SENIOR CARE

REFORMS IN INDIA

Reimagining the Senior Care Paradigm

A POSITION PAPER

FEBRUARY 2024

Senior Care Reforms in India – Reimagining the Senior Care Paradigm: A Position Paper

Publisher

NITI Aayog Government of India, Sansad Marg, New Delhi–110001, India Year of Publication: 2024

Language: English

Authors

NITI Aayog

Dr. K. Madan Gopal Ms. Rishita Mukherjee Dr. Shobhit Kumar Ms. Shrestha Hazra

IPE Global

Ms. Aali Sinha

Ms. Dipika Joshi Mr. Himanshu Sikka

Disclaimer

The report titled “Senior Care Reforms in India – Reimagining the Senior Care Paradigm: A Position Paper” relies on secondary sources and information obtained from discussions and deliberations with different stakeholders. NITI Aayog wishes to emphasize that while every effort has been made to present accurate and up-to-date data, NITI Aayog does not guarantee the accuracy of the information and does not accept responsibility for the consequences of using this data.

NITI Aayog disclaims any legal liability for the accuracy or inferences drawn from the material contained in the document or for any consequences arising from the use of this material. Reproducing any part of this report, whether electronic or mechanical, is strictly prohibited without prior permission or intimation to NITI Aayog. Users are encouraged to seek permission for reproduction through official channels to avoid any legal implications.

Contents

Message, Vice Chairman, NITI Aayog �� v Message, Member Health, NITI Aayog �� vii Foreword, CEO, NITI Aayog �� ix Abbreviations �� xi EXECUTIVE SUMMARY �� xiii SECTION 1: SENIOR CARE – AN OVERVIEW �� 1

1.1 Background……………………………………………………………………………………………………………………………..1 1.2 Key Trends……………………………………………………………………………………………………………………………..6 1.3 Market Size and Growth Potential ………………………………………………………………………………….. 15 1.4 Efforts in Senior Care ……………………………………………………………………………………………………….20 1.5 Key Issues and Challenges……………………………………………………………………………………………….26

SECTION 2: SENIOR CARE TRANSFORMATION – SERVICE DELIVERY PRIORITIES �� 37

2.1 Health – Comprehensive and Integrated Senior Care Package ……………………………. 38 2.2 Social Empowerment and Inclusion………………………………………………………………………………42 2.3 Economic Empowerment and Inclusion……………………………………………………………………….43 2.4 Digital Empowerment and Inclusion……………………………………………………………………………..45

SECTION: 3 WAY FORWARD��47

3.1 Efforts to Ensure Health Empowerment and Inclusion……………………………………………….48 3.2 Efforts to Ensure Social Empowerment and Inclusion ………………………………………………54 3.3 Efforts to Ensure Economic Empowerment and Inclusion ………………………………………. 56 3.4 Efforts to Ensure Digital Empowerment and Inclusion …………………………………………….. 57 3.5 Engaging the Private Sector and CSR Avenues in Increasing Coverage………………..59 3.6 Fueling Innovations ………………………………………………………………………………………………………….60

ANNEXURES��61

Annexure 1: Concept of ageing and senior care…………………………………………………………………61

Annexure 2: Private insurance products for seniors ………………………………………………………… 63

Annexure 3: Key learnings from across the world…………………………………………………………….66

Annexure 4: Existing package of services at various levels for geriatric care in india under the national program for the health care of the elderly……………………………………….79

Senior Care Reforms in India i

Annexure 5: Schemes, programs, and activities of Ministries and Departments of the Government of India for the welfare of the senior citizens……………………………………………… 81

Annexure 6: Landscape of NGOs, private sector, and industry associations working in senior care………………………………………………………………………………………………………………………………..99

Annexure 7: Technology for senior care …………………………………………………………………………… 105 Annexure 8: Existing landscape of training and certification courses in geriatrics….. 107 Annexure 9: Nutritional requirements of the elderly………………………………………………………109 Annexure 10: Vaccination guidelines for the elderly………………………………………………………….111

REFERENCES �� 112 LIST OF CONTRIBUTORS �� 118 LIST OF TABLES

Table 1.1. DALYs rate per 100,000 population

Table 1.2. Major Trends in the Health Domain

Table 1.3. Major Trends in the Social Domain

Table 1.4. Major Trends in the Economic Domain

Table 1.5. Major Trends in the Digital Domain

Table 1.6: Package of Services Provided at Various Levels Under National Programme for the Health Care of Elderly (NPHCE)

Table 2.1. Service Delivery Priorities for Seniors

Table 3.1. An Indicative List for Healthcare Needs Assessment Table 3.2: An Indicative List for Social Needs Assessment Table 3.3: An Indicative List for Financial Needs Assessment Table 3.4. An Indicative List for Digital Needs Assessment

LIST OF BOXES

Box 1: Key Findings from the Longitudinal Ageing Study of India (LASI)

Box 2: Senior Care Support Framework in India

LIST OF FIGURES

Figure 1A. Population by broad age groups in percentage, India, 1950–2050 Figure 1B. Life expectancy and total fertility rate, India, 1950–2050

Figure 2. Snapshot of the silver economy

Figure 3. Digital Care Ecosystem

Figure 4. Journey of senior care policy in India

Figure 5. Key challenges and issues around senior care in India

Senior Care Reforms in India

Figure 6. Healthy and inclusive ageing through convergence among stakeholders Figure 7. Inter-convergence among various stakeholders for senior care

Figure 8. Workforce required for senior care

Figure 9. Capacity building for medical personnel

Senior Care Reforms in India iii

iv Senior Care Reforms in India

Senior Care Reforms in India v

vi Senior Care Reforms in India

Senior Care Reforms in India vii

viii Senior Care Reforms in India

Senior Care Reforms in India ix

x Senior Care Reforms in India

Abbreviations

ADL Activities of Daily Living

AI Artificial Intelligence

AIC Agency for Integrated Care

AISCCON All India Senior Citizens’ Confederation

ASLI Association of Senior Living India

BMR Basal Metabolic Rate

BPL Below Poverty Line

BRICS Brazil, Russia, India, China, South Africa

CAGR Compounded Annual Growth Rate

CCRH Continued Care Retirement Home/ Housing

CHO Community Health Officer

CII Confederation of Indian Industry

CSO Civil Society Organisation

CSR Corporate Social Responsibility

DALY Disability Adjusted Life Years

DOSJE Department of Social Justice and Empowerment

EAR Estimated Average Requirement

IADL Instrumental Activities of Daily Living

FICCI Federation of Indian Chambers of Commerce and Industry

GDP Gross Domestic Product

GHE Government Health Expenditure

GST Goods and Services Tax

HRH Human Resources for Health

HWC Health and Wellness Centre

IC Intrinsic Capacity

IGNOAPS Indira Gandhi National Old Age Pension Scheme

IoT Internet of Things

IPOP Integrated Program for Older Persons

IRDA Insurance Regulatory and Development Authority of India

LTC Long Term Care

LTCI Long Term Care Insurance

ML Machine Learning

MO Medical Officer

MoHFW Ministry of Health and Family Welfare

MoSJE Ministry of Social Justice and Empowerment

Senior Care Reforms in India xi

MSDHS Ministry of Social Development and Human Security

MWPSCA Maintenance and Welfare of Parents and Senior Citizens Act

NALSA National Legal Services Authority

NAPSrC National Action Plan for the Welfare of Senior Citizens

NCD Non-Communicable Disease

NCOP National Council of Older Persons

NEA New Enterprise Allowance

NGO Non-Governmental Organization

NHA National Health Accounts

NHRC National Human Rights Commission

NHS National Health Service

NMT Nightingales Medical Trust

NPHCE National Program for the Health Care of the Elderly

NPOP National Policy on Older Persons

NSAP National Social Assistance Programme

NSSO National Sample Survey Office

OECD Organization for Economic Co-operation and Development

OOPE Out-of-Pocket Expenses

OPD Out Patient Department

PMJAY Pradhan Mantri Jan Arogya Yojana

PMVVY Pradhan Mantri Vaya Vandana Yojana

RDA Recommended Daily Allowance

REIT Real Estate Investment Trusts

RMNCH Reproductive, Maternal, Newborn, Child, and Adolescent Health.

RVJSY Rashtriya Varisth Jan Swasthya Yojana

RVY Rashtriya Vayoshree Yojana

SAC Senior Activity Centres

SAGE Senior Ageing Growth Engine

SASSA South African Social Services Agency

SCA Senior Citizen Associations

SCCT Senior Citizens Council of Thailand

SDG Sustainable Development Goals

SOP Standard Operating Procedures

SPICE Singapore Program for Integrated Care for the Elderly

UNFPA United Nations Fund for Population Activities

UNIDOP United Nations International Day of Older Person

WHO World Health Organization

xii Senior Care Reforms in India

Executive Summary

Population ageing is a global phenomenon, and the number of people over 60 years of age has been rising rapidly across the world. India, too, is witnessing an exponential growth in the number and proportion of elderly people, coupled with a decreasing fertility rate (less than 2.0) and increasing life expectancy (more than 70 years). The elderly in India currently comprises a little over 10% of the population, translating to about 104 million, and is projected to reach 19.5% of the total population by 2050.

This phenomenon of population ageing impacts all aspects of society and has numerous health, social, and economic implications, including changes in labour and financial markets, shifting disease burden, rising dependency ratios, evolving family structures, and altered consumption patterns. Moreover, medical expenses are more than double for this population segment as older people are likely to consume more healthcare services. While catering to the needs of the elderly population of this size is challenging, it also presents an opportunity for the growth of the senior care industry, which is presently estimated at USD 7 billion (` 57,881 crore).

The Longitudinal Ageing Study of India (LASI) 2021 report, a full-scale national survey and a seminal study on the status and determinants of the ageing population in India by the Ministry of Health & Family Welfare, highlights that 75% of the elderly have one or more chronic diseases. 24% of the elderly have at least one Activities of Daily Living (ADL) limitation, and 48% reported at least one Instrumental Activities of Daily Living (IADL) limitation. One in three reported having depressive symptoms, and 32% reported low life satisfaction. In terms of social protection, only 18% reported being covered by any health insurance, 28% are aware of any concession for senior citizens, and 24% reported problems in providing documents to avail services. The report highlights that 70% of the elderly population is dependent for everyday maintenance, and 78% is living without any pension cover.

The senior care system faces many challenges due to the lack of a comprehensive, integrated policy for care and support. There are gaps in infrastructure and capacities necessary for supporting the health and welfare of the elderly, evidence-based knowledge repositories for geriatric illness management, enabling frameworks and monitoring mechanisms, and emergency response systems. Other factors that need to be addressed include a fragmented and narrow social support system, inaccessible physical infrastructure, and inadequate R&D activities. A rising trend of nuclear families is also an important attribute for diminishing traditional family support systems. In addition, inadequate financial security nets and deficient financial planning for senior citizens are areas of concern, and they also tend to fall prey to financial abuse and fraud. Digital inequities have emerged as a significant challenge for seniors, as witnessed during the COVID-19 pandemic and lockdown period. There is a knowledge gap in awareness about the available welfare support provided by Government and other agencies, among the elderly and their caregivers. At present, senior care services largely consist of facility-based medical care only. Non-medical care and home-based senior care, in the field have received minimal attention.

Senior Care Reforms in India xiii

Recognizing the challenges and opportunities associated with population ageing, the Government of India has been implementing various initiatives, policies, and action plans to address this demographic shift. The Constitution of India, under its Directive Principles of State Policy, envisages protecting the rights of the citizens of India, which includes the senior citizens as well. Further, the policy response has evolved over the last two decades, guided by multiple national and international initiatives and frameworks. The Ministry of Social Justice and Empowerment (MoSJE) is the nodal ministry responsible for the welfare of senior people in India. It has led the overall policy and program development for senior people in close collaboration with line ministries such as Finance, Health & Family Welfare, Ayush, State Governments, NGOs, civil society, and the private sector.

In an attempt to develop a holistic understanding of the elderly population and their requirements, several definitions and concepts have emerged in recent years. However, there is a need to develop a conceptual framework – based on the literature review and national and international experiences – in order to deliver a comprehensive response to the elderly that addresses the various limitations, including functional mobility and capacities. This report, therefore, categorizes the specific interventions needed in terms of empowerment, service delivery, and their inclusions under four core areas: Health, Social, Economic/ Financial, and Digital.

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Priority Areas of Service Delivery for Senior Care

Health empowerment and inclusion can be achieved by promoting health literacy among seniors as well as their caregivers, strengthening geriatric healthcare within the existing healthcare system, and making special provisions for seniors. This will encompass Comprehensive Primary Healthcare Services through the Ayushman Bharat – Ayushman Arogya Mandir (Health and Wellness Centres), strengthening healthcare infrastructure with a focus on needs of elderly, expanding tele-consultation services, enhancing the skilled workforce for the elderly, and capacity building of existing workforce. It is also important to strengthen mental health services, emergency response infrastructure and services, and address nutrition-related issues through initiatives like Poshan Abhiyaan for Senior Citizens. Integrating Ayush systems for senior care through preventive, wellness, and therapeutic interventions has great potential to address their health issues in a holistic manner.

For ensuring social inclusion and empowerment, specific actions such as creating awareness to sensitize the larger community on the needs and challenges experienced

xiv

Senior Care Reforms in India

by the elderly, and establishing peer support groups are needed. Empowerment of the elderly will also come through awareness of existing legal safeguards, welfare schemes and ensuring legal reforms like strengthening the existing Welfare and Maintenance Act, and disposal of pending cases in maintenance tribunals in a time-bound manner. Reforms in the elderly-friendly living/housing sector and senior care homes are required, as also developing a ‘one-stop’ centralized portal for senior care and promoting care economy.

Specific actions required to ensure financial empowerment and inclusion include reskilling the elderly population, increasing coverage of public funds and infrastructure, and mandatory savings plans for the affording segment. Reverse Mortgage mechanism to increase liquidity for seniors, and tax and GST reforms on senior care products to increase the ease of adoption and safeguard the elderly population from the financial burden. Encouraging the private sector to design targeted and comprehensive geriatric health insurance products, and increasing liquidity and capital allocation to the senior care industry will help in addressing the needs of the affording segment. Protection for the elderly from financial fraud by increasing awareness and literacy needs to be ensured.

Similarly, specific interventions for ensuring digital inclusion include improving access to digital devices for seniors by making them affordable, focusing on increasing digital literacy, and harnessing the potential of modern technology.

This document attempts to highlight the landscape of senior care services available, as well as the gaps and challenges in the current senior care ecosystem. It strives to push the frontiers of senior care by recognizing the evolving medical and non-medical needs of seniors, thus envisioning a multi-pronged strategy for designing an effective and synergized senior care policy.

Senior Care Reforms in India xv

xvi Senior Care Reforms in India

SECTION 1:

SENIOR CARE – AN OVERVIEW

1�1 Background

According to the World Health Organization’s (WHO) World Report on Ageing and Health (2015), the percentage of people worldwide who are 60 or older is expected to nearly double between 2015 and 2050, from 12% to 22%, with significant ramifications for socio- economic structures and healthcare systems. As the population ages at an increasing rate, countries worldwide recognize the need to change their perspective on ageing and shift their focus to the needs of older adults.

In India, senior citizens, i.e. people aged 60 years and above, currently comprise a little over 10% of the population, translating to about 104 million. The United Nations Population Fund (UNFPA) projects that this population, which will make up 158 million people by 2025, is the one that is ageing at the fastest rate. By 2050, the elderly population is projected to rise to 319 million (19.5% of the total population), as shown in Figure 1A� Further, the total dependency ratio, which stood at 56.92 in 2020, is projected to decrease steadily till the 2025 due to the rise in the percentage of the working-age population; but it is expected to rise again to touch 61.22 by 2050.

Figure 1A� Population by broad age groups in percentage, India, 1950–2050

Source: United Nations (2019), World Population Prospects, the 2019 Revision, United Nations, New York

These statistics and trends are largely a result of declining fertility rates and increasing life expectancy rates, as shown in Figure 1�B. The total fertility rate stood at 5.9 in 1950 and

Senior Care Reforms in India 1

declined to 3.4 in 2000. Currently, the fertility rate is 2 as per latest SRS data. Additionally, the life expectancy at birth rose from 35.8 in 1950 to 62.5 in 2000 and is further projected to rise to 75 by 2050.

Figure 1B� Life expectancy and total fertility rate, India, 1950–2050

Source: United Nations (2019), World Population Prospects, 2019 Revision, United Nations, New York‘

The statistics stated above clearly indicate a demographic shift that will impact all aspects of society. While we have identified the future vulnerabilities such as rising dependency ratios, shifting disease burden, and increased number of senior parents to care for, little is known about the magnitude and socio-economic implications of these vulnerabilities. It is therefore necessary to comprehend the impact of ageing on our society to adapt, alter, and strengthen our infrastructure capacities as well as response mechanisms for the overall welfare of the elderly.

Box 1: Key Findings from the Longitudinal Ageing Study of India (LASI)

The Longitudinal Ageing Study of India (LASI) launched in 2016 by the Ministry of Health and Family Welfare is a full-scale national survey and a seminal study on the status of the ageing population in India. The report has provided several valuable insights into the process and impact of ageing in India. The key highlights of the report are given below.

Dimensions

Key Findings

Health

Physical Health

• Every fourth Indian over 60 years and every fifth Indian over 45 years reported having poor health

• 75% of the elderly have one or more chronic diseases

• 40% of the elderly have one or other disabilities

• 1 in 4 has some kind of multi-morbidity

• Diabetes is more common among senior citizens in urban India

• Cancer prevalence is on the rise and is higher in urban India.

Mental Health

• Around 20% of the elderly in India have mental health issues

• The prevalence of probable depression among the elderly is ten times higher than the self-reported prevalence of diagnosed depression,

implying a greater burden of undiagnosed depression

Senior Care Reforms in India

Health

• Almost a third of the elderly population exhibits depressive symptoms

Functional Abilities

• 11% have some form of impairment

• 24% of seniors have limitations in activities of daily living

• 58% have difficulty stooping, climbing, or kneeling

• 43% use an aid or supportive device

Access to Healthcare Facilities

• 7% experience hospitalization

• 60% received OPD care (one year before the LASI survey)

Social

Demography-specific

• 12% of the total population consists of elderly people and is projected to reach 319 million by 2050, growing at a rate of around 3% per year

• The overall sex ratio in the elderly population is 1065

• 58% of the total number elderly are women, out of which 54% are

widows

• The overall dependency ratio is 62 per 100 working-age population

Living Pattern–related

• Approximately 28% of the elderly are living with children without a spouse

• Overall, 6% live alone, and 09% of women elderly live alone • 7 out of 10 elderly persons reside in rural areas

Diet

• Food insecurity is increasing among India’s elderly

• Almost 6% of people in India over 45 years ate smaller portions or

skipped meals, and 5.3% did not eat, even when they were hungry

Knowledge and Awareness

•

Low awareness levels among the elderly regarding welfare provisions available for them. For instance:

– 12% are aware of the Maintenance and Welfare of Parents and Senior Citizens Act 2007

– 28% aware of any kind of senior concession

– 50%, 44%, and 12% are aware of IGNOAPS, IGNWPS, and Annapurna

Scheme, respectively

– 24% experienced problems in providing documents

Living Conditions and Quality of Life

• 32% of the elderly have low life expectations

• At least 5% of India’s elderly population reported having experienced

abuse which can be physical, sexual, psychological, or financial

• Mistreatment is more common among elderly women and those living

in rural areas

Senior Care Reforms in India 3

Financial & Economic

Work

• Male senior citizens worked at a rate of approximately 50%, while female senior citizens worked at a rate of 22%

• When compared to their urban counterparts, a greater proportion of senior citizens in India’s villages work

Pension

• 78% of the elderly population without a pension

Access to Healthcare Finance

• Only 18% of seniors are covered by Health insurance

• Mean Out of Pocket Expenditure in private health facilities is `31,933

(last in-patient visit)

• Health-related expense is the most common cause of indebtedness

(26%) in urban India

Cost of Ageing

• MPCE (monthly per capita consumption expenditure) of a household with at least one elderly is `2,948 compared to households without an elderly member (`3,001)

• MPCI (monthly per capita income) of a household with at least one elderly person is lower than households without an elderly member (`3,568 vs. `4,098).

Digital Wellbeing

Access to mobile phones

• While mobile phone is the most prevalent consumer durable, with nearly 87% of Indian households having access to it, their access, use, and utility for the elderly people is still debatable.

In India, the challenges associated with population ageing are further exacerbated by the lack of affordable healthcare services, shifting disease burden, evolving nuclear family structures, and altered consumption patterns.

India will have 319 million older adults by 2050, accounting for 20% of the total population, putting additional strain on India’s already overburdened healthcare system. Nearly one-half (45%) of India’s disease burden is projected to be borne by older adults in 2030, when the population age groups with high levels of chronic conditions will represent a much greater share of the total population.

Further, neuro-degenerative diseases like dementia mostly affect older adults, though it is not a part of normal ageing. According to the WHO, there are approximately 50 million people worldwide, who are living with dementia, and this number is expected to triple by 2050. In India, an estimated 4 million people are living with dementia, and this number is projected to increase to 13.4 million by 2050. The burden of dementia on healthcare systems is substantial, with global costs estimated at US$1 trillion annually. In addition, there is a need to address mental health concerns such as depression and anxiety as well as issues related to mobility and independence, such as fall prevention, assistive technology, and accessible transportation.

As per the Global Health Estimates data of the year 20191, the leading causes of the DALYs lost in the elderly (above 60 years of age) are due to non-communicable diseases like ischemic heart diseases, stroke, and diabetes, which develop mostly due to the consequences of Ageing. Age-

1Global Health Estimates 2019; https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/global-health- estimates-leading-causes-of-dalys

Senior Care Reforms in India

group and disease-wise list of DALYs rate per 100,000 is given in Table 1�1� Table 1�1� DALYs rate per 100,000 population*

Leading cause of DALYs

Age Group (in years)

60-64

65-69

70-74

75-79

80-84

85 & above

Ischemic Heart Disease

11076.98

13569.86

16474.63

19443.18

24934.16

23773.64

Chronic Obstructive Pulmonary Disease

6106.4

9671.94

14718.04

18820.21

27303.22

24022.85

3. Stroke 5811.64 7800.64 9114.14 10597.82 10708.75 10586.64

Diarrhoeal diseases

2637.42

4056.42

6694.12

8951.9

14723.64

17942.45

Diabetes Mellitus

4121.17

4899.1

5496.59

6399.42

7263.73

6348.5

Lower Respiratory infections

1638.76

2550.77

3789.21

4665.7

6591.35

6388.77

Alzheimer’s disease & other dementias

339.18

657.34

1289.25

2424.26

5853.98

11288

* Source: Global Health Estimates 2019; (https://www�who�int/data/gho/data/themes/mortality-and-global-health-estimates/global-health-estimates- leading-causes-of-dalys)

Moreover, many seniors, especially women and those residing in rural areas, face challenges in accessing healthcare due to the limited availability of geriatric specialists and services, high out-of-pocket costs, and a lack of awareness about age-related health issues. So, healthcare systems will face numerous challenges in providing affordable and accessible healthcare services to older adults because of their diverse physical and mental needs, along with their social and financial challenges.

Apart from the health issues, hygiene related issues also affect the quality of life among the elderly negatively. Maintaining good hygiene is essential for the health and wellbeing of elderly individuals but certain age-related changes can make it difficult for them to maintain proper hygiene. Though open defecation was a major concern earlier, the steps taken by the government have curtailed the issue to a large extent, but disabled-friendly sanitation facilities are still lacking in most public spaces.

The ageing population also has significant implications for India’s social and welfare system. Many older adults in India rely on their children for financial support and care in their later years. However, with the shift towards smaller nuclear families and increased migration due to work, education, and marriage; the elderly are left behind with scarce or practically no support system.

Further, there are numerous negative stereotypes and stigma associated with ageing in

Senior Care Reforms in India 5

India. Traditionally, ageing was seen as a natural part of life, and the elderly were respected and valued for their wisdom and life experience. However, in recent years, there has been a shift toward a more westernized view of ageing, where ageing is often associated with decline and loss. The elderly are often viewed as a burden and are marginalized in society. This shift may be due to the influence of media and globalization, which have created a culture that values youth and beauty. These negative stereotypes about ageing can have a detrimental effect on the health and well-being of older adults, leading to social isolation, depression, and other health problems.

The economic impact of an ageing population is also a significant concern for India. As the proportion of older adults in the population increases, their contribution to the labour force decreases. Also, the social benefits extended by the elderly population through their unpaid work, which includes care tasks, volunteer activities, etc., are neither recognized nor quantified. Additionally, the shift in consumption patterns, as people age, can significantly impact the demand for goods and services, including housing, healthcare, and social protection. The country’s pension system leaves many older adults without a reliable source of income in their retirement, so it needs to be strengthened and funded with additional resources.

Digital technology has become an essential part of our daily lives, and it has transformed the way we live, work, and interact with others. However, there is still a significant digital divide between different age groups, particularly when it comes to senior citizens. Seniors may face challenges in using digital devices and accessing online services due to physical, cognitive, or socio-economic reasons. According to a survey conducted by the National Sample Survey Organization (NSSO), only 13 % of people aged 60 years or older have ever used the internet. This is significantly lower than the overall internet penetration rate in India, which is around 50%. The reasons for this low rate of internet use among seniors in India include limited access to digital devices, lack of digital literacy, and limited awareness of online services. Thus, there is a growing need to bridge the digital divide for seniors.

To address these challenges, India needs to realign, reorganize, and re-orient its existing policy landscape to map out an effective and efficient senior care ecosystem. This includes various programs and policies that address the specific needs of the ageing population, such as increasing access to affordable healthcare services, strengthening the social welfare system, and promoting economic opportunities to safeguard seniors against economic hardships; in line with the concept of ageing and senior car (see Annexure 1 for details). Additionally, there is a need for increased public awareness and education about the issues facing older adults and the importance of including them in policy decisions.

1�2 Key Trends

The ageing of the population presents unique challenges for various nations and societies. The response to the challenges of population ageing should take into account the realities of each country or region, avoiding a “one size fits all” approach so that active ageing can be encouraged. To do so, it is important to first understand the key trends in the process of population ageing.

The current section highlights the key dimensions and trends observed in the sphere of senior care in India.

Senior Care Reforms in India

1�2�1 Health Domain

The health profile of a nation changes along with changes in the population. Major issues around elderly healthcare have emerged due to population ageing like the rising burden of NCDs, paucity of long-term senior care plans, deficient medical infrastructure, lack of accessible and affordable healthcare, and regional and social inequalities in healthcare.

India’s healthcare programs and policies have prioritized issues like disease control, maternal and child health, and population stabilization for many years. Long-term palliative care and senior care have received little attention. Additionally, geriatric care is still a relatively new area in healthcare and is mainly restricted to cities. So, a majority of countries take a very long time to create adequate healthcare responses and solutions for the ageing population.

To initiate reforms in the elderly healthcare landscape, it becomes important to understand the key trends surrounding it. Table 1.2 presents a brief overview of key trends and figures across various dimensions of Health.

Table 1�2� Major Trends in the Health Domain

Dimension

Key Trend

Key Figures

Remarks

Physical Health

Epidemiological shift indicating a shifting disease burden from infectious diseases to degenerative diseases and NCDs

The prevalence of co-morbidity and multi-morbidity rises with age

Every 4th Indian over 60 years reported having poor health

75% of the elderly have one or more chronic diseases

23.3% of the elderly suffer from multi- morbidity

• Because of increased longevity, many seniors face a higher risk of degenerative diseases, requiring long-term care and support. The de- cline in immunity and age-related physiologic changes further increases the burden of com- municable diseases in the elderly. Increasing incidence of CVD, Hypertension, Cancer, bone/ joint disease, Diabetes mellitus, chronic lung & heart disease, anemia, blindness & low vision, dental issues, and neurological/ psychiatric problems like dementia, Alzheimer’s, and men- tal health diseases such as depression, loneli- ness, etc. is seen among the elderly.

• 1 in 4 has some kind of multi-morbidity i.e. the presence of more than two illnesses in the same person at the same time; complicating their already deteriorating health.

Function- al Capaci- ties

Limitation in Activities of Daily Living (ADL)

and Instrumental Activities of Daily Living (IADL)

Mobility Restrictions

24% of the elderly have

at least one ADL limitation and 48% reported at least one IADL limitation

• A quarter of the elderly reported having at least one ADL limitation, and 14% reported having two or more ADL limitations. Close to half of the elderly reported having at least one IADL limitation and more than a third reported hav- ing two or more IADL limitations. The elderly residing in rural areas, the elderly women, and those who worked in the past but are currently not working, are more likely to have ADL and IADL limitations.

Senior Care Reforms in India 7

Dimension

Key Trend

Key Figures

Remarks

than 50% experience mobility restrictions

• Only 43% of the elderly reported using any aid or supportive devices and the use of such de- vices is higher in the urban areas (59%) than in rural areas (37%); suggesting better access to such assisting devices in urban areas.

Mental Health

A decline in psychological and cognitive capacities among the elderly

Around 20% of the elderly in India have mental health issues

1 in 3 elders over 60 years reported having depressive symptoms

• The prevalence of probable major depres- sion among the elderly is 10 times higher than the self-reported prevalence of diag- nosed depression, suggesting a markedly higher burden of undiagnosed depres- sion. It is higher among women than men and those in rural (9%) than those in ur- ban areas.

• A higher percentage of elderly than older adults (45-59 years) are in the lowest 10th percentile of the composite cognition score; showing a rapid decline in cogni- tion. Gender differences in cognition are very pronounced among the elderly; with over 20% of elderly women falling in the lowest 10th percentile over 7% of men.

Access to Health- care Facilities

Limited focus on senior care and limited healthcare facilities focusing on the elderly

Nearly 28% of the elderly utilized out-patient care and just 8% availed inpatient care3

• Seniors have more hospitalization needs. India’s health infrastructure is already stretched; an increase in senior patients is likely to accentuate the gap further. Further, senior-focused care like geriatric OPD, daycare centers, recreational plat- forms, etc., is mainly available at the ter- tiary level and in urban areas.

• Access to healthcare services can be a challenge for older adults in India, partic- ularly those living in rural areas. As per the National Health Profile, in 2017, there were only 43 physicians per 100,000 popula- tion in rural areas, compared to 118 phy- sicians per 100,000 population in urban areas.

Health- care Finance

Limited healthcare financing for the elderly

Only 18% of people over 60 years are covered by health insurance.

• Medical expenses incurred by seniors are financed primarily out of pocket, and there is an urgent need for increased fi- nancing in senior care. Only 1/5th of the older population (over 45 years) is cov- ered by health insurance, which falls to 18% of the people over 60 years.

• The Government provides subsidies for healthcare through various schemes for seniors, but the coverage is limited to medical care upon hospitalization, limited cover for OPD, physiotherapy, medicines, memory care, home care, home-based palliative care, etc. Although the Ayush- man Bharat Scheme covers all eligible low-income elderly, its utilization is limit- ed. Moreover, coverage of private sector insurance for seniors remains poor.

8 Senior Care Reforms in India

Dimension

Key Trend

Key Figures

Remarks

Geriatric Nutrition

Prevalence of lifestyle-based issues due

to nutritional mismatches among the elderly population

Increased incidence of food insecurity among the elderly

Special and specific needs of the elderly population are largely not recognized

More than 27% of the elderly are underweight, and 22% are overweight/ obese.

4.7% of the elderly are anemic

• Studies have shown that between 50 and 80 years, muscle mass declines by around 30%, and muscle strength reduces by 50%. The BMR is 10-20% lower in older adults com- pared to younger adults. The prevalence of underweight is almost threefold (32%) high- er in rural areas than in urban areas (12%) while overweight (27%) and obesity (12%) are more common among the elderly in ur- ban areas.

• Food insecurity is increasing among India’s elderly population. Almost 6% of people in India aged 45 and above ate smaller por- tions or skipped meals, and 5.3 % did not eat even when they were hungry.

• As the body ages, its ability to absorb es- sential vitamins and nutrients begins to de- crease. At present, no elderly-specific nutri- tion program/scheme is ongoing. Ministry of Social Justice and Empowerment has envis- aged Poshan Abhiyan for the elderly, but it’s yet to be operationalized.

Preven- tive Care

Adult Immunization remains a neglected subject

Predisposition

to a variety of preventable diseases due to the prevalence of co-morbidities and multi- morbidities

Every 2nd person above 60 has one co-morbid condition3

• The risk of severe outcomes from Vac- cine-Preventable diseases like Invasive Pneumococcal Disease or influenza-relat- ed hospitalization in this segment is even higher than the risk for the under-5 popu- lation group. At present, adult immuniza- tion is not yet operationalized in any on- going program at a larger scale.

• The highest burdens of comorbid condi- tions increase the overall risk profile of the population. These comorbid conditions predispose the elderly to many infectious diseases like Pneumonia and Influenza.

Climate Change

Increased vulnerability

due to adverse climate events like pollution, global warming, etc.

India recorded an estimated 31,000 heat- related deaths among people over 65 years in 20182

• The elderly are disproportionately vul- nerable to climate change with a signifi- cant increase in ill health and premature deaths, reduced mobility, social isolation (in some cultures), and poor access to health and social services.

• They are also at an increased risk of wa- ter and food insecurity induced by climate change and adverse climatic events

• Need for focused interventions to address the impact of climate change on the el- derly

1�2�2 Social Domain

The ageing of the population has far-reaching social consequences. India has seen the erosion of social institutions and values due to changing economic structures, urbanization, migration, mobility, and less reliance on traditional sources of income by families. The search for new opportunities has led to redefined social roles, greater economic 2 The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises

Senior Care Reforms in India 9

independence, and nuclear setups. The traditional structures, that once gave meaning to different generations, have evolved and, in some cases, weakened.

Family is the primary and fundamental source of social support for the elderly in India. It is expected to provide adequate support to the elderly when their functional and intrinsic capacities are compromised due to ageing. However, seniors are now caught between changing and eroding traditional joint families. Consequently, the inter-generational cross- learning of experiences, division of labor, social security, and cohesion among different generations have reduced considerably.

In such a scenario, it becomes important to understand the evolving social structures and their impact on the ageing population so that adequate interventions can be made. Table 1�3 showcases some key trends related to the social domain.

Table 1�3� Major Trends in the Social Domain

Dimensions

Key Trends

Key Figures

Remarks

Demography

Rising elderly population due to falling fertility rates and rising life expectancy rates

Increasing dependency ratios

12.8% of the total population comprises people over 60 years3

The total dependency ratio is 60 per 1003

• India’s population is relatively young at pres- ent, however, a substantial decline in fertility rates and death rates indicates an increase in the elderly population in the coming de- cades. Rising life expectancy rates make it important for the government to convert these years into healthy years.

• A high dependency ratio means a higher burden on the economically active popula- tion to support and provide for the econom- ically dependent older population.

Ageing and Gender

A higher percentage of women among

the elderly population

Increased incidence of poverty among elderly females

1065/1000 is the Senior Sex Ratio (Females vs. males)3

Only 10% (rural) and

11% (urban) of senior females are financially independent3

• The sex ratio of the elderly population is on the higher side for females as compared to their male counterparts. Further, the average life expectancy has increased, however, it has not risen equally for males and females. This gap means that India’s older female population is growing faster.

• 2.8 million & 0.8 million senior women live alone in rural and urban areas, respectively4. 54% of women are widows and are at higher risk of social exclusion due to a lack of social and financial security. Poor physical health and the stigma around widowhood further increase their vulnerability.

3 LASI India Report, 2020

4 National Sample Survey Organisation. Morbidity, HealthCare and the Condition of the Aged – NSS 60th Round (January-June)

Senior Care Reforms in India

Dimensions

Key Trends

Key Figures

Remarks

Rural-Urban divide

Increased proportion of the elderly residing in rural areas

71% of elderly persons reside in rural areas

• Out of the total population of the elderly in India, a very high proportion of them reside in rural India. Rural India still lacks medical infrastructure and other basic facilities such as electricity, communication, etc. Further, rural seniors reflect low healthcare utiliza- tion, along with poor coverage of financial cover

Living Patterns

Migration and socio-cultural shift

Loss of family & social support for seniors

Need for senior living communities

6% of the elderly and 9% of the elderly women live alone

19% of the elderly are divorced, separated, deserted, or live alone.

• Globalization and migration of the young- er working population are leading to an in- crease in the number of elderly population living alone, particularly in urban areas. Moreover, there are more elderly women than men who live alone.

• The disintegration of traditional family set- up & shift to nuclear families has reduced the amount of family support, home-based care, and day-to-day psychosocial support to the elderly.

• The COVID-19 pandemic exposed the vul- nerability of seniors living alone & requiring housing support. Moreover, the traditional housing system is unable to cater to the spe- cific needs of seniors, such as fall-resistant flooring, no sharp edges, and required medi- cal facilities closer to the living place.

Life Satisfaction

A decline

in life satisfaction due to decreased engagement with society

Increased likelihood of abuse and ill-treatment in the elderly population

Nearly 32%

of the elderly reported low life satisfaction

5% of the elderly reported to have suffered abuse & about 2/5th of them were ill-treated by their sons, daughters, and sons-in-law, daughter-in-law

• The loss of involvement in important life ac- tivities like work, household management, and decision-making has negatively impact- ed the life satisfaction levels among the el- derly. Further, the debate around population ageing has not focused on the social partic- ipation aspect of ageing. Numbers indicate lower social or community participation amongst the elderly.

• The elderly population is more likely to suffer abuse and ill-treatment because of a decline in their financial status and functional capa- bilities. Abuse and mistreatment are more common among elderly women and those living in rural areas. Caregivers are found to be the primary abusers, making the elderly even more helpless and reluctant to report such incidents.

Senior Care Reforms in India 11

Dimensions

Key Trends

Key Figures

Remarks

Educational Attainments

Low literacy levels among the elderly

More than 55% of the elderly population is illiterate

• The proportion of the elderly population that has never attended school increases with age. A higher proportion of elderly men (65%) attended school than elderly women (35%).

• Literacy levels are higher among older adults living in urban than those living in rural areas. Nearly 60% of older adults from rural areas do not have any formal schooling, compared to 29% of those living in urban areas.

Access to Social Security measures

Low awareness and utilization of social security schemes among the elderly

Only 28% of the elderly aware of any concessions for senior citizens

24% experienced problems in providing documents

• A little more than 50% of the elderly are aware of IGNOAPS (Indira Gandhi National Old Age Pension Scheme) and 44% of IGNWPS (Indi- ra Gandhi Widow Pension Scheme). Aware- ness of the Annapurna scheme is very lim- ited (12%). Further, only 12% of the elderly are aware of the Maintenance and Welfare of Parents and Senior Citizens Act 2007.

• Further, the awareness of social security schemes does not necessarily lead to their utilization due to many reasons. More than a third (35%) of elderly people could not uti- lize these schemes because the process of getting benefits is cumbersome.

1�2�3 Economic Domain

As per the WHO (2002), the overall well-being of older persons depends largely on their economic conditions and work participation, along with their social and health factors.

The ageing of the population has given rise to various economic concerns like increased expenditure on health and long-term care, shortages in the labour force, economic dependence, old-age income insecurity, limited coverage of old-age pensions, and an increased need for social protection. Additionally, loss of employment opportunities and lack of adequate social security measures may push the elderly population into poverty, further limiting their capacity to avail of healthcare services. Such trends may cause an economic slowdown if interventions are not made at the right time. Table 1�4 mentions key economic trends related to population ageing.

Senior Care Reforms in India

Table 1�4� Major Trends in the Economic Domain

Dimension

Key Trend

Key Figures

Remarks

Work Status

The elderly population

is financially vulnerable due to loss of work or poor work opportunities

Need of Silver economy and ‘Grey interns’

Only a little more than one-third (34%) of the elderly are currently working

• Formal work serves as a crucial physical, so- cial, and financial safety net. Loss of work due to ageing or retirement from employment is a critical point in the life of a working individu- al, which causes various socio-psychological and economic changes, and makes them eco- nomically vulnerable and prone to financial shocks.

• Appropriate interventions are required on the part of the government to provide a thrust to the “silver economy,” i.e. economy driven by goods & services demanded by the elderly. Further, work opportunities that can provide a platform for the elderly to use and utilize their experience and expertise in various sec- tors

Financial Status

Increasing financial dependency of the elderly

Increased incidence of poverty among the elderly

70% of the elderly are dependent on everyday maintenance (on family/ pension)5

78% without pension cover

• The dependency ratio to rise from 15.7% to 20.1% over the next decade (2021-31), indi- cating a growing economic responsibility on working Indians.6

• With private cover at 8%, India’s aged popula- tion is at risk of financial vulnerability post-re- tirement7. Low financial security impacts ac- cess, choice, decision-making, and reduced use of healthcare, and it often pushes the el- derly population into poverty.

Economic Cost of Ageing

Significant economic costs associated with population ageing

Health expenditure accounts for 13% of total MPCE

The mean OOPE of the elderly on inpatient care was `8,028 in public facilities and `31, 933 in private facilities

• The financial status of households with at least one elderly member is lower than those without any. The per capita health spending in households with the elderly is higher (`405) than in households with no elderly member (`352). Furthermore, the per capita income of households with an elderly member age is lower (`42819) than households with no elder- ly member (`49174).

• The contribution of medicines to the monthly healthcare expenditure is the highest, i.e., 69%.

• Health-related expenditure is the most com- mon cause of indebtedness in urban areas (26%).

5 https://www.helpageindia.org/wp-content/uploads/2022/06/Bridge-the-Gap-Understanding-Elder-Needs-a-HelpAge-India-2022- report-1.pdf

6 MOSPI, The elderly in India 2021 report.

7 https://www.pfrda.org.in/writereaddata/links/crisil%20pfrda%20report869bc61d-a231-42de-a77c-ff614b0af650.pdf

Senior Care Reforms in India 13

1�2�4 Digital Domain

The digitalization process has left many elderly people excluded from the digital sphere. Although many older adults frequently use ICTs, a majority of them live in rural areas or tier II or III cities and have minimum or no access to such technologies.

The exclusion of elderly people from the digital field is driven by many factors like lack of access to digital devices, lack of digital skills, and deteriorating vision. Moreover, the perception that older people cannot be technologically savvy further excludes them from these new and emerging digital technologies. So, policymakers need to prioritize digital inclusion of the elderly population because digital tools can help senior citizens by helping them reconnect with their friends and family; lowering dependency, raising autonomy, and boosting self-worth and confidence.

The Table 1�5 highlights some key trends related to the digital well-being of the elderly population.

Table 1�5� Major Trends in the Digital Domain

Dimension

Key Trend

Key Figures

Remarks

Digital Divide

Age-based digital divide

Nearly 87% of Indian households have access to mobile phones, but there are no major studies indicating their access to elderly people.

• Nearly 85.8% of the elderly were found to be digitally and computer illiterate. Out of this, 76.5% were elderly men and 95% were elderly women.8

• There was a surge in digital solutions during the COVID-19 pandemic which, helped people navigate the lockdown, but studies suggest that the use and utility of such technologies for the el- derly were minimal. The elderly were un- able to make use of many of the digital measures because of a lack of access to digital devices and a lack of technolog- ical skills.

Digitalization & Consumption Patterns

An expected rise in digitally driven care and support services

The digital healthcare market in India is valued at ` 52,497 crores (524.97 billion) in 2021; expected to reach ` 2,52,869 crores (2528.69 billion) by 2027 9

• As service delivery is going increasingly online, digitalization presents significant opportunities for societies with ageing populations. The market for digital tech- nologies, especially those suited to the needs of older people, like assistive & health monitoring devices, smart home technologies, and telemedicine ser- vices; is expanding in response to rising demand.

8 https://www.agewellfoundation.org/wp-content/uploads/2018/07/Annual_Report-2017-18.pdf 9 https://www.researchandmarkets.com/reports/5723420/digital-healthcare-market-in-india

10 https://www.columbiacommunities.in/news/how-lucrative-is-the elderly-market-in-india/

Senior Care Reforms in India

1�3 Market Size and Growth Potential

By 2050, one in every four Indians will be a senior citizen. In absolute numbers, it will be equal to the population of the USA for the industry in the form of a “Silver Economy”. The senior care industry in India is about USD 7 billion10 (approximately ` 57,881 crore) and it is expected to grow rapidly, showing ample opportunity for the health care companies to create solutions for the silver generation. (See Figure 2)

Figure 2� Snapshot of the silver economy

Moreover, the recent COVID-19 pandemic has highlighted the significance of the healthcare sector and has provided policymakers with the required context to explore the growth potential of the Indian healthcare market. As a result, the market for tech-based elderly solutions is expanding quickly both globally and in India. Indian elderly, especially those aged 60-70, are embracing digital technology through various means like online transactions, online shopping, social networking, etc. As more senior consumers become aware of the advantages and convenience of digital technologies, this trend is anticipated to continue.11

This sector deals with the potential of the Indian geriatric healthcare market and its driving factors.

DRIVERS OF GROWTH

1�3�1 Home Care Services

More than 75% of the elderly people in India suffer from chronic diseases and these figures indicate the potential of the home-based care market in India. The size of the home healthcare market in India was estimated at USD 6.2 billion (` 50, 840 crore) in 2020 and it is projected to reach USD 21.3 billion (` 1.74 lakh crore) by 2027. 12 The home healthcare market can lead to a 15–30% reduction in infrastructure and operational costs compared to hospital costs for the same treatment.13 Further, the COVID-19 pandemic has provided an opportunity for policymakers to explore the home-based care market in India. The hospital capacity was limited during the pandemic, which forced chronic patients to seek home-based healthcare and it may continue to be the best alternative for such people due to its flexibility and convenience.

11 Changing patterns of Income & expenditure of older people in India, Agewell Foundation 12 Investment Opportunities in India’s Healthcare Sector, Report by NITI Aayog, 2021

13 https://www.investindia.gov.in/sector/healthcare

The growth of silver economy in India will enable subsidized services required for universal access to senior care especially for the bottom of the pyramid segment.

Senior Care Reforms in India 15

1�3�2 Health Technology

In 2020, the Indian health-tech market was worth USD 1.9 billion (` 15,580 crore) and it is expected to reach USD 5 billion (` 41,000 core) by 2023. Further, the Indian digital healthcare market is projected to grow at a CAGR of 27.41%, reaching ` 485.43 billion (` 48,543 crore) by 2024 from ` 116.61 billion (` 11,661 crore) in 2019.13 Because of COVID-19, certain product categories have seen a massive demand like telehealth applications, remote patient monitoring, Internet-of-Things (IoT) products, AI-based smart housing, and home equipment, assistive technology products, which have a huge potential to transform the lives of seniors.

The following are the major growth areas within the health technology segment:

a� Wearables: The use of wearable devices for the elderly is expected to continue to grow, driven by the increasing demand for remote monitoring and the need for more personalized healthcare solutions. There are several wearable devices available in the market that cater specifically to the needs of the elderly population, including smart watches and fitness trackers with health monitoring features such as heart rate monitoring, blood pressure monitoring, and sleep tracking. There are also specialized devices such as fall detection sensors, GPS trackers, and emergency response systems that can alert caregivers or emergency services in case of a fall or other medical emergency. According to a report by Grand View Research, the global market for wearable medical devices is expected to reach USD 87.77 billion by 2027, with a compound annual growth rate (CAGR) of 27.9% from 2020 to 2027. This growth is being driven by the increasing adoption of wearable devices by the elderly population, as well as advancements in technology and the rise in chronic diseases.

b� Telemedicine: The Telemedicine market in India has the highest growth potential and is anticipated to reach from USD 830 million (` 6806 crore) in 2020 to USD 5.4 billion (` 44, 280 crore) by 2025, growing at a 31% CAGR. Further, the telemedicine market is likely to develop into a full-fledged “virtual care ecosystem,” including teleconsulting, e-pharmacy, telepathology, and teleradiology, which has the potential to bring healthcare to fingertips.

1�3�3 Health Insurance

With only 18% of people over 60 years covered with health insurance3, the elderly health insurance industry continues to remain an untapped market which presents a ton of opportunities for investors to enter the market.

Although several insurance companies offer specialized health insurance plans for senior citizens, a comprehensive and integrated insurance product for seniors, which includes OPD care, diagnostic care, preventive care, etc., is still absent. Some of the popular insurance products for seniors in India include Bajaj Allianz Silver Health, Star Health Senior Citizen Red Carpet Plan, HDFC ERGO Health Optima Senior Plan, New India Assurance Health Insurance, and National Insurance Varistha Mediclaim Policy (see Annexure 2 for details.)

Senior Care Reforms in India

» Therefore, with over 104 million seniors3, aged 60 years and above3, the geriatric health insurance sector has the potential to develop as a separate insurance segment.

» The elderly health insurance segment is likely to be driven by various factors like increasing health care costs and OOPE, rising awareness, increased incidence of chronic & degenerative diseases, and the growing number of government health insurance schemes like Ayushman Bharat.

» Moreover, India with its relaxed investment norms allows up to 74% FDI in the insurance sector. Such liberalized norms can incentivize various multinational players to explore the Indian geriatric insurance market.

1�3�4 Ayush-based Services

» The Ayush sector has grown significantly, from USD 3 billion (` 24,600 crore) in 2014 to USD 18 billion (` 1,47,600 crore) in 2022, and it is further expected to continue growing, reaching about 23 billion (` 1.88 lakh crore) by the end of 2023.

» The Ayush market has received a boost from the widespread acceptance of Ayurveda and other traditional medical practices for their healing potential.

» The growth potential of the Ayush market was highlighted during the COVID-19 pandemic in India, where people increasingly turned towards Ayush-based practices due to its holistic approach to health and overall well-being.

» Additionally, an increase in the demand from the elderly population for preventive medications with almost no side effects or very few side effects is likely to fuel the Ayush market.

1�3�5 Enabling Government Policy

» The Indian healthcare industry will be fueled by an enabling policy environment and relaxed investment norms.

» Due to a liberalized FDI regime in numerous sub-sectors like hospitals, medical devices, health insurance, etc., there is enormous potential for foreign investment in this area.

• 100% FDI is allowed under the automatic route for green-field projects and up to 100% FDI is permitted under the government route for investments in brownfield projects.

• 100% FDI is allowed under the automatic route in the hospital sector and the production of medical devices.

• 100% FDI is allowed for green-field projects and up to 74% for brown-field projects, under the automatic route for the pharmaceutical industry.

• 100% FDI is allowed in the wellness and medical tourism sectors of the Ayush sector as well.

» Further, healthcare is a notified area under Schedule VII of Corporate Social Responsibility under section 135 of the Companies Act. Even though it is on the government’s part to provide its citizens with last-mile health services, the corporate sector holds enormous potential to drive healthcare delivery as a part of the required 2% spending under their CSR.

14https://www.brookings.edu/blog/future-development/2021/01/14/the-silver-economy-is-coming-of-age-a-look-at-the-growing- spending-power-of-seniors/

15 https://social.un.org/ageing-working-group/documents/seventh/AgewellFoundationSubmission.pdf

16 https://socialjustice.gov.in/writereaddata/UploadFile/dnpsc.pdf

Senior Care Reforms in India 17

1�3�6 Growing Silver Economy

» The economic activities, goods, and services that cater to the elderly people make up the “silver economy”.

» India’s silver economy is estimated to be worth approximately `73,082 crore rupees at present and is expected to grow multi-fold in the coming years.

» It is projected that around 13.2% of India’s population will be over 60 years of age by 2031 and around 19% by the year 2050. With the rise in the ageing of the population, senior citizens are emerging as an influential consumer segment. Studies have put senior citizens, along with professionals in the 45 to 64 age group, as the ‘wealthiest age cohort’ in the world14.

» Further, research shows that healthcare constitutes about 31% of the total expenditure of senior persons.15 Hence there is a huge growth potential for health and wellness- driven businesses within the senior care segment in India.

» Overall, the silver economy presents significant opportunities for businesses and organizations that cater to the needs and wants of the elderly population. The market size is expected to grow rapidly in both India and the world, and there is significant potential for innovation and growth in this sector.

» The Government also recognizes this opportunity and is exploring various ways to promote the idea of a silver economy, some of which are given below:

» In December 2020, the government released a draft National Policy for Senior Citizens,16 which included various enabling provisions like integrated insurance products and savings schemes, comprehensive insurance and pension systems, senior-friendly tax structures, subsidized financing products, etc., to provide policy support for the silver economy.

» The government has recently launched the Senior Able Citizens for Re-Employment in Dignity or the SACRED portal to connect senior citizens with job providers in the private sector.

» Based on the recommendations of the Expert Group on Silver Economy, the Senior Ageing Growth Engine (SAGE) initiative has been launched by the Ministry of Social Justice and Empowerment government to promote and incentivize senior care products and services. The SAGE portal provides a ‘one-stop access’ to senior care products and services by identifying, aggregating, and delivering them directly to the stakeholders.17

» Further, an initial budget of 100 crore rupees has been set aside by the M/oSJ&E for promoting the silver economy in India, of which approximately 25 crore rupees had been assigned for use in FY 2021-22.18

» The Ministry of Social Justice and Empowerment has been running various schemes and programs like the Rashtriya Vayoshri Yojana, ADIP scheme (Assistance to Disabled persons for purchase/fittings of Aids & Appliances), Sambhav portal, Artificial Limb and Manufacturing Corporation, Sugamya Bharat Abhiyaan, etc.; to assist people with disabilities (including seniors).

Further, healthcare being a major need among seniors, the potential of healthcare

technologies like AI/ML monitoring devices, IoT devices, assistive devices, and wearables

17 https://sage.dosje.gov.in/

18 https://pib.gov.in/PressReleasePage.aspx?PRID=1724425

Senior Care Reforms in India

such as watches, smart cameras, etc., needs to be utilized for delivering senior care services, especially home-based care, and long-term care. These health technologies can be supported by a team of care providers who can intervene whenever necessary. Moreover, by 2030, there will be a need to shift from curative management to prevention through cost-effective, integrated ‘smart’ services and solutions. Data and analytics will allow healthcare providers to directly and continuously connect with users, placing prevention ahead of treatment and cure (See Figure 3).

Embracing transformative digital disruptions in this field can play an important role in improving the accessibility, affordability, efficiency, and quality of services, and creating more sustainable models of care. To overcome the challenges of a shortage of skilled workforce, strategic adoption of technology needs to be brought in by the government.

Figure 3� Digital Care Ecosystem

The impact that these digital disruptions could bring will boost the efficiency of the service to the elderly by–

• Increasing the reach of services, even in the remotest areas

• Reducing care worker visits to elderly homes

• Digital enabled ‘Ageing in place

• Improving the health status of the elderly

• Digitally enabled elder living facilities & healthcare facilities

• Intelligent & easy to use assistive devices improve mobility

• Early responses leading to better health outcomes

Thus, the growth potential of the silver economy must be optimally utilized by employing the right strategies and interventions in the right sectors, to realize its true potential of serving over 300 million elders by 2050. The silver economy must place a greater emphasis on including seniors as active contributors in the economy rather than reducing them to just passive recipients. To achieve this, the country needs economic and social innovation that is supported by legislative reform and executive action. Mainstreaming ageing both from policymakers as well as by manufacturers, marketers, and industry will play a pivotal role in the coming years.

19 United Nations, World Population Ageing 2019

20 https://www.un.org/development/desa/ageing/madrid-plan-of-action-and-its-implementation.html#:~:text=The%20Madrid%20 Plan%20of%20Action,ensuring%20enabling%20and%20supportive%20environments.

Senior Care Reforms in India 19

1�4 Efforts in Senior Care

1�4�1 Global Efforts

Globally, the greatest demographic challenge is no longer rapid population growth, but an increasingly ageing population. The number of people aged 65 and above worldwide in 2019 was 703 million, and by 2050, this number is expected to touch 1.5 billion; which effectively means that by 2050, 1 in 6 people in the world will be over the age of 65.19 Recognizing the challenges associated with a rapidly ageing population across the world, various multilateral frameworks and mechanisms for senior care have been initiated by various international organizations.

The Vienna International Plan of Action is the first international initiative that sparked the debate around ageing. The plan was adopted by the World Assembly on Ageing in 1982 and endorsed by the UN General Assembly later that year. It seeks to increase the ability of governments and civil society to deal with population ageing and serves as a framework for developing policies and programs on ageing.

The Vienna International Plan on Ageing was followed by the adoption of the United Nations Principles for Older Persons by the UN General Assembly in 1991. Further, in 2002, the Second World Assembly on Ageing adopted the Political Declaration and the Madrid International Plan of Action on Ageing (MIPAA). The MIPAA aims at “building a society for all ages” and indicates a paradigm shift in how the world approached ageing. Moreover, the plan offers a comprehensive framework for understanding and managing the issue of ageing. Primarily it focuses on three areas – older persons and development, advancing health and well-being into old age, and ensuring enabling and supportive environments.20

Adding to it, in 2020, the United Nations General Assembly declared 2021-2030 as the ‘Decade of Healthy Ageing,’ urging governments, civil societies, international organizations, professionals, academia, media, and the private sector to work together towards improving the lives of older people, their families, and the communities in which they live. It aims to not only add years to life but also life to years. It focuses on the following four action areas:

a. change how we perceive age and ageing;

b. ensure that communities foster the abilities of older people;

c. deliver person-centered integrated care and primary health services responsive to older people; and

d. provide access to long-term care for older people who need it.

Furthermore, efforts have also been made by various countries across the world to ensure a healthy and inclusive ageing experience for their senior citizens (see Annexure 3 for details).

Most of the developed countries, such as European nations, the United States, Japan, Australia, and New Zealand, face a greater burden of population ageing. These nations had a long time to adjust to the growing number of elderly people in their population, so, these countries have robust healthcare systems in place and have been spending a higher per- capita income on healthcare, with models maturing over the years. They rely on institutional delivery of healthcare via hospitals and non-medical care through multiple channels such as nursing, home-based care, and elderly homes. Further, these countries recognize the role of

Senior Care Reforms in India

technology in ensuring quality, efficient, and timely care to the older population and therefore support new-age technology development and adoption.

In comparison, individuals and families in many developing countries, such as Eastern and Southeast Asian countries, where reliance on public health-care systems is low, face greater pressure to finance their medical and other needs during their old age. In terms of providing services, Government funded facilities provide basic medical care and philanthropic / not- for-profit / NGOs provide long-term care homes for severely ill patients. The private sector functions along with the Government, as the provider of medical & non-medical care, senior living facilities, long-term care facilities, and nursing at-home services for those who can afford it. From a health financing perspective, developing countries mostly have a self-funded elderly care model where most non-medical and long-term care is paid for by the people themselves.

Analysis of the various country models highlights that no country has the perfect solution to address ageing at an ecosystem level. Moreover, elderly people are now seeking higher quality care because of the rise of new-age health entrepreneurs, who provide exceptional services and a wide range of options; raising people’s expectations of the quality of care available. Consequently, providing effective and affordable care for the elderly continues to remain a major global challenge.

1�4�2 Efforts by the Indian Government

The Indian Government has been very active in addressing the demographic shift driven by the ageing of the population by implementing various initiatives, policies, programs, and action plans for the welfare of the elderly population. The Indian government’s commitment to population ageing is evident from the fact that India has been a signatory to almost all the global conferences or initiatives on ageing.

Moreover, the policy landscape around population ageing has evolved over the last two decades, guided by multiple initiatives. The brief of the policy response in senior-care in India with the rising number of elderly has been shown in Figure 4:

Figure 4� Journey of senior care policy in India

Senior Care Reforms in India 21

The Ministry of Social Justice and Empowerment (MoSJE) is the nodal ministry responsible for the welfare of senior people in India. It has been leading the overall policy and program development for the senior people in close collaboration with other line ministries such as Finance, Health and family Welfare, State Governments, NGOs, civil society, and the private sector. MoSJE has led the way in framing India’s National Policy on Older Persons and is also implementing the Atal Vayo Abhyudaya Yojana (AVYAY). Under the MOSJE, the National Institute of Social Defense has been the nodal institute tasked with training and research focusing on social defense issues, including the welfare of senior citizens, for over a decade. Further, the Maintenance and Welfare of Parents and Senior Citizens Act, 2007 is a landmark legislation that was initiated by MOSJE.

The Ministry of Health & Family Welfare launched the National Programme for the Health Care of Elderly (NPHCE) during 2010–11 to provide accessible, affordable, and high-quality long-term, comprehensive, and dedicated care services to the elderly, thereby creating new “architecture” for ageing and anenabling environment for “a Society for all Ages.” The program aligns with various national and international commitments like the UN Convention on the Rights of Persons with Disabilities (UNCRPD), National Policy on Older Persons (NPOP) adopted by the Government of India in 1999 & Section 20 of “The Maintenance and Welfare of Parents and Senior Citizens Act, 2007” dealing with provisions for medical care of people aged 60 and above. It provides dedicated healthcare facilities to senior citizens at various levels of primary, secondary, and tertiary health care as shown in Table 1�6. (See Annexure 4 for details.)

Table 1�6: Package of Services Provided at Various Levels Under National Programme for the Health Care of Elderly (NPHCE)

Sr� No�

Health Facility

Functions

National Centre for Ageing

» Health Care delivery with 200 bedded facility

» Training of Health Professionals

» Research activity

» Development of Health Professionals.

» Development of IEC material and course curricula

» The NCAs will also implement a special programme for the 75+ population

Regional Geriatric Centre

» Provide tertiary-level services for complicated/serious Geriatric Cases referred from Medical Colleges, District Hospitals, and below, Conducting post-graduate courses in Geriatric Medicine

» Providing training to the trainers of identified District hospitals and Medical Colleges

» Developing evidence-based treatment protocols for Geriatric diseases prevalent in the country.

» Developing / updating Training modules, guidelines, and IEC materials.

» Research on specific elderly diseases

Senior Care Reforms in India

Sr� No�

Health Facility

Functions

District Hospitals

» Geriatric Clinic for regular dedicated OPD services to the Elderly.

» Facilities for laboratory investigations for diagnosis and provision

of medicines for geriatric medical and health problems

» Ten-bedded Geriatric Ward for in-patient care of the Elderly in addition to services provided by the existing specialties like General Medicine, Orthopedics, Ophthalmology, ENT services, etc.

» Provide services for the elderly patients referred by the CHCs/ PHCs and conduct camps for geriatric services on other sites

» Referral services for severe cases to tertiary-level hospitals

Community Health Centres

» First Referral Unit (FRU) for the Elderly from PHCs and below.

» Geriatric Clinic for elderly persons twice a week.

» Rehabilitation Unit for physiotherapy and counseling

» Domiciliary visits by the rehabilitation worker for bedridden elderly and counseling of the family members

» Health Promotion and Prevention

» Referral of difficult cases to District Hospital/higher health care facility

Primary Health Centres

» Weekly geriatric clinic run by a trained Medical Officer

» Conducting a routine health assessment of the elderly persons based on simple clinical examination relating to the eye, BP, blood sugar, etc., and provision of medicines and proper advice on chronic ailments

» Public awareness on promotional, preventive, and rehabilitative aspects of geriatrics during health and village sanitation day/ camps and referral for diseases needing further investigation and treatment, to the Community Health Centre or the District Hospital as per need.

Sub – Centres

» Health Education related to healthy ageing

» Domiciliary visits for attention and care to home-bound / bedridden elderly persons and provide training to the family care providers in looking after the disabled elderly persons.

» Screening of the elderly for NCDs (Hypertension and Diabetes)

» Arranging the suitable calipers and supportive devices from the

PHC to the elderly disabled persons to make them ambulatory

» Linkage established with other support groups and daycare centers etc. operational in the area

» Availability of Telemedicine facilities for geriatric healthcare services.

Senior Care Reforms in India 23

Additionally, the Ministry of Rural Development has been administering the National Social Assistance Programme (NSAP), which provides social assistance benefits to vulnerable groups, including seniors, widows, disabled persons, and transgender people. Presently, NSAP, through the Indira Gandhi National Old Age Pension Scheme (IGNOAPS) provides social protection to the elderly through pensions. The central contribution of pension under IGNOAPS is `200/- per month per beneficiary up to 79 years and `500/- per month per beneficiary from 80 years onwards and the State Governments may contribute over and above this amount. According to the Ministry of Rural Development, more than 2.85 crore senior citizens were receiving social pensions under the NSAP as of December 2020.

Besides this, India’s policy response to population ageing encompasses multiple programs, schemes, and laws which include social protection, financial security, and healthcare service provisions for senior people, especially those belonging to socio-economically vulnerable groups. The provisions, schemes, programs, and other initiatives for the welfare of the elderly are mentioned very briefly in Box 2. (See Annexure 5 for detailed initiatives for senior citizens by the various ministries and departments of the Government of India.)

Box 2: Senior Care Support Framework in India

Constitutional Provisions

o Article 41: Right to work, to education, and to public assistance in certain cases

– The State shall, within the limits of its economic capacity and development, make effective provision for securing the right to work, to education, and to public assistance in cases of unemployment, old age, sickness, and disable-

ment, and in other cases of undeserved want

o Article 46: Promotion of educational and economic interests of Scheduled Castes, Scheduled Tribes, and other weaker sections

– Other weaker sections include the elderly, disabled, etc.

o 7th Schedule of the Indian Constitution

– Item No. 9 of the State List and item 20, 23 & 24 of the Concurrent List relates

to the old age pension, social security and social insurance, and economic

and social planning

– Entry 24 in the concurrent list deals with “Welfare of Labour, including con-

ditions of work, provident funds, liability for workmen’s compensation, inva- lidity and old age pension and maternity benefits.

Legal Measures

o Section 20 of the Hindu Adoption and Maintenance Act, 1956 makes it an obliga- tion to maintain an aged parent

o Under Section 125 of the Criminal Procedure Code, elder parents can claim mainte- nance from their children

o Section 88-B, 88-D & 88-DDB of the Income Tax Act allow senior citizens to claim a discount in tax

o The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 o NALSA (Legal Services to Senior Citizens) Scheme, 2016

Policy Support o National Policy for Older Persons (NPOP)

Senior Care Reforms in India

Welfare Schemes & Programmes

o National Social Assistance Program (NSAP)

– Indira Gandhi Old Age Pension Scheme (IGNOAPS)

– Indira Gandhi National Disability Pension Scheme (IGNDPS)

o Atal Vayo Abhyudaya Yojana (AVYAY)

– Integrated Program for Senior Citizens (IPSrC)

– State Action Plan for Senior Citizens (SAPSrC).

– Rashtriya Vayoshree Yojana’ (RVY)

– Livelihood and Skilling Initiatives for Senior Citizens

– Promoting silver economy

– Channelizing CSR funds for elderly care

o National Program for Health Care of the Elderly (NPHCE)

o Pradhan Mantri Vaya Vandana Yojana

o VayoMitra – Ayush Geriatric Healthcare Services under Ayush Public Health Pro-

grams (National Ayush Mission)

o National Council of Senior Citizens (NCSrC)

o Rashtriya Vayoshri Yojana (RVY)

o Varishtha Pension Bima Yojana

o Atal Pension Yojana

o Ayushman Bharat – PMJAY

o Ayurswasthya Yojana

o Senior Able Citizens for Re-Employment in Dignity (SACRED)

o Action Groups Aimed at Social Reconstruction (AGRASR Self-Help Groups) o Senior care Ageing Growth Engine (SAGE)

o Annapurna Scheme & Antyodaya Anna Yojana

Other Welfare Measures

o National Helpline for Senior Citizens i.e., Elder Line with toll-free number 14567 o Senior Citizens’ Welfare Fund

o Vayoshreshtha Samman

o Accessible India Campaign (Sugamya Bharat Abhiyaan)

o E-Anudaan Portal

o Seats reserved in buses, railways, and metro trains

Overall, the government has taken foundational affirmative steps for the welfare of senior citizens, but its presence across the various domains of senior care remains limited. Further, the senior care segment is currently fragmented across a range of other providers such as voluntary and philanthropic organizations, NGOs, private providers, and industry associations (see Annexure 6). The government, therefore, has a crucial role in providing guidance and regulatory space to ensure accountability and quality of services provided by NGOs and private providers.

Moreover, the COVID pandemic, with its disproportionately higher impact on the elderly population, exposed the gaps and issues in the existing policy framework for the elderly. The pandemic has highlighted the need to review our basket of schemes and programs towards the changing context and needs of the elderly. Further, policymaking needs to embrace various strategies to promote the engagement and participation of senior citizens in the development process, for an “inclusive ageing experience”.

Senior Care Reforms in India 25

1�5 Key Issues and Challenges

This section briefly summarizes the challenges faced in providing comprehensive senior care in India across the domains of Health, Social, Economic, and Digial Inclusion. The key challenges in empowerment, service delivery response, and inclusion in senior care are elaborated in this section. Figure 5 presents a summarized overview of these challenges.

•

• • •

• •

•

• •

•

Lack of a comprehensive and integrated package of services

Elderly care infrastructure gap

Paucity of trained manpower

Need for an evidence-backed geriatric diseases knowledge repository

Limited financing of care for the elderly Inadequate emergency response infrastructure

Need for enabling frameworks and monitoring mechanisms Insufficient focus on hygiene-related issues

Need for universal and comprehensive financial systems for old age security

Insufficient levels of financial literacy Deficient support in lifetime financial planning

Financial abuse and fraud

Health Inclusion

Economic Inclusion

•

• •

•

Social • Inclusion

Digital Inclusion

• • • •

Fragmented and narrow social support system

Limited awareness regarding their rights and provisions available Changing family structure and loss of social support

Social inequality

Inadequate elderly-friendly infrastructure

Inadequate R&D activities Contribution and challenges of care workers neglected

Need to ensure digital literacy among seniors

Insufficient access to digital goods

Paucity of digital training modules for the elderly Unaffordable digital equipment and limited broadband connections

1�5�1 Health Domain

Figure 5� Key challenges and issues around senior care in India

Lack of a comprehensive and integrated package of ser- vices

o Fragmented approach to Service Delivery

– Quality healthcare for the elderly remains a challenge as multiple service providers, who continue to work in silos are involved in providing that care21 like nursing agencies, physiotherapists, and medical suppliers. Further, most providers are small in scale or unorganized, extending only a sub-optimal quality of care.

o Gap in the availability of specific healthcare goods and services for the elderly in an integrated manner

– Non-availability of targeted immunization programs for the elder- ly under national immunization programs

– Need to extend mental health services like counselling, psychiat- ric support, etc., to elderly

– Need for focused attention on the elderly nutrition

– Crucial to scale up innovations and availability of assistive devices

– Need to prioritize home-based care models to ensure service de- livery within the comforts of one’s own home and community

Senior Care Reforms in India

Eldercare Infra- structure Gap

o Mismatch between demand and supply of care & support institutions:

– The Maintenance and Welfare of Parents and Senior Act, 2007 has a provision that State Governments may set up at least one old age home in every district to house 150 senior citizens. However, less than 500 districts have old-age homes as per the report submitted by the Standing Committee on Social Justice and Empowerment in 2021.

– As portrayed earlier, the maximum number of the elderly population is staying in rural India (71%), and there is a serious deficiency in the models of senior care in rural areas.

– Moreover, the existing housing structures are not ready to cater to the needs of elders.

o Tertiary care services dependent on the private sector :

– Senior care continues to be dependent on private tertiary care centres. Holistic senior care infrastructure, customized to the special needs of elderly people, is inadequate. Services to seniors are usually delivered through internal medicine or other relevant departments. Further, dedicated senior care centres (medical and non-medical) are predominantly located in urban areas, though the majority of senior people reside in rural areas.

Paucity of trained manpower and adequate exper- tise to support the healthcare needs of seniors

o Insufficient focus on geriatric healthcare :

– The Health system, at present, is focused on RMNCH, communica- ble diseases, and NCDs, with low priority for geriatric care.

o Limited manpower :

– India has 7.35 physicians and 17.48 nurses and midwife personnel per 10,000 people, vis-à-vis a global physician and nurse density of 16.37 and 39.53, respectively (2020).22 It indicates that India is facing a shortage of skilled personnel, which is leading to poor quality of care and overcrowding of facilities.

– Besides the limited senior care workforce, there is an acute short- age of home-health care workforce and home-based services be- cause there are very few clinicians to meet the medical needs of the homebound elderly.

– Moreover, at present, the healthcare workforce is trained to re- spond to acute illness and communicable diseases, with a low pri- ority on workforce training on palliative and end-of-life care.

21 https://www.indiatimes.com/health/healthyliving/did-you-know-about-these-challenges-old-people-face-every-day-242817.html

22 https://www.who.int/data/gho/data/themes/topics/health-workforce

Senior Care Reforms in India 27

 Need for an evidence- backed geriatric disease management knowledge repository

o The rising incidences of NCDs, chronic diseases, falls, etc. among the elderly require rigorous research, while R&D activities in geriatric care remain limited. Some potential research gaps in the field of senior care services in India:

– Limited research on the health and well-being of elderly popula- tions, including research on age-related illnesses, mental health, neuro-degenerative diseases, and chronic conditions.

– Limited research on nutritional aspects of ageing, including prev- alent nutritional deficiencies and disorders caused by them, opti- mum nutritional supplementation, etc.

– Insufficient research on the impact of technology on senior care and how technology can be used to improve senior care services, including the use of wearable devices, telehealth, and other digital tools.

 Limited financ- ing of care for the elderly

o Senior people have long-term healthcare needs with high health ex- penditures, particularly OOPE. Maximum non-medical care and out- patient care of the elderly are financed out of pocket. Thus, funding remains one of the most important aspects of senior care to address. Thus, there is a need to focus on developing adequate methods for financing the healthcare needs of the elderly.

o Moreover, Senior Care Health Insurance has a very shallow penetra- tion (only 18%) with a poor pay-out history. Insurance companies, with their cumbersome process of documentation, complex eligibility cri- teria, and profit-driven approach, further limit the access to insurance for the elderly, and that too at a time when their health costs are rising.

 Inadequate Emergency

response infra- structure

o While the government has put in place a general emergency response infrastructure like ambulances, trauma units, etc., a tailored emergen- cy response infrastructure especially customized for senior citizens, is not given due attention. With increasing numbers of senior people living alone, 24-hour access to emergency facilities, lesser response time, and support like public geriatric ambulances are imperative.

 Need for en- abling frame-

works and monitoring mechanisms

o Paucity of regulatory frameworks:

– The senior care infrastructure is emerging in various models, but there are no national standards or quality checks for senior care services in India, leading to poor service delivery. Further, the ab- sence of regulatory and monitoring frameworks to ensure uniform, holistic, and quality geriatric care in the private sector makes pri- vate healthcare goods and services unaffordable and inaccessible to the elderly.

28 Senior Care Reforms in India

 Insufficient fo- cus on Hygiene related issues in seniors

o Some of the specific hygiene problems that elderly individuals include:

– Bathing and showering: Many elderly individuals may have diffi- culty bathing or showering due to mobility issues or fear of falling. This can lead to body odor, skin infections, and other hygiene-re- lated problems.

– Dental hygiene: As people age, their teeth and gums become more prone to decay and infection. Elderly individuals may also have difficulty brushing or flossing properly, which can lead to bad breath and dental problems.

– Incontinence: Incontinence is a common problem among elderly individuals, and it can lead to issues with hygiene and skin health. Those who suffer from incontinence may have difficulty keeping their skin clean and dry, which can lead to rashes and other skin infections.

– Foot care: Elderly individuals may have difficulty reaching and caring for their feet, which can lead to foot odor, fungal infections, and other foot-related problems.

1�5�2 Social Domain

 Narrow and inadequate

social security system

o Limited scope of social security nets:

– Only a small part of India’s elderly population is covered by the public social security systems. The majority of the elderly population is retired from the unorganized sector and is not covered by social security.23 Fur- ther, LASI notes that a mere 8% of people above 60 are covered under any work-related pension.

o Gaps in the implementation of social security schemes & programs :

– Although the Government has implemented several well-crafted policies and laws still; most of them are ineffective due to poor execution, defi- cient knowledge, and various other administrative, social, and geograph- ic barriers. For instance, as low as 12% the elderly people are aware of the Maintenance and Welfare of Parents and Senior Citizens Act 2007 and the Annapurna scheme.

 Limited awareness

among the elderly re- garding their rights and the provisions available to them

o The limited awareness among elderly people about various provisions and initia- tives available for their welfare excludes them from various social security nets. An awareness study conducted in 2019 revealed that 57% of the elderly population had a moderate level of awareness, whereas 39% of the elderly population had a poor level of awareness regarding benefits & provisions available to them. 24 There- fore, elderly people should be empowered and informed, and their contribution needs to be endorsed at all levels – family, society, and nation.

o Various polls and surveys have been conducted on ageing in India, such as Hel- pAge India’s “State of the Elderly in India” report, India Today-Karvy Insights Mood of the Nation poll, Global Age Watch Index, National Sample Survey’s 60th round on “Health and Morbidity” and 71st round survey on “Social Consumption: Health,” and their results highlight the lack of awareness among people regarding various government initiatives and programmes for senior care.

23 Status of Social Security and Social Protection Floors in India, Report by Age Well Foundation

Senior Care Reforms in India 29

 Changing fam- ily structure

and loss of social support

o It is often witnessed that elderly people prefer to stay with their families and communities based on various research across cultures.25 The 2011 Census data revealed that there had been a significant increase in the number of households with 1 to 4 members and a decline in households with 5 and above,26 indicating a shift towards nuclear families. This shift is likely to cause mental, physical, social, and financial insecurity among elderly people in the years ahead.

 Social Inequality

o Regional Divide :

– A study conducted in 2021 reported considerable rural-urban inequality

disfavoring rural residents. Healthcare utilization was percentage points higher among the older population residing in urban India than their rural counterpart 27, indicating the presence of a rural-urban divide among the elderly population.

o Gender-based disparity and inequality :

– Various studies indicate that older male adults are more likely to experi-

ence healthy ageing than female older adults. A large share of this gen- der gap in health status can be attributed to gender discrimination driven by the patriarchal structure of our society. In a study, at the 10th percen- tile, 55.68% of the gender health status gap was due to discrimination, and the contribution of discrimination to the total gap increased among older adults in the higher percentiles.28

o Other socio-economic inequalities :

– The elderly people are also subject to similar discrimination that the

broader society faces and their age further compounds the negative ef- fects of such discrimination on their health and overall well-being. For instance, stats in LASI highlight that more than 80% of the elderly be- longing to the Scheduled Tribes are working in agriculture and allied ac- tivities, indicating their exclusion from work-related pension schemes.

 Inadequate el- derly-friendly infrastructure

o The lack of accessible physical infrastructure is a major barrier to the social inclusion of elderly people. Basic facilities like accessible transportation, dis- abled-friendly toilets, accessible buildings, wheelchairs, ramps, wide doors, and elevators to enable unrestricted mobility are either missing or not main- tained properly, thereby limiting the access of seniors to public places.

24 https://www.ijhsr.org/IJHSR_Vol.9_Issue.6_June2019/38.pdf

25 https://www.walshmedicalmedia.com/open-access/levels-of-lonelines-and-family-structure-amng-geriatrics-2475-319X-1000135.pdf

26 https://journals.sagepub.com/doi/10.1177/21582440211008178

27 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10773-1

28 https://events.development.asia/system/files/materials/2021/09/202109-healthy-ageing-and-gender-gap-india-evidence-longitudinal- ageing-study-india-wave-1-final_0.pdf

Senior Care Reforms in India

 Insufficient R&D activities

o Various socio-economic issues around ageing like isolation and loneliness, restricted mobility, and socio-economic disengagement, require developing a thorough understanding; so that adequate response mechanisms can be mapped out. Some gaps in the research landscape in senior care are:

– Lack of research on the experiences of caregivers, including family mem- bers and professional caregivers, to identify the challenges they face.

– Lack of research on the efficacy of different senior care models, includ- ing institutional care, home-based care, and community-based care, to understand which model is most effective in addressing the needs of the elderly population.

– Limited research on the impact of social and economic factors on senior care, such as poverty, education, and social isolation, on the delivery and effectiveness of senior care services in India.

– Insufficient research on the needs of specific subgroups within the elder- ly population, such as those living in rural areas, those with disabilities, and those from marginalized communities, to ensure that senior care ser- vices are tailored to meet their unique needs.

 Contribution and challeng-

es of care work and care-workers remain ne- glected

o Contributions of care-workers remain unrecognized: Care work and care workers remain undervalued and underpaid in India. Care work is often viewed as a low-skilled job and is mostly performed by women. Although the COVID-19 pandemic has highlighted the crucial role that care workers play in providing essential services to the elderly and other vulnerable populations, there is scope for further empowerment and capacity building, particularly in countries like India, where the need for care workers is high but resources are limited.

o Various challenges faced by caregivers remain unacknowledged: Caregiv- ing for elders can be a challenging and demanding task, both physically and emotionally. Elderly care requires a significant amount of time, effort, and re- sources, and can impact the well-being of caregivers. Some of the difficulties caused by the care of elders include:

– Physical Demands: Caring for elders can involve physically demanding tasks such as lifting, bathing, and assisting with mobility, which can be challenging for caregivers, particularly if they are elderly themselves.

– Emotional Stress: Caregiving can cause emotional stress, particularly if the elder has a chronic illness or requires extensive care. Caregivers may also experience feelings of guilt, frustration, and depression.

– Financial Burden: Elderly care can be expensive, particularly if the elder requires long-term care or specialized services. Caregivers may have to bear the cost of medical bills, transportation, and other expenses.

– Social Isolation: Caregiving can be a full-time job, which can cause care- givers to become socially isolated. They may have little time to socialize with friends or participate in leisure activities.

– Time Management: Caregiving can be a time-consuming task, and care- givers may find it challenging to balance the needs of the elderly with their own personal and professional obligations.

Senior Care Reforms in India 31

1�5�3 Economic Domain

 Need for a universal and

comprehensive financial support system for old age security

o On the one hand, the elderly are assumed to be ‘less productive’ and expect- ed to retire from work, and on the other, provisions like pensions and health insurance are inadequate, pushing them into financial insecurity. Less than 20% of the elderly population is covered with any health insurance and near- ly 78% of them remain without any pension cover. Also, a major part of the healthcare expenses of the elderly are financed out of pocket and a majority of seniors are devoid of any regular source of income due to their disengage- ment from economic activities. Thus, a universal and comprehensive financial security system needs to be envisaged for seniors due to their increased vul- nerability to a financial crisis.

 Insufficient levels of financial

literacy and awareness about available financial avenues and schemes

–

Financial Illiteracy:

Over 76% of the adult population still lacks a fundamental comprehension of financial concepts.29 A 2019 report revealed that only around 25% of adults aged 50-69 years and around 23% of adults aged 70-80 are consid- ered financially literate.30 This indicates that the awareness about financial security schemes is very low among the elderly and it has emerged as a significant challenge over the years.

Digitalization of financial services

As the shift towards digital financial services continues, low financial and digital literacy levels can increase the likelihood of exclusion among the elderly; and may further threaten their financial security in old age.

 Deficient support

in lifetime financial planning

o Many adults reach old age without sufficient savings, insurance, or public or private pensions to live on or to fund long-term care. Nearly 70% of the el- derly are dependent for everyday maintenance on family & relatives5. As a result, many older adults may find it difficult to manage everyday living costs. Some mitigate this uncertainty by continuing to work in old age, attempting to borrow money to cover any shortfall, or relying on family members or so- cial assistance where available.

 Financial Abuse and

Fraud

o Elder financial abuse has received recognition as a growing socio-economic, and public health problem. The WHO estimates that 6.8% of people aged 60 years or over are subject to financial abuse,31 including fake investment oppor- tunities, phishing, fake prizes, lottery scams, and Advance-fee frauds. Older persons have more financial resources than their younger counterparts, and other factors, such as a higher prevalence of social isolation, cognitive impair- ment, etc.; make them more vulnerable to financial exploitation.

29 https://www.ibef.org/blogs/india-s-growing-financial-literacy

30 https://ncfe.org.in/images/pdfs/reports/NCFE%202019_Final_Report.pdf

31 https://www.oecd.org/finance/Financial-consumer-protection-and-ageing-populations.pdf

32 Senior Care Reforms in India

1�5�4 Digital Domain

 Need to en- sure digital lit- eracy among seniors

o According to an Age Well Foundation Survey, approximately 85.8% of respon- dents were digitally and computer illiterate. Out of this, 76.5% were elderly men, and 95% were elderly women. While the government’s National Digital Literacy Mission (NDLM) aims to empower at least one person per household with crucial digital literacy skills, the elderly population seems to be missing from the plan. Digital illiteracy has emerged as the most crucial issue leading to the digital gap among older people.

 Insufficient digital access

o Senior citizens comprise almost 8.6% of the country’s population, and less than 3% are Internet users.32 Further, the wide disparity between older and younger people in terms of internet usage can be explained partially because older people may not have the financial means to pay for digital equipment. Overall, 72% of the elderly are economically dependent on others (spouses, children, or relatives).33 Moreover, broadband services can be cost-prohibi- tive, particularly for low-income and fixed-income elders.

 Paucity of digital training modules for the elderly

o A Help Age India analysis of the elderly released in August 2020 indicates a tremendous increase in the age-related digital divide after the pandemic. Though many urban seniors have access to smartphones and other digital devices, they do not know how to use them beyond the basics. Thus, elderly people need to be equipped with the required skills needed to access the dig- ital environment through well-resourced digital empowerment and inclusion packages with tailor-made training and support.

1�5�5 Fostering Inter-sectoral Convergence

While India has recognized the concerns around population ageing at the policy level, certain emergent areas of senior care still require inter-linkages to create an integrated and comprehensive response to senior care, by bringing in seamless convergence among all stakeholders. The NPOP (1999), later renamed as NCSrC, also recommends that people, families, communities, organizations from civil society, and the private sector must work together as partners and the state should not be left alone to achieve the goals of the policy; thereby underlining the need for an inter-sectoral convergence.

There are many stakeholders and providers in the senior care ecosystem who continue to function for the welfare of the elderly but in silos, thereby limiting the scope for holistic and integrated care for the elderly. These stakeholders include the following:

• The central government, along with the Ministry of Social Justice & Empowerment as

the nodal ministry and other line ministries, including:

1. Ministry of Health and Family Welfare

2. Ministry of Ayush

3. Ministry of Finance

4. Ministry of Rural Development

5. Ministry of Consumer Affairs, Food & Public Distribution

6. Ministry of Textiles

7. Ministry of Personnel, Public Grievances, and Pensions

8. Ministry of Home Affairs

32 https://journals.sagepub.com/doi/full/10.1177/0973258619872085

33 Kumar, S., Kumar, K.A. Living Arrangement and Economic Dependency among the elderly in India: a Comparative Analysis of EAG and Non EAG States. Ageing Int 44, 352–370 (2019). https://doi.org/10.1007/s12126-019-9344-3

Senior Care Reforms in India 33

9. Ministry of Railways

10. Ministry of Road Transport and Highways Surface

11. Ministry of Civil Aviation

12. Ministry of Housing & Urban Affairs

13. Ministry of Labour and Employment

14. Ministry of Law & Justice

15. Ministry of Agriculture and Farmers Welfare

• State Government and its departments,

• International agencies,

• Not-for-profit organizations, and • Private providers.

Further, due to the federalized nature of senior care policies, service delivery is broadly fragmented and the states are expected to fund these initiatives and are also made responsible for their successful execution. Also, because the effective implementation of senior care policies and programs is mostly left to the states, their implementation remains uneven and inadequate.

Although the government has designed various enabling policies and programs for the welfare of the elderly, much remains to be done to address the emerging needs of the elderly in a comprehensive and integrated manner.

Further, it is crucial to bring a continuum across primary, secondary, and tertiary healthcare centres to cater to the special needs of the elderly and to improve geriatric care at all levels by creating inter-linkages among them.

Synergies between the voluntary sector and the government need to be explored for better health and socio-economic outcomes in the elderly population. The NGOs can be used to train village-based caregivers and generate awareness among the elderly and caregivers on self-care, healthy and productive ageing, intergenerational bonding, etc. It will not only lessen the burden on the government but will also lead to better outcomes.

The health care service delivery remains scattered across the private providers. So, it becomes important to bring a seamless convergence among all the stakeholders, including TPAs and insurers, labs, pharmaceuticals, private hospitals and clinics, wellness centres, and Ayush practitioners.

Thus, there is a vast scope and need for inter-sectoral, inter-ministerial, and inter-stakeholder convergence and linkages at all levels to provide comprehensive and integrated elderly care and service delivery (See Figure 6)�

Senior Care Reforms in India

Figure 6� Healthy and inclusive ageing through convergence among stakeholders

Senior Care Reforms in India 35

36 Senior Care Reforms in India

SECTION 2:

SENIOR CARE TRANSFORMATION

– SERVICE DELIVERY PRIORITIES

To ensure comprehensive senior care, there is a need to identify and ensure all aspects of care for seniors, which may include but are not limited to health, social, financial, and digital dimensions. The service delivery priorities for seniors under these dimensions are given in Table 2�1.

Table 2�1� Service Delivery Priorities for Seniors

HEALTH

SOCIAL

ECONOMIC

DIGITAL

– Managing chronic/ acute ill- ness through a comprehen- sive package of services, including the following:

o Early Detection and Treatment

o Focus on preventive in- terventions like Adult im- munization to deal with immunosenescence

o Promotingphysician-pre- scribed physical activity

o Ensuring recommended nutritional intake

o Enhancing functional in- dependence through re- habilitative services and assistive devices

o Ensuring palliative and long-term healthcare services, along with pain management

o Promoting mental health services

– Increasing health aware- ness

– Capacity building of medi- cal professionals and care- givers

– Realigning existing health- care infrastructure towards geriatric healthcare

– Promoting R&D in geriatric care

– Developing a com- prehensive social se- curity system to en- sure seniors’ access to basic facilities

– Strengthening legal awareness

– Encourage communi- ty-based support

– Developing engage- ment opportunities for seniors

– Developing Acces- sible Physical Infra- structure

– Build and strengthen provisions for Assist- ed Living Facilities (ALFs)

– Creating occupa- tional opportunities to utilize their expe- rience and expertise

– Promoting financial literacy

– Widening scope and coverage of pension products

– Designing special health insurance products to reduce OOPE

– Expand and diversi- fy financial security nets

o Tax benefits and senior discounts

o Strengthening the reverse mortgage mechanism

– Promoting digi- tal literacy among seniors as well as their caregivers

– Adoption of digital tools and ensuring access to digital devices

– Enhancing ease & safety of digital operation

– Developing en- abling digital infra- structure

Senior Care Reforms in India 37

HEALTH

SOCIAL

ECONOMIC

DIGITAL

– Exploring synergies be- tween the public and pri- vate sectors through PPP in geriatric healthcare

– Scaling up digital health in- terventions

Based on the above table, the service delivery priorities for seniors are detailed below.

2�1 Health – Comprehensive and Integrated Senior Care

Package

Integration of healthcare delivery to include nutritive, preventive, promotive, curative, rehabilitative, mental, dental, ophthalmological, and palliative services. A continuum of support should be evolved that includes all aspects of senior care, such as medical care, non-medical care, long-term support, and end-of-life care for a more holistic ageing experience. This usually requires a comprehensive assessment to comprehend the unique needs of seniors. Based on individual assessment, a customized and targeted plan can be prepared, which is shared across all providers to optimize service delivery.

Key aspects of health inclusion are provided below:

Increase Awareness to ensure adequate uptake of healthcare services for early identification, prevention, and management of chronic conditions. Targeted and continued support towards adopting positive health behaviors such as regular physical activity, proper nutrition, and micro-nutrient supplementation. The potential of modern technology must be explored for imparting health education to the elderly as well as to their care-givers.

Emphasize early detection for better management of both acute and chronic diseases through population based screening of seniors and regular monitoring systems.

• Expand the network and reach of diagnostic services related to common chronic conditions like high blood pressure and cholesterol, oral cancer, cervical cancer, dementia, Parkinson’s, diabetes, dental and ophthalmologic issues, etc., among the elderly through the provision of mobile screening centres.

• Establish robust monitoring systems, especially for neuro-degenerative dementia and other age-related disorders. Although, the World Health Organization (WHO) has developed the Global Dementia Observatory, and similarly, the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore has also established the Indian Dementia Observatory; there is a need to strengthen the network of these monitoring systems to help in identifying and tracking the progression of these conditions, as well as providing timely and appropriate care for those affected.

Preventive Measures

• Focus on Adult Immunization, especially in seniors with co-morbidities and

multi-morbidities, to decrease their predisposition towards contracting various communicable diseases and NCDs.

Senior Care Reforms in India

• Focus on immunity-boosting interventions for seniors to deal with immunosenescence i.e., decline in immunity with age. Promotion of preventive interventions based on the Ayush system of medicines to enhance general wellbeing among the elderly is also critical.

• Address the hygiene-related issues among the elderly by encouraging assistance from caregivers or family members, along with the use of adaptive equipment, such as shower chairs or grab bars, to make bathing and showering easier and safer. Positive hygiene practices like regular hand washing, brushing and flossing teeth, and wearing clean clothes should be inculcated among elderly individuals to prevent illness and maintain their overall health and wellbeing.

Promote physical activity and Yoga, especially for active seniors, to enhance their physical health, functional abilities and mobility, mental well-being, and quality of life, thereby ensuring an active and independent ageing experience. This requires a multi-faceted approach that includes education about the benefits, community-based activities like group exercise programs, home-based exercise programs, expanding the network of open-air gyms in public parks, and advocacy.

Encourage nutritional guidance services for seniors as well as their caregivers to address various issues around geriatric nutrition like obesity, nutritional deficiencies, electrolyte imbalances, lifestyle-based diseases, etc. Ensuring a balanced diet among seniors for delaying/decreasing the onset of various chronic diseases and for the maintenance of overall health. Provisions for nutritional supplements, such as vitamin D, vitamin B12, calcium, zinc, proteins, magnesium, probiotics, etc., to supplement the nutritious diet and under the guidance of a healthcare professional must be made to fulfill the nutrient requirements and prevent deficiencies among the elderly.

Enhance functional independence through rehabilitative care like physiotherapy, therapies from the Ayush system, assistive devices, etc. Restoring mobility among seniors through the provision of assistive devices to compensate for age-related functional losses among them. These devices can play a crucial role in improving the care of seniors by helping them with various activities of daily living, enhancing their mobility, and ensuring their safety (see Annexure 7 for details). Assistive devices for elderly care may include the following:

• Mobility aids: Devices such as walkers, walking sticks, canes, orthosis and prosthesis, and wheelchairs can help seniors move around more easily and safely. These devices can also prevent falls and injuries.

• Personal emergency response systems (PERS): PERS can help seniors in case of an emergency. These devices usually come in the form of a wearable pendant or bracelet and allow seniors to call for help at the push of a button.

• Medication reminders: There are various devices available that can help seniors remember to take their medications on time. These medical alert devices can be as simple as a pillbox with reminders or as advanced as a smart pill dispenser that

Senior Care Reforms in India 39

dispenses medication at the right time.

• Smart home technology: Smart home technology such as smart thermostats, smart lights, and smart door locks can help seniors manage their homes more easily. For example, smart lights can turn on automatically when a senior enters a room, and smart door locks can be controlled remotely, allowing family members to check on their loved ones.

• Hearing and visual aids: Hearing aids and visual aids can help seniors who have difficulty hearing or seeing. These devices can improve the communication abilities of seniors, thereby enhancing their quality of life.

Support palliative and end-of-life services to help seniors and their caregivers with pain management and symptom control, ensuring quality and dignified end-of-life care. Supporting these services is crucial for ensuring that individuals receive compassionate care during their final stages of life. This can be done by involving local NGOs and volunteers, along with collaborating efforts that involve healthcare providers, home- based care providers, caregivers, community organizations, and policymakers.

Extend mental health services like counseling and psychiatric support to senior people as well as to their caregivers to help them deal with various emotions like feelings of helplessness, isolation, stress, and anxiety; and to improve their overall well-being and quality of life. Improving the access and affordability of mental health services through various provisions like transportation facilities, tele-health options, at-home counselling, and financial assistance for those who cannot afford these services, etc., is also crucial. Further, efforts should be made to address the stigma around mental health through constructive collaborations with community organizations and by encouraging family involvement.

Capacity building healthcare professionals and caregivers: Workforce development and sensitization of medical professionals to augment their skills and competencies throughout the value chain of geriatric care is essential to improve health and wellness outcomes among the elderly population. A trained and skilled cadre of home-based care providers to cater to the care demands of the elderly needs to be developed. Further, capacity building should be prioritized among primary caregivers in families to equip them with the required skills, knowledge, and information. Additionally, healthcare providers should also be trained to recognize and address various mental health concerns among elderly patients to ensure that they receive appropriate mental health services in a timely manner.

Strengthening and realigning the existing healthcare infrastructure towards geriatric healthcare, so that healthcare services can be delivered in an efficient and time-sensitive manner to seniors.

• Expand the package of services available for senior people within the primary healthcare system to include every aspect of senior care, right from prevention to palliation.

Senior Care Reforms in India

• Integrating primary healthcare centres and facilities with other service providers like Ayush service providers/dispensaries, physiotherapists, psychologists, dieticians, rehabilitation experts, etc. to provide more holistic and comprehensive care for the elderly.

• Pooling of existing infrastructure by combining resources from different healthcare organizations, such as hospitals, nursing homes, home health agencies, Ayush centres, etc., to create a more coordinated and efficient system of care.

Develop and encourage home-based care models as an alternative and supplement to institutional care, in order to ensure the access and availability of personalized care services for seniors within the comfort of their own homes. Home healthcare providers can provide direct assistance with ADL and IADL. Further, they can provide training to seniors and their caregivers in senior care like teaching them the use of various monitoring and assistive devices, helping them in managing medication schedules, etc. Apart from being a cost-effective care model, home-based care also reduces the risk of infections among the elderly that can occur in nursing homes or assisted living facilities.

Promote R&D in geriatric care: Expand and strengthen the knowledge and evidence base in geriatric care. Undertake rigorous research in specific thematic areas like degenerative diseases (dementia, Alzheimer’s, Parkinson’s), NCDs (hypertension, cancer, diabetes, cardio-vascular diseases, stroke, osteoporosis, etc.); dental and ophthalmologic diseases, nutritional deficiencies & lifestyle-based diseases, communicable diseases, Ayush, etc. which are relevant to senior care. Disseminating the learnings among key stakeholders for the development of evidence-based integrative treatment modalities is also vital.

Explore synergies between the public and private sectors through PPP in geriatric healthcare to develop low-cost healthcare delivery models/practices for filling the infrastructure gap.

• Developing partnerships with the private sector through various PPP models to encourage private medical care at discounted prices to senior persons across the medical care cycle, from consultation to diagnostics to treatment. Private sector engagement should also be explored in providing home-based care to the elderly.

• Move beyond PPP to PPC, i.e. Public-Private-Community, to include the community members in key decisions regarding senior care. Community involvement can be used for the development, implementation, and evaluation of health services for seniors. Community support can ensure and enhance the sustainability of healthcare delivery strategies/models.

Invest in technology, and scaling up of e-health to improve the access and affordability of care and support services to senior people. Incentivizing digital health technologies like internet-based care, remote patient monitoring, wearables, digital assistive devices, medication management, etc., for chronic health monitoring and management.

• Utilizing the potential of telemedicine for providing healthcare services to the

Senior Care Reforms in India 41

elderly who may have difficulty in accessing in-person care due to various mobility issues or other health conditions. Telemedicine can also be useful for seniors residing in rural or remote areas, who may not be able to travel to far-off healthcare facilities for accessing care services.

2�2 Social Empowerment and Inclusion

Senior people require special care and attention due to their increased vulnerability to various physiological, psychological, and socio-economic problems. Recognizing the same, the government has evolved its legal and policy framework for seniors. Various enabling provisions like the ‘Integrated Action Plan for Senior Citizens’ and the ‘Maintenance and Welfare of Parents and Senior Citizens Act (MWPSC), 2007’; have been laid to ensure the social and legal rights of elders. However, due to various socio-economic barriers, these remain insufficient and underutilized.

Increased social engagement and participation of seniors to ensure a more cohesive community; and an enduring network of family, friends, and caregivers. Further, increased awareness regarding the legal provisions is required to reduce the likelihood of violence and abuse among seniors. Additionally, it is important to challenge the negative stereotypes about ageing and to promote a more positive view of ageing that values the contributions of older adults in society.

Some key aspects of social and legal empowerment of the elderly for their complete inclusion are given below:

Develop a Comprehensive and Integrated Social Security System for seniors through a multi-pronged approach, involving the government, private sector, and civil society organizations; to ensure their access to basic facilities like food, housing, sanitation facilities, etc. Expanding the scope and coverage of existing social security nets is also crucial.

• Targeted and customized social support programs for seniors to address their unique and varied needs

• Shifting from a welfare-based approach to a rights-based approach, where social security provisions are made available to seniors as a matter of right.

Strengthen legal awareness to inform elderly persons of their rights. Encouraging community-led efforts and campaigns to raise awareness of various social security benefits among seniors as well as their care-givers is essential to increase their utilization of various social services available to them. Sensitization of community members, police, and neighborhood welfare committees through online resources, workshops, seminars, community programmes, etc., is also vital. Further, the government could establish specialized courts or legal aid clinics for the speedy disposal of complaints of senior citizens relating to abuse, violence, and fraudulent dealings.

Encourage community-based support and care services for seniors. Community care can help seniors in accessing care and support services while staying in their communities, surrounded by family, friends, and others. Promoting community involvement through the provision of ‘community fellows’ or ‘care fellows’; who can assist seniors with

Senior Care Reforms in India

transportation facilities, legal formalities, and documentation, which are required to access various social security provisions.

Increase engagement opportunities for seniors – especially for those living alone, widowed, homeless, etc. – to ensure their continued engagement and socialization for a fruitful ageing experience. Increasing the participation of seniors to make sure that they aren’t marginalized through the following measures:

• Encouraging community participation/social responsibility undertaken by seniors

• Sensitizing community members about the contribution of the elderly to society

• Networking among the elderly through Octogenarian clubs, Centenarian clubs, Hobby clubs, Senior Citizens Associations, Social Support Groups, etc.

• Healthy and active engagement through recreational and sports activities like laughing clubs, activity clubs, and Yoga Centres

• Promoting community-led initiatives to address issues of social isolation and loneliness; and enhancing inter-generational transmission of expertise to help the younger generation through various engagement initiatives

Developing accessible physical infrastructure as per the specialized needs of seniors to enhance their engagement with the wider community.

• Age-friendly infrastructural changes to improve accessibility in residential buildings, public spaces, market places, public toilets, and means of transportation

• Reserve lower floors in residential societies for senior citizens

• Provision of reservation of lower berths in trains for seniors

• Ensuring easier access to assistive devices such as wheelchairs along with wheelchair-accessible ramps in public places

• Smart Housing, driven by digital technologies like Artificial Intelligence and the Internet of Things (automatic stove controllers, fire detectors, fall sensors, etc.)

Build and strengthen provisions of Assisted Living Facilities (ALFs) like adult day- care facilities and residential care facilities. ALFs can assist seniors with their daily living activities while their primary caregivers are at work. These facilities might also be employed to provide caregivers with a temporary break from their caregiving responsibilities. ALF may include health-related services like medication management, nursing, etc., along with social services like housekeeping, laundry, recreation, meals, and assistance with other ADL.

2�3 Economic Empowerment and Inclusion

The current ageing scenario is likely to increase the financial vulnerability among the senior people in India. Although the government has laid down a range of social and financial security provisions for seniors, their actual utilization remains low. Further, the current senior care financing is largely focused on funding medical care, with limited attention to

Senior Care Reforms in India 43

non-medical care and healthy ageing.34

In order to move towards financial empowerment and inclusion, ensuring financial security among seniors through various enabling and support provisions is essential, along with measures to extend subsidies and tax benefits to seniors to promote adoption and adherence to positive financial behaviours.

Key dimensions of economic and financial inclusion are given below:

Create alternative employment opportunities like training, teaching, advisory and consulting roles, work-from-home roles, etc., for seniors, so that their vast experience and expertise can be adequately utilized. Extending their economic participation will ensure their meaningful engagement with society along with financial security. The SACRED portal developed by the Ministry of Social Justice and Empowerment is one such initiative for the re-employment of able elders.35 Further, work opportunities like remote work, freelancing, involvement in NGOs, job training, etc. can be explored for seniors who want to continue working but prefer to work from the comfort of their own homes with flexible work options.

Expand financial literacy to promote healthy financial behaviours among seniors and to help them make informed decisions about their finances. This can be achieved through education and awareness campaigns, simplification of financial terms, utilizing digital technology, financial counseling, community partnerships, etc. Designing targeted financial literacy campaigns for seniors to increase their uptake and utilization of financial products is also essential. Further, it is important to build capacities around the use and utilization of financial products to help them manage their finances more responsibly and to caution them against financial fraud and scams.

Design a comprehensive public pension system to guarantee access to basic minimum facilities for seniors, which may include but not be limited to:

• Developing age-friendly micro-pension products with flexible payment and withdrawal options to help seniors in their post-retirement years

• Increasing the uptake and penetration of pension products through various government incentives like an equal contribution by the government, tax exemptions, higher returns, etc.

• Extending pension programs to cover disadvantaged and more vulnerable seniors like women and seniors working in the unorganized and informal sector, etc.

• Leveraging JAM Trinity (Jan-Dhan, Aadhar, Mobile) for streamlining the delivery of pension products

Provision of a comprehensive and universal geriatric insurance which includes both medical as well as non-medical care. Expanding the scope and coverage of existing insurance products to cover provisions of home care, institutional care, assisted living, long-term care, care related to degenerative diseases like dementia and Alzheimer’s, outpatient costs, etc.

34 https://iussp.org/sites/default/files/event_call_for_papers/T.V%20Sekher-IUSSP%20pdf.pdf 35 https://sacred.dosje.gov.in/

Senior Care Reforms in India

Key aspects:

• Incentivize geriatric health insurance and address insurance companies’ hesitancy

in providing insurance products to seniors because of their deteriorating health

• Leverage PPP in the insurance sector to build comprehensive, targeted, and tailored insurance products for seniors as per their unique needs

Expand and diversify financial security nets to ensure financial support to seniors in their sunset years. This may include:

• High-yielding investment opportunities and long-term saving plans to incentivize the habit of savings among seniors;

• A strengthened and simplified reverse mortgage mechanism to help seniors with their financial requirements, saving them from financial distress;

• Tax incentives and relaxations in income tax to seniors;

• Senior discounts on senior care products like geriatric ambulance services, home

care services, assistive devices, etc., to enable faster penetration of such products and services.

2�4 Digital Empowerment and Inclusion

One of the most important lessons from the COVID-19 pandemic was the need to address the digital divide among the elderly population. Digital empowerment has the potential to connect people and has gained global recognition as a driver of social and economic inclusion, especially among seniors. Recognizing the same, “Digital Equity for All Ages” was decided to be the theme for the United Nations International Day of Older Persons in 2021.36 It reaffirmed the elderly’s need for access and participation in the digital world.

Ensuring the reach and coverage of digital tools and services to senior people is key towards their digital empowerment and inclusion. It is also important to understand the penetration of technology among seniors, their current use of digital tools, and barriers in accessing these digital technologies in order to develop focused strategies.

Some key aspects of digital empowerment of the elderly for their complete inclusion in the digital world are given below:

Digital Literacy Campaign: Ensuring timely and accurate information to senior people as well as their caregivers regarding the use of digital platforms, along with cautioning them against online risks and fraud is crucial to increase their uptake of digital tools. It is vital to identify the specific needs and challenges of seniors concerning digital technology.

• Addressing the lack of trust among seniors related to the use of digital devices

• Addressing seniors’ negative attitudes and anxiety around smart gadgets

• Designing user-friendly and easy-to-understand instructional materials, including video tutorials, step-by-step guides or hands-on training sessions, online learning modules, etc., to enhance digital skills among seniors.

36 https://www.un.org/development/desa/ageing/2021-unidop-digital-equity-for-all-ages.html

Senior Care Reforms in India 45

• Collaborating with local organizations to enhance the reach of digital literacy campaigns to a wider audience.

Increasing the uptake and adoption of digital tools by making their access cheaper and easier through various measures like senior discounts

• Ensuring a smooth digital experience for seniors through larger screens, bold letters, simpler interfaces with larger app icons, etc.

• Ensuring installation and maintenance support of digital devices

• Ensuring continuous support to seniors who might require additional assistance or have questions regarding the use of digital tools.

Designing user-friendly digital infrastructure for catering to the various needs of the elderly like telemedicine, e-banking, etc.

• Developing digital platforms to encourage the engagement of younger people with seniors, bridging the inter-generational gaps

• Encouraging digitally enabled living through developing age-friendly digital service delivery platforms like telemedicine, e-pharmacies, online grocery delivery, e-banking, e-payments, online cabs, etc.

• Developing a One Stop-Senior Citizens App to link multiple services, products, and information for elderly users

• Ensuring the safety and security of seniors through digital tools like location tracking services, emergency buttons on phones, smart-watch alerts, etc.

• Developing digital assistive devices like speech-to-text systems, audiobooks, smart home devices, etc.

Develop a digital safety mechanism to ensure the ease & safety of digital operations, especially among seniors, who may not be as familiar with technology and the potential risks associated with it. Further, it is crucial to encourage seniors to adhere to basic internet safety guidelines, such as creating strong passwords, enabling two- factor authentication, installing anti-virus software on digital devices, not clicking on suspicious links, avoiding downloading unknown attachments, and not sharing personal information with strangers online; to save them from online frauds and attacks.

• Toll-free numbers to assist seniors with digital tools

• Speedy disposal of senior citizens’ complaints relating to online fraudulent dealings

The aforementioned service delivery priorities are designed to give seniors the support and assistance they need for their healthcare, social, financial, and digital inclusion in society. To maximize the intrinsic and functional abilities of seniors and to ensure them a dignified and inclusive ageing experience, an inter-sectoral, inter-ministerial, and inter-stakeholder convergence, cross-cutting across various aspects of senior care, must be sought.

Senior Care Reforms in India

SECTION 3: WAY FORWARD

In order to achieve comprehensive senior care, a paradigm shift is required that is focused on the needs of the senior people, bringing various stakeholders, both public and private sector, through the continuum of care, in delivering quality care to support holistic wellness and address the priority areas listed in the previous section. This will ensure comprehensive senior care, where seniors receive all required services and care.

Recognizing senior care as a sector with appropriate regulations and standards, policy support, tax structures, availability of subsidized financing, and appropriate governance mechanisms need to be undertaken. Policy and regulatory reforms with a clear evaluation framework need to be implemented to strengthen the elderly care program to be more outcome-oriented.

The government has initiated several strategies under numerous welfare schemes and programs across various dimensions for senior citizens. These initiatives can be better implemented through coordinated efforts by several Ministries and Departments of the Government of India. The Ministry of Social Justice and Empowerment, being the nodal ministry for senior care, needs to take an anchoring role in close coordination with other line ministries, including the Ministry of Health & Family Welfare, Ministry of Finance, Ministry of Ayush, Ministry of Rural Development, and others. Further, many other organizations like Panchayati Raj Institutions, Urban Local Bodies, Non Governmental Organizations and private providers are also working for elderly care (see Annexure 6 for details) but in their limited capacities. Hence, coordinated and complementary efforts, by bringing in inter-convergence across all stakeholders, are required to implement these programs in an effective, efficient, and time-bound manner (Figure 7).

Empowerment, Service Delivery, and Inclusion for Seniors

Health

Ministry of Social Justice and Empow- erment.

Ministry of Finance. Ministry of Health & Family Welfare.

Ministry of Ayush.

Social

Ministry of Social Justice and Empowerment.

Ministry of Finance. Ministry of Consumer Af-

fairs, Food, and Public

Distribution.

Ministry of Home Affairs. Indian Railways.

Ministry of Civil Aviation. Ministry of Housing and

Urban Affairs. Ministry of Road Trans-

port & Highways.

Financial Digital

Ministry of Social Justice and Empow- erment.

Ministry of Finance. Ministry of Rural Devel-

opment.

Ministry of Textiles. Department of Pension

and Pensioners Welfare.

Ministry of Social Justice and Empow- erment

Ministry of Health & Family Welfare. Ministry of Finance

State and UT Governments, Panchayati Raj Institutions, Urban Local Bodies, NGOs, and Private Players

NITI Aayog: Inter-Sectoral Convergence, Monitoring, and Nudging the States

Figure 7� Inter-convergence among various stakeholders for senior care

Senior Care Reforms in India 47

It is necessary to facilitate convergence between various Ministries/ Departments, and other stakeholders. It is vital to nudge the States/UTs for implementing various mandates assigned to them as per various central Acts and welfare schemes for senior citizens in a time-bound manner.

Given the demographic transition, by 2050, collectively, 19% of India’s population will comprise senior citizens that would need a senior care support system. India, therefore, requires a well-thought-out action plan that allows the emergence and development of such a senior care ecosystem. The following focus areas need to be intensified with a strategic & outcome-oriented approach:

3�1 Efforts to Ensure Health Empowerment and Inclusion

A proposed model for healthy & active ageing in India should focus on enabling the elderly to remain independent and healthy as they age. To achieve the same, a tailored service delivery plan should be mapped out based on their specific needs and preferences. A trained health worker/provider should be able to conduct a standardized healthcare needs assessment for the elderly to customize their package of services. An indicative list for needs assessment, is given below in Table 3�1.

Table 3�1� An Indicative List for Healthcare Needs Assessment

Information category

Objective

Basic health status

To capture basic information like patient’s age, weight, height, and com- mon vitals at home/institution

Medical history

To list the patient’s past & current medical diagnoses, surgeries, hospital- izations or other medical conditions, ongoing medications & procedures, immunization status & allergies, if any (should cover all aspects of physical & mental health), and ABHA registration

Risk assessment

Risk evaluation for fall risk screening, pain assessment & scoring

Nutritional status and needs

Information on preferred /prescribed diet type & restrictions, medical con- ditions limiting/enhancing diet, any difficulty faced during eating, chew- ing, swallowing, etc.

Hearing, speech, vision, and sleep

Basic information on vision, hearing & speech challenges & abilities, sleep- ing patterns & quality of sleep

Functionality assessment

To evaluate the level of functional independence and to measure the mag- nitude and type of mobility restrictions

Continuity and transition

Physical activity (type, intensity & duration), emotional well-being, conti- nuity at work, overall health rating by patient

Personal goals and expectations

Patient health & wellness goals, health motivation, any additional remarks/ concerns that patients wish to share

Based on the above assessment, an integrated and comprehensive healthcare ecosystem should be developed and designed by the government with the following focus points:

1. Promote health literacy among seniors as well as their caregivers to enhance their understanding of geriatric health issues and related risks. Additionally, there is a need to inform them of the various healthcare programs and provisions available for the

Senior Care Reforms in India

elderly to promote the penetration and utilization of health services among them. To augment health literacy among the elderly, there should be a special focus on using plain and simple language, along with providing accessible formats. Digital technology like mobile applications and specifically tailored health education programmes may be used to promote health literacy among the elderly.

2� Strengthen Comprehensive Primary Healthcare Services through the Ayushman Bharat – Health and Wellness Centres initiative: Provisions for screening and management of common NCDs, including cancer, have been made at the primary healthcare level. Screening of the senior population for age-specific disorders like dementia, Parkinson’s, fall tendency, etc., needs to be included in the comprehensive assessment plan for the elderly. The existing packages of services like rehabilitative services, including physiotherapy, palliative services, etc., need to be strengthened. Moreover, the package of services under CPHC should be further expanded to include the following packages for fall tendency, psycho-social services, and post-menopausal gynaecological health services for elderly women:

a) Provide Fall Prevention Package: A fall prevention package, including regular physical activity, home safety modifications, and medication review, to prevent falls should be included in the CPHC program to address the high incidence of falls among the elderly.

b) Provide Women’s Health Package: A women’s health package should be included in the CPHC program to address the unique health needs of women, especially those residing in rural areas. This package can include post-menopausal gynaecological health services for issues like fibroids, cysts, hot flashes, genital prolapse, etc.; breast and cervical-uteri cancer screening services; orthopedics services to deal with issues like osteoporosis, etc.

c)Provide Psycho-Social Support Package: A psycho-social support package, including counselling services, online therapy services, access to support groups, and mental health professionals, should be included in the CPHC program to address the mental health needs of the elderly population.

3� Expand tele-consultation services: Currently, the provision of tele-consultation services has been made at the primary healthcare level. However, there is a need to expand the coverage and scope of these services for the senior population through outreach efforts, health camps, home-based care, mobile medical units, and other accessible platforms in order to bring care closer to their homes. This requires a comprehensive telemedicine strategy that addresses the issues surrounding the accessibility and affordability of technology, along with the provision of additional support services like remote technical support or telehealth navigators.

4� Focus on strengthening healthcare infrastructure with a focus on senior needs.

a) Develop a framework for setting up senior care facilities and operations to ensure sustained high-quality services. While developed nations have a regulatory framework, enabling the establishment of senior care facilities, there are no model

Senior Care Reforms in India 49

acts or guidelines in terms of minimum standards for setting up senior care facilities or home operations in India. There is a need to develop legal provisions, SOPs, and guidelines at the Central and State levels to facilitate the development of independent senior care facilities at block, district, and state-level hospitals. There is a requirement to set up independent geriatric hospitals, research centers, and health facilities in all the States/UTs with an added focus on rural and remote areas.

b) Making specific provisions for geriatric healthcare within existing healthcare infrastructure for catering to their unique healthcare needs. Special provisions like separate beds, queues, and facilities for senior citizens need to be developed in both public and private sector hospitals. Ayush services and infrastructure also need to be better utilized for senior care. NHP-2017 also recognizes the growing need for palliative and rehabilitative care for all geriatric illnesses and advocates the continuity of care across all levels. The same needs to be ensured in a mission mode. Further, NHP-2017 also advocates that most drugs and diagnostics should be free or subsidized at the tertiary care level, at least for in-patients and outpatients in geriatric and chronic care segments. The same needs to be ensured at all levels.

5� Enhance skilled workforce for elderly care: Human resources for health (HRH) is identified as one of the core building blocks of a health system (WHO 2006). The WHO Global Strategy on Human Resources for Health highlighted that investment in HRH can deliver a triple return of improved health outcomes, global health security, and economic growth. Although the geriatric workforce shortage affects all care settings, it is especially critical in home-health care, partly because we are starting with far too few clinicians to meet the medical needs of the homebound elderly. Currently, the health workforce is trained to respond to pressing health needs associated with acute illness and communicable diseases rather than proactively anticipate and counter changes in people’s intrinsic capacity (physical and mental). Moreover, the geriatric component within the current medical education and training landscape has not been given a prominent place. See Annexure 8 for the existing landscape of training and certification courses in geriatrics.

Figure 8� Workforce required for senior care

Figure 8 illustrates the workforce requirements in order to address the gaps in senior care provision. Key interventions that need to be employed to achieve an appropriately trained workforce in senior care:

» » »

Train all healthcare professionals in gerontology and geriatrics

Include core geriatrics competencies in all health and medical curricula

Match the supply of geriatricians to the population’s needs, and develop geriatric units

Senior Care Reforms in India

to manage complex cases.

» Introduce new workforce cadres and extend the roles of existing staff to act as care coordinators and self-management counselors.

» Ayush human resources can be skilled and utilized in senior care, especially for preventive care, NCDs, and nutrition-related issues. Department of Jara Chikitsa (Geriatrics) can be started in Ayurveda academic institutions for making specific provisions for geriatric healthcare within existing healthcare infrastructure.

» Creating a cadre of personnel trained in home-based care

» Periodic capacity building and training of CHOs/MOs/Mid-level health providers at

primary level needs to be strengthened

» Capacity building of family members and primary caregivers on identifying early signs of dementia, deafness, declining visual capabilities, mobility, cognitive abilities, etc.

A large presence of an under-skilled but practicing health workforce in India, if leveraged strategically, could boost the country’s overall health system. The bridge between the under-skilled to the skilled workforce could be achieved through effective education and training programs, as shown in Figure 9.

Figure 9� Capacity building for medical personnel

Hence, there is a need to develop training institutions that are dedicated to training personnel in senior care industry requirements. The efforts of the Department of Social Justice and Empowerment (DoSJE) and the National Institute of Social Defense must be appreciated in this regard in setting up training centers for geriatric care programs. It is essential to increase partnership possibilities between academic bodies, senior care institutions, and senior care service providers to enhance the supply of trained resources in the sector. NHP-2017 also recognizes the need to develop specialized nursing training courses and curricula for palliative care and the care of terminal illnesses.

Senior Care Reforms in India 51

6� Increase accessibility of services –

a) Home Health Care is an emerging area that includes health care services provided

by both skilled (physical therapy, nursing care, doctor visits) and non-skilled medical (companion and personal care activities, assistance with ADL, transportation, etc.) professionals in the comfort and convenience of the home. The demand for home- based care is expected to increase manifold in the coming years. Although home- based care models offer great potential for improving healthcare, it’s also critical to carefully evaluate and mitigate their risks. Therefore, regulatory provisions must be developed to define the scope and standards of services to safeguard consumers. Moreover, their effective implementation needs to be prioritized.

b) Poshan Abhiyan for Senior Citizens to address their specific nutrient requirements, as envisaged by the Ministry of Social Justice and Empowerment, needs to be operationalized in a mission mode. Further, it is crucial to work closely with the Ministries of Health and Family Welfare, Women and Child Development, and Ayush for framing guidelines and nutritional packages for the elderly; so that the recommended estimated energy requirements (EER) for various essential macro and micro-nutrients for the elderly can be ensured.37 Provisions for nutritional supplements under the guidance of a suitable healthcare professional should be made to fill any nutritional gaps in the diet (see Annexure 9 for details).

c) Mental Health Services: Although we have the National Program for Health Care of the elderly in place, there is immense scope for integration and strengthening of mental health services, particularly neurological and substance use conditions among seniors. Further, focusing on the mental health of the elderly within the existing mental health services ecosystem is required to address the increasing burden of mental illness on the elderly population. It is also crucial to increase the awareness of various mental health conditions among the elderly as well as their caregivers through community outreach programs, and informational sessions, along with the promotion of regular mental health check-ups to identify potential mental health issues at early stages. Finally, specialized geriatric mental health training is also crucial for skilling the human resources involved in the same.

d) Ensure emergency response infrastructure and services for senior citizens. While we have a general emergency infrastructure in place, targeted efforts should be made to make the existing infrastructure more sensitive to the healthcare needs of seniors. Timely availability of ambulance services with Basic Life Support and Advance Life Support care for senior citizens must be ensured. Further, a needs assessment can be carried out to identify the specific needs of senior citizens and gaps in the current emergency infrastructure. Based on that assessment, a comprehensive geriatric emergency response plan should be mapped out that outlines the emergency response infrastructure and services to be put in place to support senior citizens during emergencies.

37 ICMR-NIN Expert Group on Nutritional Requirements for Indians, Recommended Dietary Allowances (RDA) and Estimated Average Requirements (EAR). ICMR-National Institute of Nutrition. 2020

Senior Care Reforms in India

e) Harness the potential of technology for enhancing the accessibility and affordability of health care services. Assistive devices, medication reminders, emergency alarm systems, fall detectors, virtual assistants, and smart health monitoring services through wearables to track individual health and its linkage to ambulance and hospital services, in order to deliver adequate healthcare interventions without losing time.

f) Ensure the availability of rehabilitation services like physiotherapy along with palliative and end-of-life services. There is a need to improve the infrastructure needed for providing these services, like rehabilitation centers, equipment, etc., along with the training and capacity building of healthcare professionals such as physiotherapists, nurses, etc., in specialized areas of care such as palliative care and end-of-life care.

7� Incentivize preventive health – health checks, annual health assessments, vaccinations, etc. a) Periodic screening to assess the levels of decline in functional ability & mental capabilities, along with regular check-ups to screen for common geriatric issues. Efforts like educating the elderly about the benefits of these screenings, providing them with regular reminders, family involvement, and transportation services to the screening centres should be used to ensure that the elderly can attend these

screening appointments.

b) Elderly immunization for vaccine-preventable diseases is also an important area that requires immediate attention. Strengthen immunization under the NPHCE for preventable diseases like pneumonia, influenza, pneumococcal diseases, herpes zoster, tetanus, diphtheria, pertussis, etc., as per the recommendations and guidelines of various leading societies in India, such as the Geriatric Society of India,38 the Association of Physicians in India39, Indian Medical Association40, etc. (see Annexure 10 for details).

c) Harness the potential of Ayush for the prevention of diseases and wellness interventions. Ayush practices can be integrated into the conventional medicine system and treatment plan to promote its use among the elderly. Further, there is a need to conduct thorough research on the effectiveness of Ayush treatments for preventing various NCDs and other chronic conditions among the elderly by partnering with various research institutions.

d) Promote a healthy lifestyle through physical activities, yoga practices, Ayurveda Aahar, and a nutritious diet for maintaining their physical health, functional independence, mobility, mental health, and overall well-being.

8� Strengthen research & setting up research institutions to enhance the knowledge repository of geriatric healthcare.

a) A national senior care resource center, to focus on research. Such a center could

38 Indian Guidelines for Vaccination in Older Adults. Geriatric Society of India. 2015

39 Expert Group of the Associaton of Physicians of India on Adult Immunization in India. The Association of Physicians of India Evidence- based Clinical Practice Guidelines on Adult Immunization. J Assoc Physicians India. 2009; 57:345-356

40Tandon, RN, Ravindra, W, Monga, VK. Life Course Immunization Guidebook. A Quick Reference Guide. Indian Medical Association

Senior Care Reforms in India 53

be used to feed in continuous data for the formulation of evidence-based strategies and policies and to provide knowledge and technical assistance for implementation.

b) Robust data repositories for capturing age-specific health issues, age disaggregated NCDs screening and management, and OOPE data to serve as a solid evidence base for formulating policy actions and plans.

3�2 Efforts to Ensure Social Empowerment and Inclusion

An integrated and comprehensive social support system must be envisaged by the government for the social inclusion of seniors within the wider society. Although the government has taken foundational steps by framing various enabling acts and welfare schemes, their utilization remains low due to various socio-economic barriers. Thus, tailored strategies need to be designed as per the social needs assessment of seniors, an indicative list of which is given in Table 3�2.

Table 3�2� An Indicative List for Social Needs Assessment

Information category

Objective

Patient demographics

Capture information like patient name, age, gender, place of residence, access to healthcare services, etc.

Family and Caregiver situation

Evaluate family information (home support available) – the patient’s place of residence, family members & caregivers, relevant family medical history

Activities of daily living

Identify information on assistance required for activities of daily routine, hygiene & grooming, mobility-related challenges, meal preparation & in- take, getting in & out of bed, and patient’s main method of commuting

Social interactions and patterns

Capture patient’s information on smoking habits, alcohol consumption, and any other addictions, socialization patterns

Awareness levels

Assess awareness levels among seniors regarding various social and legal provisions available for their welfare and protection

Based on the above assessment, a comprehensive social protection and inclusion landscape, with the following focus areas need to be prioritized:

1� Awareness: Efforts need to be made to sensitize the larger community on the needs and challenges experienced by the elderly, to facilitate their social inclusion. Concurrently, efforts to empower the elderly through awareness of existing legal safeguards and available welfare schemes, which specifically cater to their needs, are required to be undertaken through workshops and seminars, legal clinics, online orientations, peer support groups, flyers, and brochures, etc. Legal professionals or community leaders can undertake these measures.

2� Elder for the elderly model: Establishing peer support groups where seniors can exchange experiences and information about various issues. This can be a wonderful way to create a community of support. Further, various participatory and inclusive models of Self-Help Groups must be encouraged to address the various needs such as:

Senior Care Reforms in India

a) Non-medical (mental health, emotional support, psycho-social support)

b) Age care (helplines, senior citizen care homes, daycare centers, physiotherapy) c) Livelihoods (elder-self-help groups; linkages with government schemes)

d) Disaster Response (e.g., COVID19 relief response)

e) Advocacy and Awareness (on rights and policies relating to elders)

3� Legal reforms for the elderly concerns

a) Strengthening the existing Welfare and Maintenance Act to encompass the components of abuse, harassment, protection, maintenance, and other support specific to the elderly population. The amendments proposed in the Maintenance and Welfare of Parents and Senior Citizens (Amendment) Bill, 2019, especially regarding maintenance, maintenance amount, abandonment or abuse of senior citizens, home care services, healthcare, police protection, and so on, are in line with the recommendation described above. There is a need to expedite the process of its notification.

b) The States need to ensure the availability of sufficient human resources, training, and infrastructure for the disposal of pending cases in maintenance tribunals in a time-bound manner.

For instance, the National Legal Services Authority (NALSA) under the NALSA (Legal Services to Senior Citizens) Scheme, 2016 has made various enabling provisions for ensuring legal aid and advice to senior citizens, but the senior citizens’ eligibility for these free legal aids depends on the rules framed by the respective State Governments in this regard. Thus, states need to be encouraged to set up the required legal aid institutions or legal services clinics to ensure legal justice for all senior citizens in a time-bound manner.

4) The elderly-friendly living/housing sector reforms

a)A participative regulatory framework should be developed to support the development of the private sector and provide necessary market stewardship while ensuring the highest quality of service delivery.

b) To widen the discussion on standards and accreditation and have a framework for Quality Certifications and Accreditation of senior care facilities

c) Draft model bye-laws for the development of senior living in India

d) Availability of at least one care home and one multi-service day centre in each district, along with defined minimum standards and provision for registration of these facilities with defined regulatory authorities at the State level, is an immediate requirement.

e) Support informal caregiving and encourage ‘ageing in place’ by enabling home and community-based services and community-managed caregiving (example of Palliative Care Societies of Kerala, Elders Self Help Groups in Tamil Nadu, Pondicherry, Bihar, and West Bengal) for destitute elders.

Senior Care Reforms in India 55

f) A single window approval for senior living projects: will expedite the pace of execution, resulting in faster completion and possession, which is the prime need of seniors. Typically, a 4–5-year development cycle is not a desirable condition for seniors.

5� A ‘one stop’ centralized portal: A national portal for senior care – must be developed for senior citizens to provide easy access of services to them. The portal would act as a citizen charter to disseminate important information to the population about the available services, infrastructure, collection of data, conduct needs and means assessments, provide training modules for caregivers, and create a grievance redressal mechanism. The portal could also be used for filing online applications related to maintenance. Further, provisions for tracking the progress of such applications need to be given.

6� Promoting care economy for senior care: There is a need to recognize care work as well as care workers in the senior care sector by ensuring their rights, emoluments, and entitlements, especially for women, who continue to bear most of the burden of care activities. Further, there is a need to bring the care economy under the regulatory ambit for improving care policies, care service provisions, and ensuring decent working conditions for care workers. Skilling activities and certificate courses for care workers must be expanded to utilize the full potential of the care economy.

3�3 Efforts to Ensure Economic Empowerment and

Inclusion

An ideal financial inclusion landscape must include a robust pension and insurance system, financial literacy, and enabling employment opportunities for the elderly. While we have several financial security nets in place for seniors, their scope and coverage remain limited. Therefore, the government should intensify and consolidate its financial empowerment strategies to achieve the complete inclusion of seniors within the financial sphere. Further, these strategies should be based on the financial needs assessment of seniors, an indicative list of which is given below in Table 3�3.

Table 3�3� An Indicative List for Financial Needs Assessment

Based on the above assessment, an integrated and comprehensive financial protection and inclusion ecosystem must be designed with the following focus areas:

1� Reskilling of the elderly population:

a) Initiatives to foster age-friendly labor markets and employment opportunities,

incentivizing the elderly population by reforming pension schemes and public

Information Category

Objective

Work Status

Information on the occupational status, income levels, and retirement benefits among seniors

Financial independence

Identify the levels of financial independence among seniors and evalu- ate the magnitude of their financial independence/dependence

Insurance penetration

Assess insurance penetration among seniors to evaluate their vulnera- bility to financial distress in case of an adverse health event

Senior Care Reforms in India

benefits systems to stay in the labor markets, and utilizing reskilling platforms.

b) Incentivizing the private sector to introduce age-friendly employability opportunities, especially in tech-based roles.

c) Encourage non-governmental organizations to focus on reskilling the elderly population in technology-based roles.

d) Support to senior-owned businesses – easy financing, tax benefits & concessions.

2� Increase coverage of public funds and infrastructure –

a) Increase coverage of the PMJAY scheme to cover the entire elderly population and increase its coverage to various non-medical and at-home needs.

b) Extending pension support to the elderly population from the unorganized sector as well. There is a need to revise the pension amounts to account for inflation.

c) Mandatory needs and means the assessment for referral to high-cost institutional care.

3� Mandatory savings plan for the affording segment: Since the social security framework in India is limited, most seniors depend on the income generated from their savings. Variable interest rates result in the erosion of their income, sometimes even below sustenance levels. Therefore, a regulatory mechanism is required to set a viable base rate for the interest accrued on senior citizen deposits. Giving a further concession to older women will contribute to their financial well-being.

4� Encourage the private sector to design a targeted and comprehensive geriatric health insurance product, including OPD consultation, diagnostic services, assistive devices, dental and ophthalmological services, rehabilitative services like physiotherapy, Ayush- based services, counselling services, telemedicine and telehealth services, home-based care, palliative care, etc.

5� Increase liquidity and capital allocation to the senior care industry

a) Reverse Mortgage mechanism – The Government should reassess the Reverse Mortgage mechanism to increase liquidity for seniors and by making necessary amendments to the current reverse mortgage rules.

b) Tax and GST reforms, etc., on senior care products to increase the ease of adoption and safeguard the elderly population from the financial burden.

6. Protection from financial fraud – There is a need to increase awareness regarding different types of financial fraud that the elderly population may be more susceptible to using various means. Further, ensuring accessibility to safeguards against the possibilities of such financial fraud and expedited redressal mechanisms is critical.

3�4 Efforts to Ensure Digital Empowerment and Inclusion

Recognizing the opportunity in digital disruption & fostering innovations that help scale big & fast will help make the Indian senior care ecosystem truly future-ready. Governments, private companies, and non-profit organizations can play a crucial role in providing

Senior Care Reforms in India 57

digital devices, internet connectivity, and digital literacy training to seniors. Inspired by innovations in the global senior consumer market, large companies and startups in India have begun to design innovative solutions for this market. Further interventions and strategies for digital empowerment and inclusion of seniors should be designed as per the needs assessment, an indicative list of which is given in Table 3�4�

Table 3�4� An Indicative List for Digital Needs Assessment

Digital literacy levels Assess and capture digital literacy levels among seniors

Based on the above assessment, a robust digital inclusion ecosystem must be designed with the following priority areas:

Information Category

Objective

Digital penetration

Record information related to the adoption, access, use, and penetra- tion of digital tools and devices by seniors

1�

2�

Improving access to digital devices for seniors by making them affordable through various means like senior discounts. Further, the hesitancy and reluctance of senior people concerning digital technologies need to be addressed. Additionally, developers can design digital products and services that are accessible and user-friendly for seniors. By addressing the digital needs of seniors, we can ensure that they are not left behind in the digital age and can lead healthy and fulfilling lives.

Focus on increasing digital literacy, especially among the elderly population, through targeted campaigns, workshops, self-help groups, and non-governmental organizations to improve digital adoption.

Efforts such as setting up community-based centers in rural and urban areas to provide such workshops at the community level may be undertaken. Identification of Digital Champions is a highly effective and sustainable way of delivering digital skills – an individual who is a registered member of the program at respective Centers, has undertaken the required online courses, and volunteers to engage, support, and encourage older people to develop their digital skills and confidence. The themes of these workshops could encompass –

» Mobile phone essentials, such as apps and settings

» Voice control of mobile devices

» Using map apps

» Social media apps

» Photo and video apps

» Making safe and secure digital operations

» Tele-consultation

» Online shopping

Efforts should be made to harness the potential of modern technology like artificial

3�

Senior Care Reforms in India

intelligence, the internet of things, big data, and machine learning to take charge of routine procedures. Adequate support should be extended to startups, innovations & entrepreneurship in the senior care space to create a digital-ready workforce & seniors should be among the priority areas of the government to promote and further digital transformation in the elderly care segment.

3�5 Engaging the Private Sector and CSR Avenues in

Increasing Coverage

Bringing in the private sector players will play a crucial role in ensuring that the government’s objectives in the eldercare area are met effectively, efficiently, and economically. It will create opportunities for the development of the private sector for strengthening eldercare, contribute to the development of the local economy and employment, and ensure the interests of the elderly population are served.

Areas for the involvement of the private sector could be –

1� To add new capacity – building new facilities, institutions, and solutions, and

introducing innovative models of care integration & service delivery

2� To augment existing capacity – building specialized services in conjunction with public facilities, refurbishing, equipping, and operating existing public facilities, or elevating public capabilities with digital tools, expertise, etc.

3� In areas where public facilities are limited – such as emergency response services, digital services, education, and training services, etc.

Various modes and mechanisms to incentivize the involvement of the private sector in the senior care ecosystem could be:

1� Strengthening the PPP model for senior care: The PPP model in India needs a robust implementation framework and governmental support to ensure a balanced division of risks & rewards, and to boost participation by non-governmental players. The collaboration between private, government, and financial bodies like the existing healthcare PPP model could support the development of private infrastructure and enhance access to senior care facilities for all economic segments of seniors.

2� Channelizing CSR funds for elderly care: Earmarking CSR funds as a contribution to national funds or for care provided to the non-affording category of seniors in their facilities in lieu of concessional land, utilities, tax rebates, etc. E.g., the Hospital scheme under Maharashtra Public Trusts Rules 1951.

Private sector synergies through Public Private Partnership (PPP) models and Corporate Social Responsibility (CSR) funds can be explored in the following areas:

1� Elder care homes: Private companies can partner with the government to set up elder care homes that provide accommodation, medical care, and other support services to the elderly. CSR funds can be used to support the construction and operation of such homes.

2� Mobile medical units: Private companies can sponsor mobile medical units that Senior Care Reforms in India 59

travel to remote and rural areas to provide medical care and screening services to the elderly. These units can be staffed by trained medical professionals and equipped with medical equipment and supplies.

3� Private sector Insurance: The possibility of integrated insurance for seniors, including clinical and non-clinical needs, can be explored. International best practices on bundled insurance products need to be explored to develop similar products in partnership with insurance firms and the IRDA. Further, healthcare players are to be engaged to define an internal “Senior Care master plan” to create inclusive, affordable, and customized products and services for seniors. There is a need to remove the insurance rider of a minimum waiting period to cover NCD for senior citizens.

4� Health camps: Private companies can organize health camps for the elderly, where they can receive free medical check-ups, screenings, and consultations. These camps can be held in partnership with local hospitals or clinics and can be funded by CSR funds.

5� Technology-enabled care: Private companies can develop and deploy technology- enabled care solutions that help elderly people monitor their health, stay connected with their caregivers, and access medical care remotely. These solutions can be funded by CSR funds and can be developed in partnership with healthcare providers and technology companies.

6� Skill-building programs: Private companies can sponsor skill-building programs for caregivers and healthcare professionals who work with the elderly. These programs can be developed in partnership with training institutes and can be funded by CSR funds.

7� Advocacy and awareness campaigns: Private companies can launch advocacy and awareness campaigns to raise awareness about the needs and challenges of the elderly and promote policies and programs that support their well-being. These campaigns can be funded by CSR funds and can be developed in partnership with advocacy groups and healthcare organizations.

3�6 Fueling Innovations

Setting up incubation support to facilitate disruptive digital solutions: Prioritized support to startups in the sector should be planned to pave the way for disruptive technology- based solutions in terms of products and services.

In enhancing the institutional funding ecosystem, collaboration should be sought for seeking patient capital (through Impact Funds) with a senior care focus rather than traditional private equity routes. Social entrepreneurship is a vital component for achieving the silver economy, and public policy should build enabling frameworks to help these efforts flourish.

New, flexible models for careers and pensions can encourage people to work longer and plan better for the future. If coupled with life-long reskilling and the adoption of smart and

Senior Care Reforms in India

ANNEXURES

ANNEXURE 1: CONCEPT OF AGEING AND

SENIOR CARE

Global Perspective

The ageing of the population can be described as an increase in the number and proportion of older adults in a population. Ageing is linked to physiological changes and illnesses and has socio-economic and political consequences. Moreover, the experience of ageing is diverse at an individual level due to different socio-economic backgrounds, gender, place of residence, education level, family, and social support.

The diversified and varied experience of ageing across the nations makes it important to take into account the global perspective around the concept of ageing.

WHO’s Framework for Healthy Ageing

The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Along similar lines, WHO presented the concept of “healthy ageing,” according to which “Healthy Ageing is developing and maintaining the functional ability that enables well- being in older age.” Besides focusing on the absence of disease or illness, the concept of healthy ageing places more emphasis on physical and mental capabilities, and the creation of environments that support them.

The concept of healthy ageing is built on the concept of “Intrinsic Capacity and Functional Ability,” as defined below.

Important Definitions with respect to Healthy Ageing Concepts

• Functional ability: It comprises the health-related attributes that enable people to be and to do what they value. It is made up of the intrinsic capacity of the individual, relevant environ- mental characteristics, and the interactions between the individual and these characteristics. It includes a person’s ability to:

a) meet their basic needs;

b) learn, grow, and make decisions;

c) be mobile;

d) build and maintain relationships and;

e) contribute to society.

• Intrinsic capacity: It is a multidimensional indicator of health, which is defined as the combi- nation of one’s physical and mental abilities, which enables the elderly population to continue doing what they value most. It comprises cognition, mobility, psychological, vitality, and sen- sory functions.

• Environment: It is understood in the broadest sense and includes physical, social, and policy environments. It includes home, communities, and the broader society along with the people and their relationships, attitudes, values, health and social policies, and the systems that sup- port them.41

41 WHO CLINICAL CONSORTIUM ON HEALTHY AGEING, NOVEMBER 21-22, 2017, GENEVA, SWITZERLAND. https://www.who.int/ageing/ health-systems/clinical-consortium/CCHA2017-backgroundpaper-1.pdf

Senior Care Reforms in India 61

Intrinsic Capacity

• Cognitive

• Psychological

• Sensory

• Neuromusculoskeletal

• Voice and speech

• Cardiovascular

• Haematological

• Respiratory

• Immunological

• Digestive

• Metabolic

• Endocrine

• Reproductive

Functional Ability

• Learning and applying knowledge

• Communication

• Mobility

• Self-care

• Domestic life

• Interpersonal interactions and relationships

• Major life areas

• Gainful employment and

financial security

• Community, social and civic

life

Environment

• Products and technology

• Natural and built environment

• Social support and relationships

• Attitudes

• Services, systems and

policies to strengthen financial and health inclusion

Unpacking key dimensions of Intrinsic Capacity, Functional Ability & Environmental Response

The interaction between intrinsic capacity, functional ability, and the prevailing environment defines the experience of ageing for an individual. For instance, the ageing experience related to mobility restrictions experienced by an urban elder would be different from a rural elder with similar functional ability, as their environment would be diverse.

Concept of Senior Care in India

Recognizing the issues around population ageing, the MOHFW’s definition of ageing promoted the concept of Active and Healthy Ageing, which is reflected in the operational guidelines for the Elderly Care under the Health & Wellness Centres Initiative. The guidelines envisage a mobility-based classification of the elderly people into three categories: Mobile elderly, Restricted elderly (mobility only with personal assistance/device), and Bed bound elderly (assistance required in some form/home-bound elderly for any reason and those requiring palliative care or end of life care). Similar classifications are being used in the assessment of high-risk elderly, who would be prioritized accordingly for service delivery42.

The “National Program for the Health Care of The elderly, 2010”, uses the term ‘senior citizen’ and ‘the elderly’ for people aged 60 or more. NPCHE is a comprehensive plan for health service delivery to seniors in India. It seeks to provide accessible, affordable, and high-quality long-term dedicated care services to senior citizens. It aims to create a new “architecture for ageing”, and build a framework to create an enabling environment for a “Society for all Ages”.

Furthermore, “ageing in place” or “home-based care” is another policy response that has emerged and gained prominence. It refers to an older person’s ability to live in their own home and community safely, independently, and comfortably regardless of age, income, or level of intrinsic capacity. This home-based care system is viewed as a better alternative for the care of the elderly and has significant financial benefits in terms of healthcare costs. Additionally, the global experience of living under a pandemic has led to the widespread emergence of digital technologies, especially those related to telemedicine, communication, and connectivity.

42 https://nhsrcindia.org/sites/default/files/2021-06/Operational%20Guidelines%20for%20The elderly%20Care%20at%20HWC.pdf

Senior Care Reforms in India

ANNEXURE 2: PRIVATE INSURANCE PRODUCTS FOR SENIORS

S� No�

Health Insurance Package

Benefits

Star Health Red Carpet

• Offering extensive coverage with an increased entry cap of 65-75 years

• Premium: `4450-18000 (service tax excluded)

• Insurance Cover includes:

– In-patient hospitalization charges like ICU expenses, nursing ex- penses, surgeon’s fees, specialist fees, cost of blood, oxygen, cost of drugs, diagnosis, etc. are covered

– Pre and post hospitalization expenses of up to 7% are covered

– Emergency ambulance charges covered

– Treatment at network hospitals only

– Domiciliary treatment is covered

– No medical screening is required, and pre-existing diseases get covered right from the first year

– 30 days initial waiting period with no coverage

– 24/7 toll-free helpline

– Direct in-house settlement

National Insur- ance Varistha Mediclaim

• 60-80 years entry allowance

• Premium: For Mediclaim: `4180-6890 and for critical illnesses: `2007- 2288

• Insurance Cover includes:

– Hospitalization expenses, including nursing expenses, boarding expenses, ICU expenses, nursing expenses, surgeon’s fees, cost of blood, oxygen, cost of drugs, pacemaker, etc., are covered

– Domiciliary expenses covered

– Organ donor’s expenses covered

– Optional critical illness coverage

– Pre-existing diseases are covered right from the start with a 10% extra premium

Senior Care Reforms in India 63

S� No�

Health Insurance Package

Benefits

Oriental Insur- ance HOPE

• This insurance policy is designed for all senior citizens above the age of 60

• Premium: `4500-29000

• Provides a discount on the premium on voluntary co-payment

• Insurance cover includes:

– Hospitalization expenses, including boarding and nursing expenses and ICU charges, doctor, surgeon, anesthetist, consultant or spe- cialist’s fees, are covered

– Emergency ambulance charge is covered

– The cost of anesthesia, blood, oxygen, operation theatre charges, surgical appliances, and diagnostic tests like X-rays are covered

– The cost of medicines, drugs, consumables, artificial limbs, and prosthetic devices like a pacemaker is covered

– The benefit of domiciliary hospitalisation

• The entry-exit age gap is 60-80

• Premium: `3850-7650

• Insurance cover includes:

– Pre-hospitalisation expenses are covered for 30 days

– Post-hospitalisation expenses of 60 days are covered

– Hospitalisation expenses covered for treating injuries/illnesses

– Ambulance charges are covered

– Coverage is limited if the patient is hospitalised in a registered ho- meopathic/Ayurvedic and Unani hospital or government hospitals

– Pre-existing disease coverage can be availed only if the patient has continued the policy for at least 18 months with the company

– Pre-existing illnesses like diabetes mellitus and the issues associ- ated with it, hypertension, etc., get covered after the policy has continued for a minimum of 18 months, provided the additional premium has been paid

sum assured can be either `1 lac and/or `1.5 lakhs depending upon

• The

the preference of the customer.

New India As- surance Health Insurance

64 Senior Care Reforms in India

S� No�

Health Insurance Package

Benefits

• Entry-age for the applicants is 46 to 70 years

• This is an annual plan with lifetime policy renewal

• The sum insured is on an individual basis

• Insurance coverage includes:

– Covers hospitalization expenses

– Pre and post hospitalization expenses equal to 3% of permissible hospitalization expenses

– Ambulance charges up to `1000 per claim

– Pre-existing diseases are to be covered from the second year. Up to

50% of the sum assured amount will be reimbursed

– 130 daycare procedures are covered

– After 4 years policy period, free health-checkups at designated diagnostic centers- including ECG, fasting glucose test, physician consultation, lab tests, blood glucose test, cholesterol, chest X-ray, and complete blood count

Bajaj Allianz Silver Health

• Entry – Any time after the age of 61 years.

• Once covered, the plan can be renewed for lifetime

• Cashless treatment facility

• Insurance coverage includes:

– In-patient Treatment

– Post Hospitalization

– Pre-Hospitalization

– Day Care Procedures

– Domiciliary Treatment

– Organ Donor

– Emergency Ambulance

– E-opinion

HDFC ERGO Health Optima Senior Plan

Senior Care Reforms in India 65

Dimension

Digital Inclusion

– Digital healthcare system that seamlessly combines

technology & medical data.

– New-age technologies like AI and Virtual reality, such

as AI-driven wheelchairs

that move on a pre-select-

ed path; body sensors, and communication tools are

driven by virtual reality, etc.

to help elderly people live

more independently

Economic Support

– Employment-tili-65

law for ensuring

employment for the

elderly to increase their

productive years – Employees’ Pension

Insurance program

& National Pension

Program with pension

amount adjusted

depending on the age at which payments begin.

Social Support

– Launched Asia Health

and Wellbeing Initiative

(AHWIN) in 2016 in collaboration with other

Asian nations to build an

active & healthy society

where people can live long,

fruitful lives

– “Community-based

Integrated Care System”

(CbICS), to build

comprehensive up-to-

the-end-of-life support elements of self-help, services, including key

mutual aid, social solidarity

care, & government care

Healthcare

– Healthcare policy includes both

assisted by trained & licensed

care workers

» Both MC & LTC are offered insurance systems. MC services National Health Insurance (NHI) separately through distinct are financed through the

system; & LTCI was introduced

in 2000, as a mandatory social

people above 65 are eligible for

– “Healthy Japan 21 Program” to

promote active ageing through

(non-smoking) & smart check-ups

Medical care (MC) & long-term care » LTC services available 24/7 are (LTC)

program, where each person over

40 makes a contribution & all the

benefits

smart walk, smart diet, smart breath

Country

Japan

ANNEXURE 3: KEY LEARNINGS FROM ACROSS THE WORLD

43 http://japanhpn.org/en/longtermcare/

44 https://cepr.org/voxeu/columns/japans-age-wave-challenges-and-solutions

66 Senior Care Reforms in India

Dimension

Digital Inclusion

care’ by leveraging digital – Creation of ‘smart home technologies like smart

monitoring, call-service platforms, virtual nursing

systems, robotics, IoT, etc.

Economic Support

– A boom in the senior

care sector, with the 11th FYP suggesting

simultaneously “cultivating the

consumer market for

senior products and the elderly to rational services” & “guiding

consumption.”

– Planning to establish

dedicated to the silver

about 10 industrial parks

economy.

Social Support

– Rule of ‘90-7-3’, i.e. 90% of the elderly are cared for by

family, 7% receive com- munity care & 3% live in – The Chinese tradition of institutional facilities.

“filial piety”, where adult children are expected to

care for their ageing par-

– Various laws like the Elder’s Protection Law to maintain a traditional family support

ents

system for the elderly

– Development of new

elderly care infrastructure

with elderly home care as a foundation, community elderly care as support;

and state institutional care

as a supplement

– Day-care; and recreational & cultural activities to keep

the elderly engaged

Healthcare

– Increased healthcare spending over past years, focussed on building 45

hospitals, clinics, community cen- ters, and facilities for meeting the

needs of retirees throughout their

retirement

erage skill base & quality of service ance to finance major LTC costs of

– Specialized university programs to train elderly care professionals in geriatric nursing, for improving av-

– Introduced Long Term Care Insur-

the elderly

Gerontology’ in 2016 for integrat-

ing scientific research, clinical care,

rehabilitation services, public health

into one

– Established ‘National Centre for

policies, and health management

Country

China

45 https://www.coresponsibility.com/wp-content/uploads/2016/06/The elderly-in-China.pdf 46 https://encyclopedia.pub/entry/23328

Senior Care Reforms in India 67

Dimension

Digital Inclusion

–

Economic Support

–

Social Support

– Adult daycare to ease the burden on caregivers

Healthcare

people above 65 years; & Medicaid, – Medical care through private in- surance funds, a large portion of which is financed by govt. through Medicare, covering hospital care for covering long-term care insurance

plans.

patients to use Medicare, making services accessible to those in need

costs.

– Integration across medical & long-

term care providers with the launch of new models of care like PACE

– Needs assessment of eligible

& to curb overutilization & contain

(Program of All-Inclusive Care for

the elderly)

Country

USA

68 Senior Care Reforms in India

Dimension

Digital Inclusion

– The digital strategy priori-

tizes continued investment

in digital infrastructure through access to free – Digital skill development training. NGOs deploy

models such as setting up a

Digital Champions Network,

undertaking the required

online courses, and volun- teers to engage, support and encourage older peo- ple to develop their digital

– Organizations working with tech companies to help

skills.

them develop user-friendly

technologies and practical

solutions for seniors.

Economic Support

– Reforming the pension

and public benefits sys-

tem to provide incen- tives to stay in the labor

adults go back to work like the New Enterprise Allowance (NEA), which

force

or disabled individuals

– Policies that aid older

aims to help unem- ployed, low-income,

start their businesses.

Social Support

– Enabling environment for

local governments and organizations to deliver

services independently to

– The proactive role of NGOs and the private sector to

the elderly

improve the quality of life

for older adults

Healthcare

– Free public healthcare to all citi-

zens through the National Health

Service (NHS), (including ambu- lance, and mental health care),

Structured financing mecha-

–

Commissioning Groups or local

bodies). NHS pays for long-term

terms of non-medical care, 60% is

40% from OOPE.

Vertical integration from hospital

–

(composed of medical staff, care

coordinators, community nurses,

apists, and social workers)

which is funded primarily through

general taxation.

nisms, for both medical (NHS) and

non-medical LTC (through Clinical

care for people with care needs. In

financed by local bodies/NHS and

to home and horizontal integra- tion across multidisciplinary teams

occupational therapists, physiother-

Country

Senior Care Reforms in India 69

Dimension

Digital Inclusion

–

Economic Support

– Approximately 85%

of the population is

covered by compulsory

public health schemes, and the remaining 15% has private insurance.

– Mandatory contribu-

tion by employees and

employers towards State

health insurance funds insurance programs to and long-term care

reduce the burden on government funds. – Employees and their employers make con-

tributions towards a

Retirement pension fund, which is used to

provide cash benefits to

the elderly.

Social Support

– Senior Activity Centres (SACs) are drop-in cen- tres for low-income and

vulnerable seniors living in subsidized public housing apartments. They offer so- cial and community space,

information and referral

services, manage emer-

gency alert response and monitor frail and/or home-

bound older people.

– Senior Group Homes

enable assisted living for

the elderly with care needs

through a supportive

environment by bringing

vulnerable older people with the same physical impairments together in a cluster of rental units.

Healthcare

– Healthcare coverage is largely

– A robust and structured healthcare needs, though OOPE is quite high financing system for non-medical

and long-term care expenses are

expected to rise

– There is an excessive burden on

young people as they indirectly

sizing health, inclusive of an ageing

driven by private insurance, with the government playing a policy-mak-

ing role.

finance elderly care through taxes – From Health Care to Health: empha-

population

Country

Germa-

70 Senior Care Reforms in India

Dimension

Digital Inclusion

–

Economic Support

–

Social Support

– The Integrated Care for the

elderly (SPICE) program

was developed by the

Agency for Integrated Care

(AIC) to provide compre-

hensive, integrated Centre

and home-based services

or non-medical services to support caring for the

elderly.

Healthcare

– Largely self-financed healthcare

infrastructure as individuals pay for

government subsidizing part of the medical expenses (financed through

their healthcare

taxes/ government budget). The remaining costs are covered by pa- tients using the mandatory savings

schemes (Medisave) with com- prehensive coverage, along with

mandatory co-payments to prevent

– A regulated healthcare marketplace

misuse.

with an advanced healthcare deliv-

ery system. Public hospitals offer

high-quality services, thus forcing

private health providers to maintain prices at public levels to avoid pric-

ing themselves out of the market.

– Funding mechanism based on

Country

Singa-

pore

Senior Care Reforms in India 71

Dimension

Digital Inclusion

Economic Support

– National Basic Liveli- hood Security System (NBLSS) guarantees a minimum standard of living to the elderly who earn less than the mini-

mum cost of living and

those with no immediate family members capable

of supporting them

– Re-employment for job-seeking elders through the ‘Aged Em-

ployment Promotion Act

2003’

– National Pension service

for the elderly pension to people above 65 and

basic old age pension

system providing 5% of

48 Koreans’ average wage for 70% of the elderly – Unemployment insur-

ance

– Senior discounts

Social Support

– Universal Social Insurance

for Social Care services through the Comprehen-

sive Welfare Program,

launched in 2016

– The elderly welfare com- munity care program by local governments for

assistance in everyday

routine activities. Later

extended to include public

silver housing equipped

with safety devices; and

the elderly day-care

– Meal service(Free or low-

– Social activity programs to ensure social engagement

price)

and entertainment

Healthcare

– Social Insurance (for all)

» National Health Insurance

» National Long-term Care Insur-

ance for Elders – Tax based services

» Center for dementia support

» Service for early detection of

» Support for treatment for demen- dementia

tia

» Support for the old-age-related

optical surgery

Country

South

Korea

47 https://www.unescap.org/sites/default/files/Session1_Mr.KimChanWoo_RoK.pdf 48 http://www.ijssh.org/papers/355-A10040.pdf

72 Senior Care Reforms in India

Dimension

Digital Inclusion

(2017-21) started initiatives – 12 National Economics & Social Development Plan like Thammasat Model & th

schools for reskilling older people, particularly direct-

ed towards improving dig-

people

ital literacy among senior

Economic Support

– Social Pension Policy – Old Age Allowance was

made universal in 2009

– Senior Citizens Council of Thailand(SCCT) de-

vising new & innovative

mechanisms to ensure better occupational opportunities for the elderly

Social Support

– National Plan for Older

lives, including:

1. Establish a System

Protection for Older

Adults (MSDHS)

Income (MOL)

3. Develop Health Sys-

4. Modify Housing and

Safety (MOI)

tem (MSDHS)

6. Educate the Young

ration in All Aspects

Persons & 2 National Plan nd on the elderly to promote dignified & quality ageing

Society (2018) acknowl- – National Agenda on Aged edges active ageing &

focuses on 6 sustainable

goals for improving their

of Welfare and Social

2. Promote Elder Employ- ment and Sustainable

tem for Aged Society

Public Spaces for Elder

(MOPH)

5. Set-up Time Bank Sys-

Generation for Prepa-

(MOE)

Healthcare

– Institute of The elderly Medical Science, Department of Medical Service, Ministry of Public Health

– National Strategy on Long-Term Care and Policy on Develop-

ing Long-Term Care in 2006 to

holds to care for the elderly

spinal trauma, etc.

teer-based approach

– Joint management of long-term

best practice model of local long-

is the nodal agency for the elderly

healthcare

strengthen the capacity of house-

care by community hospitals in – Policy by the Ministry of Public Health for providing intermediate acute conditions of stroke, brain &

– The Buddy Home Care model was

developed in 2012 by NGOs for pro-

viding cost-effective & high-quality healthcare services at home, with disadvantaged youths support-

ing the elderly through a volun-

care by SAOs & local hospitals as

well as communities emerged as the

term care

Country

Thailand

Senior Care Reforms in India 73

Dimension

Digital Inclusion

Economic Support

Social Support

– The Elderly Act (2003)

for the social, economic & health protection of the

elderly

Committee of Senior Cit- – Established the National izens to promote a posi-

tive attitude towards the

– Older adults clubs & health

elderly

promotion temples to

ensure engagement of the

elderly in society

Healthcare

Country

74 Senior Care Reforms in India

Dimension

Digital Inclusion

Economic Support

– Senior Housing by

Swedish municipalities considering the needs of

the elderly and people

with disabilities

– Legal right to remain in the workforce till 69 » National Retirement

Pension System through Swedish

Pensions Agency and other agencies like:

» National Pensioner’s Organization (PRO)

» Swedish Pensioner’s

Association (SPF)

» Swedish Municipal

Pensioners’ Association

(SKPF)

Social Support

– The elderly Care Policy

– National Action Plan on Policy for the Elderly contains about 20 mea-

sures for the welfare of the

elderly

– Social Services Act

governs elderly care, and the elderly care is largely

funded by municipal taxes

& government grants

meals for the elderly under

is based on local deci- sion-making with emphasis placed on the quality of life for the elderly & their

families

– Municipality-funded home-

– Adel Reform (1992) shifted the onus of providing home

help services

health services to local mu-

munity involvement, citizen accountability. There is a nicipalities; ensuring com- empowerment & public provision of pre-cooked

this.

Healthcare

– Decentralized national health care

system

– Emphasis on 5 focus areas pertain-

Accessibility to home health & prac-

a. Preventive care

c. Physician prescribed physical activ-

ity

d.Timely Treatment, ensuring doc- tor’s appointment within 7 days & not exceeding 90 days in case of

– Subsidized healthcare costs for the

specialist

ing to elderly care

b.Priority to ageing in place

tical health services

elderly

Country

Sweden

49 https://sweden.se/life/society/the elderly-care-in-sweden

Senior Care Reforms in India 75

Dimension

Digital Inclusion

– Technology-driven solution for the elderly to empower

& encourage them to be

active through information sharing & joint decision

– ColumnaCura, an electron- ic citizen record, provides mobile support and engag- es citizens in the treatment

making

of the elderly

Economic Support

funded by heavy taxa- the majority of retirees – The pension system is tion on salaries, which will have paid for 40

years

Social Support

– The elderly care policy

ensures that senior people

maintain an independent life and are healthy in their

own homes as long as – Senior Citizen Council in possible

each municipality looks af-

ter the rights of the elderly

– Every three years, local au- thorities and practitioners

gather with leaders from Denmark’s five geographi- cal regions to plan service

improvements.

Healthcare

– National Action Plan on Dementia

(2025)

– Nursing homes are typically run by municipal councils, with even

inspections and subsidies to bring

facilities

– The Danish long-term care (LTC) system is a universal program, which includes home assistance

abled, institutional care, and infor-

private facilities subject to local

costs in line with those of public

services for the elderly and the dis-

mal care

Country

Den-

mark

50 https://www.theguardian.com/world/2016/feb/02/for-pensioners-something-is-spot-on-in-the-state-of-denmark

76 Senior Care Reforms in India

Dimension

Digital Inclusion

Economic Support

– The elderly care services contribute a large share

in the services sector,

accounting for a quarter

of the total municipal budget, which is almost

3% of the GDP

– Universal pension cover- age for everyone above

Social Support

– An extensive public long- term care (LTC) program that is funded by national

taxes but implemented

locally, and depending on

the level of care required,

co-payments may be 51 decided

» Services include home

practical care, home

medical care, institution-

al day and night care, daytime relief for infor-

mal caregivers, provision

of assistive devices and technology, economi- cal support to informal

caregivers, social contact

assistance, and personal assistance for disabled

– Provision of specially

constructed ‘smart’ apart- ments, especially for those

suffering from dementia

Healthcare

– Spends around 2.2% of its GDP on

the elderly care

– Decentralized elderly Care Model

where local municipalities are re-

sponsible for primary healthcare – Secondary healthcare, including ambulance services, is owned & run

by the government through regional

health authorities

– Municipalities invest in-home care

or at-home nursing stations instead

of relying upon institutional care

Country

Norway

51 https://www.oecd.org/norway/47877969.pdf

Senior Care Reforms in India 77

78 Senior Care Reforms in India

ANNEXURE 4: EXISTING PACKAGE OF SERVICES AT VARIOUS LEVELS FOR GERIATRIC CARE IN INDIA UNDER THE NATIONAL PROGRAM FOR THE HEALTH CARE OF THE ELDERLY

Structure of Geriatric Healthcare in India

At present India has three National Centres for Ageing at the central level of administration, followed by points of care at regional hubs, district hospitals, community health centres, primary health centres, and sub centres. The following illustration depicts the structure of geriatric healthcare in India, with the number of such facilities given in parenthesis alongside.

National Centre for Ageing (3) Regional Geriatric Centre (18) District Hospitals (718) Community Health Centres (4869) Primary Health Centres (18407) Sub – Centres (90719)

The various service areas in the existing package of healthcare services for geriatric care under the Government of India’s National Program for the Health Care of the Elderly are described as follows:

Existing comprehensive healthcare package for the elderly

Sr� No

Service Areas

Package of Services

Nutritional Assessment

• Nutritional history

• Screening using a Geriatric Assessment Tool

• Mini-Nutritional Assessment Scale

Mental Health Assessment

• History of mental health disorders

• Screening for mental health diseases

NCD Management

• Screening for hypertension and diabetes

• Management and follow-up of hypertension and diabetes

Oral Assessment

• Oral care examination and screening for dental caries

• Assisted oral care

Ophthalmic Assessment

• Visual acuity testing

• Near vision testing

• Screening for cataracts

Cardiovascular Risk Assess- ment

• History of smoking, alcohol

• Health education to prevent cardiovascular diseases

Senior Care Reforms in India 79

80 Senior Care Reforms in India

ANNEXURE 5: SCHEMES, PROGRAMS, AND ACTIVITIES OF MINISTRIES AND DEPARTMENTS OF THE GOVERNMENT OF INDIA FOR THE WELFARE OF THE SENIOR CITIZENS

The schemes, programs, and activities of Ministries and Departments of the Government of India for the welfare of the senior citizens are categorized as per Ministry and detailed below. (Sources of scheme details are included in the References)

1� Ministry of Social Justice and Empowerment

Name of the Scheme/ Program/ Activity

Goal/Benefits

Atal Vayo Abhyudaya Yojana (AVYAY), for- merly known as Na- tional Action Plan for Senior Citizens (NAPS- rC)

AVYAY targets the four basic needs of senior citizens: financial security, food, health care, and human interaction/life of dignity. Basic amenities, shelter, food, entertainment opportunities, etc., are provided free of cost to indigent senior citizens. It also covers matters related to seniors’ safety and protection, along with awareness generation and sensitization of society. AVYAY is an umbrella scheme that has been in existence since April 1, 2021, and includes the following schemes:

• Scheme of Integrated Program for Senior Citizens (IPSrC) *

• State Action Plan for Senior Citizens (SAPSrC) *

• Rashtriya Vayoshree Yojana’ (RVY) **

• National Helpline (Elderline) **

• Seniorcare Ageing Growth Engine (SAGE)- Promoting Silver Economy**

* Source of funding: Budget

** Source of funding: Senior Citizens’ Welfare Fund

Senior Care Reforms in India 81

Name of the Scheme/ Program/ Activity

Goal/Benefits

Scheme of Integrated Program for Senior Cit- izens (IPSrC)

Provision of financial assistance to eligible organisations for running and main- tenance of Senior Citizen Homes/Continuous Care Homes to improve the qual- ity of life of the senior citizens, especially indigent senior citizens by providing basic amenities like shelter, food, medical care, clothing and entertainment op- portunities and by encouraging productive and active ageing.

Following Projects are admissible for assistance under the IPSRC:

a. Maintenance of Senior Citizens Homes for 25 beneficiaries to provide food, care and shelter for a minimum number of 25 indigent Senior Citizens.

b. Maintenance of Senior Citizens’ Homes for 50 beneficiaries to provide food, care and shelter for a minimum number of 50 indigent Senior Citizens (male only/male and female combined).

c� Maintenance of Senior Citizens Homes for 50 elderly women only: Deeply concerned that the situation of older persons in many parts of the Nation has been negatively affected by the poverty, financial and economic crisis, and noting with concern the high incidence of poverty particularly among older single women.

d� Maintenance of Continuous Care Homes and Homes for senior citizens af- flicted with Alzheimer’s disease/ Dementia for a minimum of 20 Senior Cit- izens who are seriously ill requiring continuous nursing care and respite or those who are afflicted with Alzheimer’s disease/ Dementia.

e� Maintenance of Regional Resource and Training Centres: Regional Resource and Training Centres (RRTCs) will work as key nodal agency on aged care and coordination under the overall direction & supervision of Department of Social Justice and Empowerment, providing overall technical support and inputs on senior citizens programs in their assigned States allocated by the Ministry. The main role and responsibility is to provide mentoring, hand-hold- ing support to the SrCHs in their jurisdiction to ensure that they all maintain the standards laid down under these guidelines. They would also be respon- sible for carrying out advocacy, awareness generation, training of stakehold- ers, database generation, inspections, monitoring, research and liaising with the Governments of the States assigned in the field of old age care.

f� Maintenance of Mobile Medicare Unit (MMU) for Senior Citizens and Phys- iotherapy Clinics for Senior Citizens: Renewal/Ongoing projects of MMU and Physiotherapy Clinics for senior citizens henceforth will continue to be sup- ported by the Ministry of Social Justice and Empowerment under the IPSRC. No new MMU shall be supported under the scheme.

Additionally, the Department of Social Justice and Empowerment has pre- scribed norms pertaining to Old Age Homes including land, living space, facil- ities and operational standards such as nutrition, medical facilities/ medicare, recreation, security, clothing, rooms, bathroom and toilet, hygiene and sanita- tion, etc.

82 Senior Care Reforms in India

Name of the Scheme/ Program/ Activity

Goal/Benefits

State Action Plan for Senior Citizens (SAPS- rC)

Grant-in-aid is provided to States/UTs for State-specific activities for the welfare of senior citizens. Grant-in-aid is provided on the basis of the demand of the States/UTS and requisite documents provided by them. SAPSrC was launched in 2019- 20. Funds are released for the following activities:

(i) Maintenance of Mobile Medicare Units (MMU) for Senior Citizens: To provide medical care to the senior citizens living in rural, isolated and backward areas. The Mobile Medicare Unit is meant for Senior Citizens living in slums, rural and inacces- sible areas where proper health care facilities are not available. Under this, grants would be provided to the District level hospitals in the Aspirational Districts for improving the healthcare facilities in the underserved areas. This grant would be in addition to and would operate in synchronisation with the efforts for healthcare facilities under the NHM. The project aims to enable Senior Citizens to assume an active role in maintaining and improving their own health and in encouraging others to do the same. Each Medicare Unit should cover minimum 400 Senior Cit- izens per month. Each MMU should make at least 10 trips per month to such areas. Grant-in-aid to organisations/NGOS/VOS for the programme of Mobile Medicare Units for senior citizens shall henceforth be given by the State Government.

(ii) Physiotherapy Clinics for Senior Citizens: Grant-in-aid under this project to be giv- en to agencies that have shown a credible track record in running projects for the welfare of the Senior Citizens for running of physiotherapy clinic for a minimum of 50 Senior Citizens per month. This is permitted only in the Govt District Hospitals.

(iii) Creation of a pool of trained Geriatric Caregivers for senior citizens: Grant- in- aid is to be given to the agencies, which have shown good track records in health care especially in Geriatric care, for providing training for the creation of a pool of trained Geriatric Caregivers or to provide bedside assistance to needy elderly.

(iv) Special drive for cataract surgeries for senior citizens to achieve the vision of Cataract/Blindness-Free State for Citizens: Senior Citizens Rural Outreach Programme for Cataract Surgery is an effort to assist the National Program for Control of Blindness. This is to be done, by envisaging easing of the burden of the continuing rise in the prevalence of cataract blindness due to the increase in the population of senior citizens by arranging special drives for Cataract Surgeries’. Cataract Surgeries will be carried out in all districts in Government Hospital or at suitable places like community health centres every year in such a way that every district may achieve the vision of cataract blindness free districts for senior citi- zens. Surgery of Senior Citizen BPL card holder shall be done free of cost including providing medicines etc. In this regard, necessary funds may be demanded by submission of the State Action Plan every year through E-Anudaan portal.

(v) State-specific activities for the welfare of senior citizens, especially who are indigent in the States/UTS: As far as possible 20% of the funds allocated to the State, may be utilised by the State Governments for innovative pro- grammes, as per requirement, for the welfare of the elderly.

Senior Care Reforms in India 83

Name of the Scheme/ Program/ Activity

Goal/Benefits

Seniorcare Ageing Growth Engine (SAGE) -Promoting Silver Economy

To encourage youth to think about the problems of the elderly and come out with innovative ideas for elderly care and promoting them into start-ups by providing equity support. Industrial Finance Corporation of India (IFCI) Venture Capital Ltd. will hold the equity support given to the innovative startup projects, on behalf of the Ministry (not exceeding 49%). Each selected startup is provid- ed a maximum of 1 crore as equity share.

Channelizing CSR funds for elderly care

This is also a new scheme to direct CSR funding to aged care projects in the most efficient way possible. Under Schedule VII of Section 135 of the Compa- nies Act, setting up old age homes, daycare centres, and such facilities for Se- nior Citizens is an approved item for CSR funding.

Scheme for Aware- ness Generation and Capacity Building for the welfare of Senior Citizens

• Components like the National Helpline for Senior Citizens, research, awareness, sensitization, etc., for the welfare of senior citizens, spreading awareness and sensitizing the youth and other sections of the society towards the issues related to the elderly.

• The National Helpline: National Helpline for Senior Citizens – Toll-free No. 14567 – for all senior citizens of the country. It was launched on 1st October 2021 to provide free information, guidance, emotional support, and field intervention in cases of abuse and rescues in order to improve the quality of life of senior citizens. Elderline is operational from 8 a.m. to 8 p.m., all 7 days of the week. The National Institute of Social Defence (NISD) has been nominated as the Central Nodal Agency for Elderline.

Rashtriya Vayoshri Yo- jana (RVY)

•

» »

This scheme aims to provide physical aids and assisted living gadgets to senior citizens who are BPL and have age-related disabilities or infirmities to restore near-normalcy in their bodily functions. The Scheme is being funded by the Senior Citizens’ Welfare Fund (SCWF).

The Scheme has been revised w.e.f. F.Y. 2020-21. Under the revised Scheme, the criteria for selecting beneficiaries under the amended Scheme have been expanded to cover not just senior individuals who fall into the BPL category but also senior citizens who have a monthly income of less than `15000/- and who suffer from age-related disabilities/infirmities.

The number of devices previously provided has been enhanced under the updated RVY Scheme. At present, the following items have been included for distribution:

Generic Items: Walking sticks, Elbow crutches, Walkers/Crutches, Tripods/Quad pods, Hearing Aids, Artificial Dentures, and Spectacles Special Items: Wheelchairs, Wheel Chairs with Commode, Chair/ Stool with Commode, Silicon Foam Cushion, Knee Brace, Spinal Sup- port, Cervical Collar, Lumbosacral Belt (LS), Walker/Rollator with Brakes, Walking Stick with Seat, Foot Care Kit.

The Scheme is fully financed (100% funded) by the Central Government from Citizens’ Welfare ‘Senior Fund’. The extent of support free of cost distribution of “Physical Aids and Assisted-Living Devices” commensu- rates with the extent of disability/ infirmity that is manifested among the eligible senior citizens. In case of multiple disabilities /infirmities, the as- sistive devices will be given in respect of each disability /impairment that is manifested in the same person. The Implementing Agency shall pro- vide one year of free maintenance of the aids and assisted living devices supplied by them. The maximum cost of devices will not be exceeding ` 7,000/-per beneficiary

84 Senior Care Reforms in India

Name of the Scheme/ Program/ Activity

Goal/Benefits

Senior Citizens’ Wel- fare Fund

In pursuance of the Budget Announcement 2015-16, this welfare fund has been created to be utilized for the promotion of the welfare of senior citizens. The fund is administered by an Inter-Ministerial Committee, comprising of Depart- ment of Financial Services, the Ministry of Health and Family Welfare, the Min- istry of Rural Development, the Ministry of Housing & Urban Affairs, and the Ministry of Labour and Employment, with the Ministry of Social Justice and Empowerment as the Nodal Ministry for the administration of the Fund.

National Council of Se- nior Citizens (NCSrC)

• In pursuance of the National Policy for Older Persons (NPOP), the Nation- al Council for Older Persons (NCOP) was constituted in 1999 to oversee the implementation of the Policy and to advise the Government in the formulation and implementation of policy and programs for the aged.

• It was reconstituted and renamed as National Council of Senior Citizens (NCSrC) in 2012 with a mandate to advise Central and State Governments on the entire gamut of issues related to the welfare of senior citizens and the enhancement of their quality of life.

Vayoshreshtha Sam- man

• To recognize the efforts made by eminent Senior Citizens and Institutions involved in rendering distinguished services for the cause of the elderly persons, the Ministry of Social Justice and Empowerment started cele- brating the International Day of Older Persons (IDOP), since 1st October 2005.

• Further, to showcase the Government’s concern for senior citizens and its commitment towards them, the Vayoshrestha Samman was upgraded to National Award, and the Scheme of National Awards for Senior Citizens was notified in the Gazette of India on 22.01.2013. The Awards are given under thirteen categories.

• The National Awards were presented for the first time in 2013, on 1st Octo- ber, on the occasion of International Day of Older Persons (IDOP).

Accessible India Campaign (Sugamya Bharat Abhiyan; Dept� of Empowerment of Persons with Disabil- ities)

The Campaign was launched in 2015 as a nationwide campaign for achieving universal accessibility for Persons with Disabilities (PwDs). This includes the creation of elder-friendly, barrier-free environments in buildings, public toilets, buses, bus stands, airports, and other public places to create age-friendly cities.

e-Anudaan portal

e-Anudaan is an initiative by the Ministry of Social Justice and Empowerment to enable Non-Government Organizations (NGOs) to register online and log in to apply for Grant-in-aid to help implement various schemes of the Ministry.

Senior Care Reforms in India 85

2� Ministry of Finance

Name of the Scheme/ Program/ Activity

Goal/Benefits

Pradhan Mantri Vaya Vandana Yojana’ (PMVVY)

• The scheme aims to protect elderly persons aged 60 years and above against a future fall in their interest income due to the uncertain mar- ket condition and provide social security during old age. It is being implemented through the Life Insurance Corporation (LIC) of India. It provides an assured return of 8% per annum, payable monthly for 10 years. A loan facility is available after the completion of 03 policy years. The differential return, i.e., the difference between the return generated by LIC and the guaranteed return of 8% per annum, would be borne by the Government of India as a subsidy on an annual basis.

• The scheme was open for subscription for one year, i.e., from 4th May 2017 to 3rd May 2018. The minimum purchase price under the scheme was ` 1.5 lakh per family for a minimum pension of ` 1,000/- per month, and the maximum purchase price was ` 7.5 lakh per family for a maximum pension of ` 5,000/- per month.

• In pursuance of Budget Announcement 2018-19, Cabinet approved the extension of PMYVY up to 31st March 2020 and a maximum pur- chase price limit of ` 7.5 lakhs per family under the scheme has also been enhanced to ` 15 lakhs per senior citizen.

• The Union Cabinet approved a further extension of PMVVY up to 31st March 2023 in May 2020 with some amendments in the interest rates and minimum investment amount.

Pradhan Mantri Suraksha Bima Yojana (PMSBY)

The Scheme of PMSBY is available to people in the age group of 18-70 years with a bank or post office account and give consent to join/enable auto-debit. The risk coverage under the Scheme is ` 2 lakhs in case of accidental death or total permanent disability and ` 1 lakh for partial per- manent disability.

Atal Pension Yojana (APY)

[Pension Fund Regulatory and Development Authority (PFRDA)]

The scheme was launched on 9th May 2015, to create a universal social se- curity system for all Indians, especially the poor, the underprivileged, and the workers in the unorganized sector. It is open to all citizens of India be- tween 18-40 years of age who have a bank account in a bank or post office. Five pension plan slabs are available under the scheme, namely, ` 1000, ` 2000, ` 3000, ` 4000, and ` 5000, guaranteed by the Government of India to the subscriber at the age of 60 years.

Varishtha Pension Bima Yojana (VPBY)

Under this Scheme, the subscribers on payment of a lump sum amount get a pension at a guaranteed rate per annum (payable monthly). Any gap in the guaranteed return over the return generated by the LIC on the fund is compensated by the Government of India by way of subsidy payment in the scheme. The scheme allows withdrawals of deposit amounts by the annuitant after fifteen years of purchase of the policy. The scheme is ad- ministered through the Life Insurance Corporation of India.

Senior Citizens’ Saving Scheme (SCSS)

The SCSS is a retirement benefit program. Individuals over 60 years old can opt for the SCSS scheme by making an individual or joint investment. The installment amount ranges between 1,000 and 15 lakhs. This amount is constricted to the retirement benefits. This Scheme also provides tax benefits.

86 Senior Care Reforms in India

Name of the Scheme/ Program/ Activity

Goal/Benefits

Higher rate of Interest

With respect to senior citizens having savings accounts in banks and post offices, higher interest rates are given to such senior citizens.

Door-step Banking

As per the directions of the Reserve Bank of India, all banks are to provide separate basic banking facilities such as door-step banking including with- drawal of cash, pick up of cash delivery for Demand Drafts, submission of KYC documents and life certificates at the residence of customers who are senior citizens and individuals with disabilities.

Income Tax Rebate

Ministry of Finance provides Income Tax Rebates to Senior Citizens Income.

• Tax exemption for senior citizens is up to ` 3 lakhs, and only 5% is levied on income between ` 3 lakhs and 05 lakhs as per the existing tax regime.

• Senior citizens above 80 years are exempted from paying income tax up to ` 05 lakhs.

• Deduction in the case of every senior citizen u/s 80DDB of the In- come Tax Act on expenditure on account of specified diseases has been increased.

• Section 80TTB of the Income Tax Act has provisions relating to tax benefits available on the interest income from deposits with a banking company, post office, or co-operative society engaged in carrying on the banking business of an amount up to ` 50,000 earned by the senior citizen (i.e., an individual of the age of 60 years or above)

• Existing provisions of section 207 of the Income-Tax Act, 1961 ex- empt individual resident senior citizens (60+ years) at any time during the previous year from payment of advance tax which does not have any income chargeable under the head ‘Profits and gains of business or profession.’

To incentivize the younger generation to look after their parents’ medical needs, section 80D of the I.T. Act provides a deduction to keep insurance on the health of the parents or parents of the assessee. A similar deduction is also available to a Hindu Undivided Family (HUF) in respect of health insurance premiums to effect or to keep in force insurance on the health of any member of the HUF.

Service Tax

Under the Service Tax laws of the Ministry of Finance, activities relating to the advancement of education programs or skill development relating to persons over the age of 65 years residing in a rural area by an entity reg- istered under Section 12AA of the Income Tax Act, 1961 are exempt from Service Tax. Concerning Savings Accounts in Banks and Post Offices, high- er interest rates are given to senior citizens.

Scheme for Reverse Mortgage

The Scheme was launched in 2007 by the Ministry of Finance. Under the Scheme, senior citizens can mortgage their property with Bank and get a maximum loan amount of up to 60% of the value of the residential prop- erty. The maximum tenure of the mortgage is 15 years, and the minimum is 10 years. Some banks are now also offering a maximum tenure of 20 years.

Senior Care Reforms in India 87

Name of the Scheme/ Program/ Activity

Goal/Benefits

Health Insurance

Insurance Regulatory Development Authority (IRDA), under the Ministry of Finance, vide letter dated 25.5.2009, issued instructions on health insur- ance for senior citizens to CEOs of all General Health Insurance Companies, which, inter-alia, include:

• Allowing entry into health insurance scheme till 65 years of age

• Transparency in the premium charged

• Reasons to be recorded for denial of any proposals on all health in-

surance products catering to the needs of senior citizens

• Likewise, insurance companies cannot deny renewability without

specific reasons.

88 Senior Care Reforms in India

3� Ministry of Health & Family Welfare

Name of the Scheme/ Program/ Activity

Goal/Benefits

National Program for Health Care of the Elderly (NPHCE)�

NPHCE, launched during 2010-11, is a State oriented program with the ba- sic thrust to provide comprehensive and dedicated health care facilities to elderly persons above 60 years of age at various levels of primary, second- ary, and tertiary health care.

I� Primary & Secondary Geriatric Care Services: The program com- menced with 100 districts in the 11th plan period. Presently 718 Health districts have been sanctioned for geriatric primary & secondary care services of OPD, 10 bedded Geriatric Ward, Physiotherapy, and laboratory services.

I� Tertiary level activities of NPHCE: Renamed as ‘Rashtriya Varisth Jan Swasthya Yojana’ in 2016-17. Regional Geriatric Centres (RGCs) in selected Medical Colleges of states have been sanctioned for ter- tiary care service delivery under NPHCE in the form of specialized OPDs, geriatric wards, earmarked beds in various specialties like urology, orthopedics, ophthalmology, etc., human resources de- velopment & research activities. Presently OPD services are being provided through 18 RGCs, inpatient services in 16 RGCs, physio- therapy in 14 centers & laboratory services in 13 centers. Two Na- tional Centres for Ageing (NCA) have also been developed as the Centre of Excellence for Geriatric Care services. Two hundred bed- ded NCA at Madras Medical College, Chennai, and another NCA at AIIMS, New Delhi.

II� Training Modules: Three sets of Training modules for Medical Of- ficers, Nurses, and Community-based workers to deliver Compre- hensive Geriatric care have been developed. State-level Training of Trainers of Medical Officers for Comprehensive Geriatric Care has been conducted in various states.

NPHCE Website: An interactive and dynamic website cum MIS of the NPHCE program has been initiated through the Center for Health Informat- ics (CHI) to provide comprehensive information along with data regarding geriatric facilities and services available throughout the country.

Senior Care Reforms in India 89

Name of the Scheme/ Program/ Activity

Goal/Benefits

Longitudinal Ageing Study in India (LASI) Project

The Ministry of Health and Family Welfare launched this project in 2016 to assess the health, economic, and social status of the elderly (aged 45- 60). LASI is a full–scale national survey of scientific investigation of the health, economic, and social determinants and consequences of popula- tion ageing in India. Ministry of Health & Family Welfare has undertaken the Longitudinal Ageing Study of India, through the International Institute for Population Sciences (IIPS), Mumbai, in collaboration with Harvard School of Public Health, University of Southern California, USA, Dt.GHS, United Nations Population Fund (UNFPA), and National Institute on Ageing.

• The LASI, Wave 1 covered a baseline sample of 72,250 individuals aged 45 and above and their spouses, including 31,464 elderly per- sons aged 60 and above and 6,749 oldest-old persons aged 75 and above from all States and Union Territories (UTs) of India (excluding Sikkim).

• A unique feature of LASI is the coverage of comprehensive bio- markers. No other survey in India collects detailed data on health and biomarkers, together with information on family and social net- works, income, assets, and consumption.

• LASI will provide an evidence base for national and state-level pro- grams and policies for the elderly population.

Ayushman Bharat PMJAY

GoI has launched ABPMJAY to cover over 10 crore poor and vulnerable families (approx. 50 crore beneficiaries), providing coverage up to ` 5 lakhs per family per year for secondary and tertiary hospitalization.

• With the launch of the PMJAY, RSBY, and SCHIS have been sub- sumed in it. All enrolled beneficiary families of RSBY and SCHIS are entitled to benefits under PMJAY.

Health and Wellness Centres (HWCs)

More than 1,50,000 Ayushman Arogya Mandir (Erstwhile Health & Well- ness Centres) are being operationalized. These centres have a provision for the elderly and Palliative Health Care Services.

Senior Citizen Health Insurance Scheme (SCHIS)

This Scheme, implemented since 2016, provides insurance coverage to se- nior citizens as a top-up over the existing RSBY Scheme. It provided a health insurance cover of ` 30,000/-, which was available to senior citi- zens, in addition to the coverage of ` 30,000/- under RSBY. If in any RSBY enrolled family, there were more than one senior citizens, then the addi- tional cover was in multiples of ` 30,000/- per senior citizen.

• Treatment packages were covered under SCHIS, in addition to 1516 packages under RSBY.

• This scheme was subsumed into PMJAY.

90 Senior Care Reforms in India

Name of the Scheme/ Program/ Activity

Goal/Benefits

Central Government Health Scheme (CGHS)

CGHS has been providing comprehensive medical care to the Central Gov- ernment employees and pensioners enrolled under the scheme for the last six decades. CGHS is the model health care facility provider for Central Government employees and pensioners and is unique of its kind due to the large volume of beneficiary base, and open-ended generous approach of providing health care. As of 29.08.2023, a total of 17,68,717 pensioners are getting the benefits of this scheme.

4� Ministry of Rural Development

Name of the Scheme/ Program/ Activity

Goal/Benefits

National Social Assis- tance Program (NSAP)

It is a Centrally Sponsored Scheme, under which the elderly, widows, and disabled persons belonging to BPL and fulfilling eligibility criteria pre- scribed in the NSAP guidelines, are provided financial assistance ranging from `200/- to `500/- p.m. Further, in the case of the breadwinner’s death, lump sum assistance of `20,000/- is given to the bereaved family. The scheme is implemented by States/UTs, and a Top-up, over and above the Central assistance, is also provided by State Governments/UT Administra- tions. The schemes under NSAP for the elderly and divyangs are detailed below:

• Indira Gandhi National Old Age Pension Scheme (IGNOAPS): A monthly pension of `200/- is given to the elderly aged 60-79 years belonging to the BPL category. The pension increases to `500/-per month upon attaining the age of 80 years. The total beneficiaries under the scheme are 221 lakhs.

• Indira Gandhi National Disability Pension Scheme (IGNDPS): A monthly pension of `300/- is given to BPL persons aged 18-79 years with severe and multiple disabilities (80% disability level). The pension increases to `500/- per month upon attaining the age of 80 years. The total beneficiaries under the scheme are 10.58 lakh.

Senior Care Reforms in India 91

5� Ministry of Ayush

Name of the Scheme/ Program/ Activity

Goal/Benefits

Medical Facilities for Se- nior Citizens

The Ministry is providing the following facilities to senior citizens:

• Free consultation and yoga therapy under Yoga and Naturopathy.

• OPD services are being provided in various Government Hospitals in Delhi, Haryana, Tripura, Kerala, Madhya Pradesh, Andhra Pradesh, and Jharkhand.

• Free Yoga training at 50 Yoga Parks is being run through NGOs in var- ious states.

• In addition, other programs such as Health Promotion Programs, Yoga Therapy Training Programs, Individual Yoga Therapy Sessions, Weekend Yoga Training Programs, and Monthly Clinical Yoga Therapy Workshop are also being imparted.

• Ayurveda, Homoeopathy, and Siddha Research Councils functioning under the Ministry of Ayush through its peripheral research and clinical units are providing health services to the elderly through special Geriat- ric Clinics throughout the country.

AYURSWASTHYA Yojana

Ayush and Public Health (PHI), a sub-component of this scheme, is man- dated to provide Ayush intervention on common public health issues relat- ed to communicable diseases, non-communicable diseases, MCH, Geriatric care, mental health, etc.

Vayo Mitra- Ayush Geri- atric Healthcare Services

National Ayush Mission has provision for Ayush Public Health Programs; one of the recently approved programs under its ambit is Vayo Mitra, which is mandated to provide specialized and comprehensive Ayush Geriatric Health Care Services to create awareness within the community on differ- ent aspects of ageing and measures to reduce morbidity during old age and to promote the value of the healthy the elderly persons to the commu- nity and need for maintaining the Quality of life.

6� Ministry of Consumer Affairs, Food & Public Distribution

Name of the Scheme/ Program/ Activity

Goal/Benefits

Annapurna Scheme

Department of Food and Public Distribution allocates food per requirements projected by the Ministry of Rural Development under the Annapurna Scheme, wherein indigent Senior Citizens, who are not getting a pension under IGNOAPS, are provided 10 kg of food grains per person per month free of cost.

92 Senior Care Reforms in India

Antyodaya Anna Yojana(AAY)

Under this scheme, rice and wheat are provided at a heavily subsidized rate to homes headed by widows/terminally ill/disabled persons/senior citizens, with no assured means of maintenance or societal support.

7� Ministry of Textiles

8� Department of Pension & Pensioners Welfare

9� Ministry of Home Affairs

Name of the Scheme/ Program/ Activity

Goal/Benefits

Financial assistance

The Ministry of Textile has a scheme through which financial assistance of `3,500/-per month is given to handicrafts awardee artisans above 60 years of age with an annual income of less than `50,000/-.

Name of the Scheme/ Program/ Activity

Goal/Benefits

Retiring Benefits and Pension

The Department of Pensions and Pensioners Welfare supervises and ensures that retiring Central Government employees receive retirement benefits, including pensions so that they can live an active and dignified life after retirement.

Name of the Scheme/ Program/ Activity

Goal/Benefits

Safety and Security

The Ministry has issued two detailed advisories to all State /UT governments, dated 27-3-2008 and 30-8-2013, advising them to take immediate measures to ensure safety and security, as well as to eliminate all forms of neglect, abuse, and violence against old people through various initiatives such as senior citizen identification, police personnel sensitization on the safety and security of older people, regular beat staff visits, and the establishment of toll-free senior citizen helpline; setting up of senior citizen security cell; verification of domestic helps, drivers, etc.

Senior Care Reforms in India 93

10� Indian Railways

Name of the Scheme/ Program/ Activity

Goal/Benefits

Measures for the welfare of senior citizens

Indian Railways have taken various measures for the Welfare of senior citizens, some of which are:

» In the computerized Passenger Reservation System (PRS), there is a provision to allot lower berths to Senior Citizens, automatically, even if no choice is given, subject to the availability of

accommodation at the time of booking.

» In all trains having reserved sleeping accommodation, a combined quota of six (6) lower

berths per coach in Sleeper class and three (3) lower berths per coach each in AC 3 tier and AC 2 tier classes has been earmarked for Senior Citizens, female passengers of 45 years of age above and pregnant women. In the case of Rajdhani, Duronto, and fully Air Conditioned/ Express trains, the number of berths to be earmarked under this quota in 3 AC is 4 (four) lower berths per coach as against 3 (three) lower berths per coach in normal Mail/Express trains.

» Accommodation is also earmarked for Senior Citizens during specified hours on suburban sections by Central and Western Railways.

» Instructions exist for the provision of wheelchairs at stations. Moreover, Zonal Railways have also been advised to provide free-of-cost ‘Battery Operated Vehicles for Disabled and old Aged passengers’ at Railway Stations. In addition, passengers can book e-wheel chairs online through the IRCTC portal “www.irctc.co.in.”

» To help old and disabled passengers requiring assistance at the stations and strengthen the existing services, “Yatri Mitra Sewa’ is being provided through IRCTC at major stations to enable passengers to book wheelchair services cum porter services, etc.

» After the departure of the train, if there are vacant lower berths available in the train and if any person with a disability or a senior citizen, or a pregnant woman, who has been allotted an upper/middle berth, approaches for allotment of vacant lower berths, the onboard Ticket Checking Staff has been authorized to allot the vacant lower berth to them making necessary entries in the chart.

» Separate counters are earmarked at various Passengers Reservation System (PRS) centres for dealing with the reservation requisitions received from physically disabled persons, Senior Citizens, and other specified persons if the average demand per shift is not less than 120 tickets.

» Electric Multiple Unit (EMU) local trains have a compartment earmarked for differently-abled persons (Divyangjan).

» Unlike other compartments, the doorway Centre pole is relocated to the sides to enable entry of wheelchairs.

» Disabled-friendly Integral Coach Factory (ICF) designed SLRD (Second class cum Luggage cum Guard Van & Disabled Friendly Compartment) coaches have been incorporated. It is endeavored to have at least one coach in each Mail/Express train having ICF-type coaches. At present, 3519 ICF-type SLRD coaches (as of 31.03. 2021) are in the fleet of Indian Railways.

» Production units have already started manufacturing LHB Second Luggage, Guard & Divyangs Compartment (LSLRD) type coaches for Divyangs Passengers. These coaches are suitably designed for the needs of disabled/wheelchair-borne passengers.

» All Production Units have been advised to provide at least two doors of 920 mm width, one on each side of the coach in the future in all newly manufactured coaches for improved accessibility.

» For the assistance of visually impaired travelers, integrated Braille Signage is being provided in all the newly manufactured coaches. Further, retrofitting the same in existing coaches is also continuing in a phased manner.

94 Senior Care Reforms in India

11� Ministry of Civil Aviation

Name of the Scheme/ Program/ Activity

Goal/Benefits

Measures for the welfare of senior citizens

Various guidelines issued by the ministry for the welfare of senior citizens are given below:

» The airline/airport operator shall ensure the provision of automated buggies, free of charge, for all senior citizens in the terminal building to facilitate their access to boarding gates located beyond reasonable walking distance at all airports having annual aircraft movements of 50,000 or more.

» Airport operators shall adequately display information regarding the availability of automated buggies and small trolleys in the terminal building at prominent locations, including dos and don’ts. This shall also be published on the website of the airport operator.

» Remove all physical barriers to facilitate easy entry and exit at all airports and airlines.

» Change the design of the frisking booths in the security hold areas so that the elderly are not required to climb and descend while undergoing security checks;

» Pay special attention to provide help/assistance to them, particularly after alighting from vehicles at the airports and until the person reaches the check-in counters

» Pay special attention to the elderly and those needing assistance at the booking offices of airlines

» Give preference in reservation and earmarking of seats in the airlines.

» Dedicated check-in-counter, departure gate/ lane.

» Priority is to be given to senior citizens at pre-queuing area and Pre- Embarkation Security Check (PESC) points

Apart from these measures, the Ministry of Social Justice and Empowerment provided budgetary support for the welfare of senior citizens from the Senior Citizens Welfare Fund of `97.80 Lakhs to the Ministry of Civil Aviation in the year 2018-19 for operating 30 Electric Operated Golf Cart at 8 designated Airports as well as to release funds to the Airports Authority of India (AAI) to facilitate the Senior Citizens movement irrespective of the class of their travel and to achieve the desired level of customer satisfaction. 20 AAI Airports are now equipped with Ambu lifts to facilitate flyers with reduced mobility.

Senior Care Reforms in India 95

12� Ministry of Housing and Urban Affairs

Name of the Scheme/ Program/ Activity

Goal/Benefits

Elder friendly environment

Various enabling guidelines by the ministry for creating an age-friendly environment:

» Ministry of Housing and Urban Affairs, Department of Urban Development has issued the Model Building Bye-Laws, 2016 (MBBL) prescribing standards for the creation of an elder-friendly barrier-free environment related to buildings, toilets, etc. Urban Local Bodies shall implement the Policy by adopting the Model Building Bye-Laws, 2016.

» Further, under Urban Bus Specification-II issued in 2013, the emphasis on buses financed by the Department of Urban Development is on the procurement of low-floor buses with proper ramps for easy access of the passengers and adequate space for wheelchairs to be placed in the bus for the benefit of disabled persons and senior citizens.

» All metro rail projects implemented/under implementation in the country have disabled and elder-friendly infrastructure, such as proper ramps/lifts to the stations. There is a provision for the reservation of seats in metro rail coaches for differently-abled persons and senior citizens.

Further, Housing for All Mission/Pradhan Mantri Aawas Yojana Guidelines has been circulated to State/UT Governments to meet the demand for housing in their States/UTs, which interalia incorporates that ‘while making the allotment, families with senior citizens should be given priority for allotment on the ground floor or lower floors.

The Ministry of Housing & Urban Affairs is implementing the Deendayal Antyodaya Yojana-National Urban Livelihoods Mission (DAY-NULM) to reduce poverty and vulnerability of urban poor households on a sustainable basis. The Mission, inter- alia, aims to provide permanent shelter equipped with essential services to the urban homeless in a phased manner under the Shelters for Urban Homeless, irrespective of age.

13� Ministry of Road Transport & Highways

Name of the Scheme/ Program/ Activity

Goal/Benefits

Divyang/ elderly-friendly environment

Ministry of Road Transport and Highways (MoRTH) vide GSR notification 959 (E) dated 27th December 2019 has notified amendments to the Central Motor Vehicles Rules for providing Divyang-friendly features. Arrangements for priority seats, signs, securing of crutches/canes/walkers, handrail/stanchions, controls at priority seats, and wheelchair entry/housing/locking arrangement for wheelchairs for differently-abled passengers or passengers with reduced mobility to be checked and ensured at the time of fitness inspection.

The MoRTH issued the Accessibility Guidelines for Bus terminals and Bus Stops on 29.08.2022. It covers the planning and design aspects of areas in bus ports/ bus terminals and bus stops so that these areas can be made accessible to all. Special emphasis has been laid on ensuring ease of access for the use of these facilities by end users. The aim is to ensure seamless inclusion of Divyangjan, irrespective of their disability in the context of accessibility to any such infrastructure. The above guidelines have been circulated amongst the SRTUs of all States/UTs and are also placed on the website of MoRTH.

96 Senior Care Reforms in India

14� Ministry of Culture

15� Ministry of Communications

Name of the Scheme/ Program/ Activity

Goal/Benefits

Scheme for Financial Assistance to Veteran Artists

Ministry of Culture provides assistance of `6,000/- as a monthly allowance to artistes aged 60 years and above, and `5,999 /- per month in case of transfer of financial assistance to spouse on the death of initial beneficiary.

Name of the Scheme/ Program/ Activity

Goal/Benefits

Concessions extended by BSNL & MTNL

Bharat Sanchar Nigam Limited (BSNL) exempts senior citizens (65 years &above) from payment of registration charges for Landline Telephone Connection. Further, Mahanagar Telephone Nigam Ltd. (MTNL) provides a concession of 25% in installation/activation charges and monthly services/ rental charges for Landline connections under Plan-250 in the Senior Citizens Category, to Senior Citizens who are more than 65 years of age.

16� Ministry of Women & Child Development

Name of the Scheme/ Program/ Activity

Goal/Benefits

Home for Widows

Ministry of Women and Child Development has constructed a Home for Widows at Vrindavan, Uttar Pradesh, with a capacity of 1000 widows to provide them safe and secure place to stay along with health services, nutritious food, legal and counseling services etc. The design of the Home is old age friendly with facilities such as ramps, lifts, supply of adequate electricity, water, and other amenities for meeting the requirement of senior citizens and persons with special challenges.

Senior Care Reforms in India 97

98 Senior Care Reforms in India

ANNEXURE 6: LANDSCAPE OF NGOS, PRIVATE SECTOR, AND INDUSTRY ASSOCIATIONS WORKING IN SENIOR CARE

HelpAge India

» Founded in 1978, the organization’s programs are focused on direct interventions in the areas of Healthcare (mobile healthcare units, cataract surgeries), Age care (helplines, senior citizen care homes, and day-care centres, physiotherapy), Livelihoods (elder-self-help groups; linkages with government schemes), Disaster Response (e.g., COVID19 relief response), as well as advocacy and awareness on rights and policies relating to elders.

» HelpAge is working with more than 5560 Senior Citizen Associations (SCAs) across India with over 10 lakh members.

» HelpAge has started a ‘Digital Literacy’ program, introducing elders to the online world by conducting workshops across the country with the technical assistance of CSC Academy.

VridhCare

» Founded in 2019, VridhCare works towards the objective of serving the underprivileged elderly community in both rural and urban areas.

» Established to provide dignity, and physical, emotional, and mental well-being to the elderly population.

» The organization provides financial assistance and recognizes the talent or skill of individuals to help them get dignified jobs, relevant to them.

» VridhCare has partnered with and served over 50 NGOs, and works on providing nutrition, rehabilitation, and livelihood to the elderly groups.

Age Well Foundation

» Founded in 1999, Age Well has been set up to initiate better interaction between generations. It aims to bring about a change in the perception of old age. It also endeavors to create a senior citizens-friendly environment, evolve a sense of moral and social responsibility towards senior citizens, advocate for the needs and rights of senior citizens, and extend a helping hand to senior citizens, wherever required.

» Age Well interacts with over 25000 older persons on daily basis through its volunteers’ nationwide network.

ElderCare

» Founded in 2014 with a vision to support the vulnerable elderly.

» Elder Care Trust provides medical /surgical support, social, educational, and legal assistance to senior citizens; along with the delivery of lectures for the benefit of everyone in the geriatric category.

» The Trust assists those elders who are physically dependent on others for their daily living.

Senior Care Reforms in India 99

Dignity Foundation

» Dignity Foundation has been working for senior citizens since 1995, offering an enriching set of opportunities to the elderly.

» It deals with their psycho-social challenges and helps them tackle their loneliness and insecurities.

» Its programs are centered around the mental health and social well- being of seniors (day care centres around loneliness mitigation, dementia care, physical and spiritual well-being, etc.), along with recreational activities (exploring hobbies and talents) and helping the elderly groups to explore ‘Second Careers’.

Hindrise Social Welfare Foundation

» Founded in 2018, the Hindrise Foundation has listed various healthcare activities and programs for senior citizens. It looks after the physical and mental health of elders by enhancing the inter-generational dialogue between the elderly and young adults.

» It extends its services in urban as well as rural areas, with all essential resources such as high-quality food cooked in a healthy environment, prescribed medicines, a wide range of information, counselling support, and providing survival kits.

Nightingales Medical Trust

» Nightingales Medical Trust (NMT) is a professionally managed not- for-profit organization working for the well-being of the elderly and persons with Dementia and Alzheimer’s since 1998.

» It strives to strengthen family bonds and promote community-based support systems for Senior Citizens of all Socio-economic groups through various innovative and need-based projects aimed towards Dementia Care, Active Ageing, Social Integration, Empowerment, Capacity Building, and prevention of Elder Abuse

» Its various programs for the elderly include dementia care, active ageing, and social integration, empowering senior citizens, assisting them in restarting their careers, addressing elder abuse, and providing capacity-building programs.

ELDER CARE- TATA TRUST

» Founded in October 2017, the Trusts’ elder-care initiatives were aimed at serving the varied needs of the elderly in India with a major focus on seniors residing in rural areas.

» It aims to play a transformational role in the geriatric sector by focusing on the critical gap areas to create an empathetic senior care ecosystem.

» Their comprehensive elder-care initiatives covered preventive, curative, promotive, and rehabilitative treatment for the overall well-being of older people. They have initiated various activities and programs towards improving the quality of life of seniors through caregiving, decreasing their dependency, and generating social and economic opportunities.

100 Senior Care Reforms in India

All India Senior Citizens Confederation (AISCCON)

» Formed in 2001, The All India Senior Citizens’ Confederation (AISCCON) is a national-level organization of senior citizens.

» It devotes itself to networking, advocacy, and research on the issues concerning the welfare and development of senior citizens with governments at both the state and national levels. The organization also provides service activities, including health care (physiotherapy services, eye care services, and other advisories) services.

Broad Landscape of the Private Sector in Elderly Care

TriBeCa Care

» Founded in 2013, TriBeCa Care is an eldercare platform that assists the elderly to live an independent life by offering a range of elderly services, including emergency services and specifically designed elderly care programs.

» It provides rehabilitative care to patients suffering from chronic pain, depression, and mobility issues through the provision of expert physiotherapists or psychologists.

» It also extends various other services like home-based services, physiotherapy, senior travel services, dementia care, old age homes, ambulance services, and help with hospitalization.

Antara

» Introduced in 2010 with the core philosophy to create an environment, where senior citizens feel free to reflect and reconnect with themselves while enjoying the company of like-minded people. Antara’s mission is to respond to their evolving needs and desires through a perfect blend of life care and lifestyle offerings that deliver a comprehensive and seamless experience.

» Antara has launched Assisted Care Services which include-

a) Independent Living Residences for Seniors

b) Care Homes for Seniors

c) Care at Home services

d) Medicare Products

Emoha Eldercare

» Emoha is a team of senior care experts, who aim to create the world’s most comprehensive digital community of seniors.

» It is a connected community of 10000+ seniors, surrounded by care givers who help simplify, secure, and energize their lives.

» It provides various services like remote health monitoring, daily engaging activities, etc. to help them live a safer, healthier, more convenient, and more active life in the comfort of their own homes.

Senior Care Reforms in India 101

Life Circle Health services

» Founded in 2013, its vision is to help seniors stay healthy in their homes for as long as they want. Life Circle is a subscription-based home healthcare service for seniors and has provided more than 500,000 hours of care services and 10,000 home visits till date.

» It provides home care services, where the professional caregiver assists seniors with ADL like assistance in feeding, bathing, brushing, dressing, and grooming. Homecare services consist of nursing services like blood pressure monitoring, blood sugar monitoring, insulin administration, oxygen administration, etc. It also provides medical equipment like oxygen concentrators.

» The Senior Care Ageing Growth Engine Program of the Ministry of Social Justice and Empowerment, Government of India, has chosen Life Circle as the first step in promoting a “Silver Economy.”

Care 24

» Care24 is a home healthcare service provider that offers personalized care plans for the elderly, including nursing care, physiotherapy, and medical equipment rentals. They have various care packages starting from ` 4,500 per month.

» Since its inception in 2014, Care 24 has offered professional care from trained caregivers that help the patient recuperate at home. Some of the major services offered by Care24 include caregiving services, nurse services, and physiotherapy services.

» Its qualified clinical staff specializes in providing round-the-clock elder care services along with assisting seniors with home exercises.

Elder Aid

» Founded in 2015, Elder Aid provides a range of at-home services.

» A designated Care Manager is assigned to every elder, whom they can call for all their needs – ranging from emergency medical support, arranging for a full-time caretaker, paying their bills, helping them use their smartphone or just spending time chatting with them.

» They also conduct elderly wellness events, host common interest groups, bring engaging talks, and provide other information to elders.

KITES Senior care

» KITES Senior Care is a geriatric care specialist brand set up in 2016, with a vision to be the trusted out-of-hospital care continuum partner to the elderly & their family.

» Kites Care provides the following services:

a) Transition and rehab care: Ensures total coordination and continuity of care among elders during their transition from hospital to home or other settings.

b) Palliative care and hospice: Comfort care, pain management and counselling

c) Dementia and Alzheimer’s Care: Apart from the stay-in facilities, they also provide daycare activities for neighborhood elders with dementia.

d) Geriatric Home Care: Deliver high-quality geriatric care to seniors in the comfort of their homes, covering post-hospitalization rehab care, palliative care, and dementia care.

102 Senior Care Reforms in India

Nemacare

» Founded in 2019, Nema Elder Care provides comprehensive hospitality and healthcare services to seniors. Their services include healthcare services, entertainment activities, food services, housekeeping, and laundry.

» It also provides Assisted Living Care Homes, which is part of a continuum of long-term care services that include housing, personal care services, senior citizens assisted living facilities for dementia care, and health care designed to respond to individuals who need assistance with normal daily activities.

» It has also launched Continued Care Retirement Home/ Housing (CCRH) with customized care services for seniors.

Portea

Portea is a home healthcare service provider that offers a range of services for the elderly, including nursing care, physiotherapy, and medical equipment rentals. They have various care packages starting from ` 2,000 per month.

Anvayaa

Anvayaa is a technology-driven home healthcare service provider that offers various care services, including home nursing, physiotherapy, and medical equipment rentals. They have various care packages starting from ` 3,000 per month.

Eldercare

Eldercare is a home healthcare service provider that offers personalized care plans for the elderly, including nursing care, physiotherapy, and medical equipment rentals. They have various care packages starting from ` 5,000 per month.

Apollo Homecare

Apollo Homecare is a home healthcare service provider that offers various care services, including home nursing, physiotherapy, and medical equipment rentals. They have various care packages starting from ` 3,000 per month.

ElderEase

ElderEase is a home healthcare company that provides elder care services including nursing, physiotherapy, doctor consultations, and medical equipment rental. They also offer specialized services such as post-surgical care and cancer care.

Medwell Ventures

Medwell Ventures is a home healthcare company that provides a range of elder care services including nursing, physiotherapy, doctor consultations, and medical equipment rental. They also offer specialized services such as palliative care and respiratory care.

Healers at Home

Healers at Home is a home healthcare company that provides elder care services including nursing, physiotherapy, doctor consultations, and medical equipment rental. They also offer specialized services such as diabetes care and cardiac care.

Senior Care Reforms in India 103

Industry Associations Working in the Area of Elderly Care

Federation of Indian Chambers of Commerce and Industry (FICCI)

» Established in 1927, FICCI is the largest and oldest apex business organization in India. From influencing policy to encouraging debate, and engaging with policymakers and civil society, FICCI articulates the views and concerns of industry.

» FICCI provides a platform for networking and consensus building within and across sectors and is the first port of call for the Indian industry, policymakers, and the international business community.

NATHEALTH

» Nathealth along with ASLI, FICCI, and MTaI released a whitepaper on catalyzing & reforming senior care in India in which FICCI suggested introducing a dedicated ‘National Mission for Ageing and Senior Welfare’, with the active participation of the central and state governments, industry and the civil society.

» The paper was released during the 7th FICCI Health Insurance Conference and aims to act as a catalyst of change to encourage policymakers and stakeholders for working towards the much-needed transformation in the area of elderly care financing.

Confederation of Indian Industry (CII)

» The CII works to create and sustain an environment conducive to the development of India, partnering with the industry, Government, and civil society, through advisory and consultative processes.

» CII organizes annual conclaves which focus on key areas that require huge capacity in building the Senior Care ecosystem. CII also releases the Senior Care Industry Report at each conclave to unlock the gap areas pertaining to geriatric care.

Association of Senior Living India (ASLI)

» It is the first National Senior Living Association in India founded in 2011. It strives to advance excellence in senior living in India and champion quality of life for the millions of Indian seniors who will benefit from professionally-managed senior living communities.

» It aspires to create a model of self-regulation and work in tandem with the government on the guidelines of minimum standards for attaining operational excellence by its members in particular and the industry at large. The members of ASLI exemplify the principles of choice, dignity, and independence for seniors to thus enhance their quality of life.

104 Senior Care Reforms in India

ANNEXURE 7: TECHNOLOGY FOR SENIOR CARE

1� Wearables for smart monitoring, including activity trackers, blood pressure and heart rate monitors, continuous glucose monitoring devices, smart watches, wearable pain relief technology, etc. Some of the popular wearables are given in the table below.

S�No�

Wearable

Features

Apple Watch

The Apple Watch is a popular smart-watch that can be used by the elderly to monitor their health and fitness, receive notifications, and communicate with loved ones.

FitBit

Fitbit is a wearable device that tracks physical activity, heart rate, and sleep patterns. It also has a feature for tracking food intake and water consumption.

Lively Mobile Plus

The Lively Mobile Plus is a wearable device that can be worn as a pendant or clipped onto clothing. It has an emergency button that can be used to call for help in case of a fall or other medical emergency.

GreatCall Lively Wearable:

The GreatCall Lively Wearable is a smart-watch that can be used to track physical activity, heart rate, and sleep patterns. It also has an emergency button that can be used to call for help in case of a fall or other medical emergency.

Samsung Galaxy Watch:

The Samsung Galaxy Watch is a smart-watch that can be used to track physical activity, heart rate, and sleep patterns. It also has a feature for monitoring stress levels and provides breathing exercises to help manage stress.

Philips Lifeline

Philips Lifeline is a wearable device that can be worn as a pendant or bracelet. It has an emergency button that can be used to call for help in case of a fall or other medical emergency.

2� Personal Emergency Response Systems (PERS): PERS devices are wearable gadgets that help the elderly to call for emergency help in case of a fall or medical emergency. They come with features like fall detection and GPS tracking.

3� Smart Home Automation: Smart home automation systems help the elderly to manage their homes easily. These systems can control lighting, temperature, and security features, and can be operated using voice commands or mobile apps.

4� Medication Management Systems: Medication management systems like medication reminders or alarms help the elderly to take their medication on time. They can remind users to take their pills, track medication usage, and even dispense pills automatically.

5� Assistive Aids and Devices: Assistive devices like wheelchairs, walkers, walking sticks, elbow crutches, tripods, quadpods, artificial dentures, spectacles, orthosis, prosthesis like artificial limbs, hearing aids, visual and communication aids, memory aids, etc. can help the elderly to maintain their independence.

6� Virtual Reality: Virtual reality technology can help the elderly to experience new places and activities, which can help to reduce social isolation and improve mental health.

7� Robotic Assistance: Robotic assistance devices like robotic vacuum cleaners and robotic companions can help the elderly to manage their homes and provide companionship.

Senior Care Reforms in India 105

8� Digital Assistants: Digital assistants like Amazon Alexa and Google Home can help the elderly to manage their daily routines and access information hands-free.

9� Social Networking: Social networking platforms like Facebook and WhatsApp can help the elderly to stay connected with friends and family, reducing social isolation and loneliness.

10� Other aids and devices: like adjustable shower tools/commodes, back/neck collar, safety rails and bed rails, etc.

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Senior Care Reforms in India

ANNEXURE 8: EXISTING LANDSCAPE OF TRAINING

AND CERTIFICATION COURSES IN GERIATRICS52

In India, there is a growing need for skilled workers in the field of elderly care. There are several certification courses available for individuals interested in pursuing a career in elderly care. Some of the popular courses and certifications include:

• The National Initiative on Care for the Elderly (NICE), which later on got subsumed

under the NPCHE, launched two academic programs on geriatrics – certificate course and post graduate diploma program and they continue to be offered.

i� A post graduate diploma: It is a one year full-time course with subjects like Gerontology, Public Policy and Planning, Clinical Geriatrics, Geriatric Management, Psychology and Counseling, Research Methodology.

ii. A certificate course in geriatric care: It is a full-time six months course to develop a cadre of skilled Geriatric Care Givers, specializing in home care in family and community settings. The course covers subjects like Social Gerontology, Basic Geriatrics, Applied Geriatrics, and Geriatric Nursing.

• Institutions offering Doctor of Medicine (MD) in Geriatrics

1. All India Institute of Medical Sciences, New Delhi

2. All India Institute of Medical Sciences, Rishikesh

3. Amrita Institute of Medical Science & Research Centre, Kochi, Kerala

4. Armed Forces Medical College, Pune

5. Bangalore Medical College and Research Institute, Bangalore

6. Christian Medical College & Hospital, Vellore, Tamil Nadu

7. Dr. SN Medical College, Jodhpur

8. Government Medical College, Kolkata

9. Government Medical College & Hospital, Aurangabad, Maharashtra

10. Institute of Medical Sciences Banaras Hindu University, Varanasi, Uttar Pradesh

11. JSS Medical College, Mysore

12. Madras Medical College, Chennai

13. Mahatma Gandhi Missions Medical College, Navi Mumbai, Maharashtra

14. Padmashree Dr. D.Y. Patil Medical College, Navi Mumbai

15. Shri B.M. Patil Medical College, Hospital and Research Centre, Bijapur, Karnataka

16. Yenopoya Medical College, Mangalore

• Post Graduate Diplomas offered by various educational institutes�

1. Post Graduate Fellowship in Geriatrics – CMC Vellore

2. Post Graduate Diploma in Geriatrics (PGDGM) – CMC Vellore

3. Post-Graduate Diploma in Geriatric Medicine (PGDGM) – Indira Gandhi National

Open University, New Delhi

4. Krishna Institute of Medical Sciences Deemed University, Karad

5. Fellowship in Geriatric Medicine Training Program at KMC, Manipal

52 Pati S, Sharma A, Pati S, Zodpey S. Teaching of geriatric health in India: Mapping the terrain. Gerontol Geriatr Educ [Internet]. 2017;38(1):92– 103. Available from: http://dx.doi.org/10.1080/02701960.2016.1232590

Senior Care Reforms in India 107

•

6. Post Graduate Diploma in Health and Social Gerontology by Institute of Home Economics (Delhi University)

7. Diploma in Gerontology by Tata Institute of Social Sciences

8. PG diploma in geriatric medicine program by DCM Institute, Amritsar

9. Post graduate diploma in geriatric care by KMM (Kochi)

10. Post graduate certificate course in geriatric care and management by the Institute

of Distance Education, Kerala University

11. Post graduate diploma by A.D.N. Institute of Paramedical Sciences and Hospital

Other institutions that offer these courses and certifications include:

1. National Institute of Social Defence, Delhi

2. HelpAge India, Delhi

3. All India Institute of Medical Sciences, Delhi

Geriatrics content in family medicine courses: At present, geriatric medicine and care of the elderly are incorporated to varying extents in the twelve academic programs offered under the family medicine courses.

Geriatrics teaching in public health courses: Geriatric care has not been given a priority in the Masters of Public Health (MPH) curriculum, and the teaching primarily focuses on policy and program aspects and not detailed apart.

Geriatrics component in undergraduate health professional curricula: During the undergraduate period, medical students get 1–2 weeks of formal education and training in Geriatric medicine; but that is, less than 1% of the total time in medical school. Further, there is no geriatric dentistry and nursing specializations per se in India. With respect to the nursing staff, the Graduate Nursing curriculum comprises of medical-surgical nursing of adults including geriatrics. A one year Post basic diploma in Gerontological Nursing has also been launched by the Indian Nursing Council.

Other Courses:

1� Certified Nursing Assistant (CNA): This is a vocational training program that prepares individuals to work as nursing assistants in hospitals, nursing homes, and other healthcare settings. The course typically takes six to twelve months to complete.

2� Bachelor of Science in Gerontology: This is an undergraduate degree program that provides in-depth knowledge of ageing, health, and social issues related to the elderly. The duration of the course is typically three years.

3� Master of Science in Gerontology: This is a postgraduate degree program that focuses on the study of ageing and its impact on society. The course duration is usually two years.

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Senior Care Reforms in India

ANNEXURE 9: NUTRITIONAL REQUIREMENTS OF THE ELDERLY

Need of Elderly Nutrition 53

Age-related changes in nutritional status can depend on a variety of factors like physiological, metabolic, immunological, and cellular/molecular. Further, micronutrient deficiencies are linked to a number of age-related disorders, which negatively impacts the health of the elderly. Therefore, it is necessary to specify and ensure adequate nutrient requirements for the elderly.

Nutritional needs of elderly people due to age-related changes:

Dimension

Age-related changes

Nutritional Needs

Loss of muscle mass, bone mass and body mass

Protein, Vitamin D, Calcium

Reduced GI Tract function leading to decreased nutrient intake

Iron, Vitamin B12, Calcium and Zinc

1. Physiological

Altered senses of taste and smell

B Vitamins and Zinc

Impaired vision

Carotenoids, Vitamin C and E, Zinc, Copper

Metabolic

Decreased physical activity

Protein, Vitamin D, Calcium

Immunological

Immunosenescence

Vitamin B6, Zinc and Selenium

Molecular and Cellular

Increased oxidative stress due to cellular ageing

Vitamin B12 and Folate

Micronutrient linked to age-related disorder:

2. Vitamin C and Zinc

4. Vitamin D

5. Vitamin C

6. Vitamin B6, B12 and Selenium

7. Thiamine, Manganese and Copper

8. Thiamine

9. Vitamin D and Calcium

Alzheimer’s Disease

Obesity, CVD

Cataract

Reduced immune response Glucose intolerance Depression

Osteoporosis

Micro-nutrient Deficiencies

Related Disorder

Zinc

Age related Macular Degeneration (AMD)

Vitamin B6, B12 and Folate

Cognitive impairment, Cardio Vascular Disease (CVD)

10.

Protein, PUFA, Vitamins B6, B12, C, D, E, Folate, ß-carotene and Selenium

Frailty

53 Tattari Shalini, Gavaravarapu SubbaRao M., Pullakhandam Raghu, Bhatia Neena, Kaur Supreet, Sarwal Rakesh, Rajkumar Hemalatha, Reddy G. Bhanuprakash. Nutritional requirements for the elderly in India: A status paper. Indian Journal of Medical Research 156(3):p 411-420, September 2022.

Senior Care Reforms in India 109

Nutritional recommendation for the elderly:

Energy (Kcal) 1700 — 1500 —

Dietary Fibre — 30 — 25

Protein (g) 43.0 54.0 36.3 46.0

Vit-A (μg) 460 1000 390 840

Thiamin B1 (mg) 1.2 1.4 1.1 1.4

Niacin (mg) 12 14 9 11

Vit-C (mg) 65 80 55 65

Vit-B6 (mg) 1.6 1.9 1.6 1.9

Folate (μg) 250 300 180 200

Vit-B12 (μg) 2.0 2.2 2.0 2.2

Vit-D (IU) 400 800 400 800

Calcium (mg) 1000 1200 1000 1200

Magnesium (mg) 370 440 310 370

Iron (mg) 11 19 11 19

Zinc (mg) 14 17 11 13.2

Iodine (μg) 95 140 95 140

Nutrients

Men

Women

EAR

RDA

EAR

RDA

Riboflavin B2 (mg)

1.6

2.0

1.6

1.9

110

Senior Care Reforms in India

ANNEXURE 10: VACCINATION GUIDELINES FOR THE ELDERLY 54

Vaccination Guidelines by Various National Societies for People Aged 60 and above

Vaccines

Geriatric Society of India

Association of Physicians of India

Indian Medical Association

Indian Association of Occupation Health

Influenza D

Pneumococcal D

Herpes Zester D

Tetanus D

Diphtheria D

Pertussis D

Measles D

Mumps D

Rubella D

D D

Up to 60 only

54 Life Course Immunization: Pulse of a Resilient Health System. USISPF

Senior Care Reforms in India 111

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Wang Tim, Morris William & Brubaker Richard. Editor: The elderly in China, 2016 [Internet]. Retrieved February 19, 2023 from: https://www.coresponsibility.com/wp-content/ uploads/2016/06/The elderly-in-China.pdf

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Senior Care Reforms in India 117

LIST OF CONTRIBUTORS

Core Technical Team

NITI Aayog

Dr. Vinod K. Paul, Hon’ble Member (Health)

Shri Rajib K. Sen, Senior Adviser (Health)

Dr. K. Madan Gopal, Former Senior Consultant (Health) Mr. Shoyabahmed Kalal, Deputy Secretary (Health)

Ms. Rishita Mukherjee, Consultant (Health)

Dr. Shobhit Kumar, Research Officer (Health)

Ms. Shrestha Hazra, Consultant (Health)

Ms. Oshia Garg, Intern (Health)

IPE Global

Ms. Aali Sinha

Ms. Dipika Joshi Mr. Himanshu Sikka

List of Other Contributors

NITI Aayog

Dr. Rajeshwara Rao, Former Special Secretary

Dr. Rakesh Sarwal, Former Additional Secretary (Health) Dr. Sumita Ghosh, OSD (Health)

Brig. (Dr.) K. Venkatnarayan, OSD (Member- Health)

Dr. S. B. Muniraju, Deputy Advisor (SJE)

Ms. Vaishnavi Iyer, Young Professional (Health)

Mr. Anant Kumar Goel, Intern (Health)

Dr. Sivarchaka Omkarnath, MD (CHA) Resident, NIHFW

Ministry of Social Justice and Empowerment

Mr. Saurabh Garg, Secretary

Mr. R. Subramanyam, Former Secretary

Mr. Surendra Singh, Additional Secretary

Mr. Bharat Lal Meena, Director, Admn., Senior Citizens

Ministry of Health and Family Welfare

Ms. Rekha Shukla, Joint Secretary

Dr. Gowri N. Sengupta, ADG (Directorate General of Health Services)

Ministry of Ayush

Dr. N Srikanth, Deputy Director General, Central Council for Research in Ayurvedic Sciences

Department of Financial Services, Ministry of Finance

Mr. Saurabh Mishra, Joint Secretary

118

Senior Care Reforms in India

Association of Senior Living India

Mr. Ankur Gupta Ms. Bani Jain Mr. Jiji Philip

Ms. Neha Sinha Mr. Rajagopal G

Aurum Senior and Assisted Living

Mr. Amit Gupta

Mr. Sanjoy Pasricha

FICCI

Dr. Arun Agarwal Mr. Praveen Mittal Ms. Sarita Chandra Ms. Shilpa Sharma Dr. Suneela Garg Mr. Vikas Malhotra

HelpAge India

Dr. Rajeshwar Devarakonda

NATHEALTH

Ms. Anuradha Sriram Dr. Arvind Lal

Mr. Ashok Kakkar

Dr. Harsh Mahajan

Dr. Karthik Narayan R Mr. Mayank Bathwal Ms. Nanki Singh

Dr. Om P Manchanda Dr. Ranjit Mehta

PHDCCI

Dr. N Subramanian Prof. Parag Singhal Dr.Ravi Rathod

Dr. Sameer Gupta Mr. Vivek Seigell

PWC

Dr. Rana Mehta

Senior Care Reforms in India 119

120 Senior Care Reforms in India

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Communication Cell, NITI Aayog

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