It also aims to educate the general public about issues
pertaining to the elderly. Since its inception, the centre has become an extension of
the lives of members. This is reflected in their relationships with their own families
and a general improvement in their overall wellbeing. The centre offers a broad
spectrum of activities and programmes, ranging from yoga, laughter club sessions
and group therapy to talks on spirituality, music and dance, festival and birthday
celebrations and picnics. Over the next few years, more such centres will be
established to further the vision of Harmony.
The monthly magazine Harmony-Celebrate Age, launched in June 2004, is the
national voice of silver citizens with a motivational and upbeat tone. Though the
magazine is targeted at people over 50, it’s a great read for the entire family. It
includes inspiring profiles, in-depth features, national and international news, selfhelp sections and columns on subjects like finance, yoga and legal aid. From health,
lifestyle and travel to technology, books and leisure, the magazine has it all. The
package is stylish and reader-friendly and guarantees food for thought and value for
money.
The paperless medium www.harmonyindia.org is positioned as the future face of
Harmony. The portal aims to create networking and awareness about the needs of
the elderly, and highlight the resources and opportunities at hand for seniors in India
and their NRI friends and counterparts overseas. It reflects the overall image of
Harmony as a single window information centre, a virtual platform created to reach
out to people from all strata of society globally and an opportunity to voice opinions
for a better tomorrow. It is widely viewed both nationally and internationally.
The Harmony Initiative intends to promote sound and forward-looking strategies
and mechanisms to enhance the abilities and participation of silver citizens in the
overall development of society. In this regard, we are in the process of initiating
research and training programmes with a view to strengthen these components in the
overall framework of ageing issues. The present report, Ageing in India in the 21st
century: A Research Agenda (Priority Areas and Methodological Issues)-Series I, is
an important step in this direction.