Ageing Health and Socioeconomic Determinants: An Introspect

Introduction

Ageing is a natural transformation in the physical body where a person observes many changes in the body, health, cognitive behaviour, attitude, and habits. How we treat and accept ageing depends upon our own perspective based on past living experience and the situation we perceive in future. Ageing brings both opportunities and challenges (WHO). There are many factors like income, health family, status etc., that decide the ageing life as an opportunity or challenge. However, with age, the body gets weaker and a person gradually falls to the prey of natural disability. He also becomes more vulnerable to infection and diseases. Thus, the health issue becomes one of the greatest challenges for the elders. The health challenges are apparent to face by everyone, and no one can escape of it. Now, it is the state’s healthcare system and the elder’s own financial and social capacity that decide how successfully one can overcome those challenges.

In India, there are around 104 million older people with age more than 60 years. It constitutes around 8.6% of the total population of India. The elder women are outnumbered by elder men. With medical advancement and better healthcare, the mean longevity has also increased. Currently, the life expectancy is 70.42 years in India, almost a 12% increase over the past two decades (WHO). On the other hand, the breakdown in the social fabric and decline in joint family pushed the elders into neglect and loneliness. Thus, different kinds of health issues, poor mobility, and weak support from family lead to quite a discomfort life for elders. The government’s National policy for Older Persons, 1999; Maintenance and Welfare of Parents and Senior Citizens Act, 2007; and National Policy for Senior Citizens 2011 provide a comprehensive legal framework to support the need of elders. Apart from these, there are several welfare schemes currently running. ‘Varishta Mediclaim Policy’, ‘Rashtriya Vayoshri Yojana’, ‘Vayoshreshtha Samman’ are some of the government schemes for elders to financially support them in their livelihood and medical needs.

The National Sample Survey (NSS) 71st and 75th round survey on health reveals that healthcare access in India is quite uneven. The degree of healthcare access largely varies across the socioeconomic determinants. For example, urban households have greater healthcare access than rural ones; men have greater healthcare access than women and people from the upper caste are better off than others in healthcare access. The majority of the elder population live in the rural area and therefore, the cases of unmet need among them is higher (NSS 75th round survey). The rural healthcare centres are also ill-managed with fewer number of doctors & staff and poor facilities [1]. Hence, the elders in rural areas have less healthcare access than elders in urban areas. Similarly, the impacts of gender and income gap are largely observed on healthcare access (NSS 75th round survey), the condition of male elders from the poor income class is more worrisome. The poor healthcare access among the elders is caused by three major sources – first, their own poor physical immobility and large dependency on others create high unmet needs for them. Second, the unsupportive attitude of their family (generally observed in urban areas) makes them vulnerable to speedy health deterioration in absence of timely medical intervention. Third, the socioeconomic status of an elder, sometimes proves to be burden for elders and lead them to high unmet need.

In this paper, we analyse the status of health and unmet need (non-access to healthcare) among the elders across socioeconomic determinants like gender, caste, class, education and others. There are several chronic and communicable diseases, an elder is exposed of. However, we take only the ‘hypertension’ chronic disease in our study due to its vast impact on the elder’s health and its strong association with other health issues. The study helps to identify the most marginalized elders who have larger unmet needs so, appropriate healthcare intervention can be designed and implemented. Most of the government’s elder policy and schemes are equally apply to all. However, few of them are specifically designed for the poor elders or elders from Schedule Caste & Schedule Tribe (SC-ST) community (eg: Ayusman Bharat scheme; Ambedkar Medical Aid Scheme etc), no other specific provisions for elders from rural areas, women elders, and elders from Other Backward Group (OBC). Hence, it is important to identify the real beneficiary of elder health policy and plans to make healthcare access available to them at par of others so, they may also lead a dignified life.

Data and Methods

The study is based on secondary data taken from Longitudinal Ageing Study in India (LASI) – Datasets wave 1 (2017-18) that consists of in-depth data on ageing, economic aspects, health status, social relationships, social support, family, and life satisfaction among the elders. The data is available on all India level with the sample size of 73,396 elders with age 45 and above.

First, the overall health status of elders across different socioeconomic determinants is studied through descriptive statistics. The findings are presented through tables and graphs. Then, a regression model is run to test the association of hypertension with socioeconomic determinants. The model is as follows:

Y (hypertension) = α + β (Place of residence) + β (Income class) + β (Gender) + β (Caste) + β (Living with spouse) + (β (Working status) + β (Education level) + β (Religion) + €0 Another regression model is run to test the association between the unmet needs (non-access to healthcare) among the elders and the socioeconomic determinants. The model is as follows: Y (unmet need) = α + β (Place of residence) + β (Income class) + β (Gender) + β (Caste) + β (Living with spouse) + (β (Working status) + β (Education level) + β (Religion) + €0 All the calculation and analyses are done in SPSS ver. 20. The findings are presented through tables and graphs followed by discussion and conclusion.

Discussion

Hypertension is one of the leading health issues among the elders Vasan, et al. [3] & Levi, et al. [4]. Apart from several physiological changes, there are several other factors that significantly contribute to the development of hypertension. The relationship between socioeconomic status and hypertension is quite complex and unclear, but recent studies have confirmed that poor socioeconomic status leads to the high prevalence of hypertension [5, 6]. In our study, except for the rural-urban gap and gender gap, all the socioeconomic determinants are significantly associated with hypertension among the elders. Further, it is found that the poor are more vulnerable to hypertension along with the people who are currently working. The SC-ST group are less exposed to hypertension than others, while better education lessens the chances of hypertension.

As far as the role of socioeconomic status in unmet needs is concerned, the rural-urban gap significantly contributes to health status and healthcare access. Poor healthcare facilities along with other infrastructure deficiencies like poor transportation, lack of diagnostic devices, lack of intensive care support, a smaller number of beds, doctors, and nurses etc., are some of the major issues, the rural area faces and hence, healthcare access turns to be low with poor health outcomes [7]. However, in a few studies, health issues are more profound in urban areas [8, 9]. Overall, there is a mix of results on health status and healthcare access between the rural and urban areas.

Income and wealth are the most prominent determinant of ageing health conditions [10]. The higher the income, the higher the healthcare access [11]. In our result, the cases of unmet needs of middle-income class elders are even higher the unmet needs of the poor. It is due to the reason that the financial assistance in the form of health insurance coverage by the government mainly covers poor families. The rich are themselves capable of financing any healthcare needs. It is the middle-income class who has neither sufficient savings nor any financial support to healthcare services and hence, they are largely left of accessing quality healthcare services.

The cases of unmet needs arise due to both physical and cognitive reasons. In country like India, the public health infrastructure is poor and inadequate. The public health expenditure is only 1.02% of the country’s GDP, equivalent to only Rs. 3 per capital per day (National health profile, 2018). The Indian health system is severely marred with inadequate doctors, nurses, primary and tertiary healthcare centers, hospital and others. Consequently, a large section of population depends upon the private healthcare system which leads to the high Out-of-the-Pocket expenditure (OOPE). In India, the OOPE is as high as 54.78% of total health expenditure (World Bank, 2022), higher than most of the poor countries like Congo (45.86%), Angola (37.46%) and Bhutan (17.79%). The cost of medicine is the top most reason contributory factor of high OPPE Saksena [12] & Shahrawat, et al. [13] followed by doctor’s fees. Therefore, high OOPE prevents the people to access the healthcare and creates high unmet need Falkingham, [14]. In our study, the higher case of unmet needs among the middle-income class indicates the two important things. First, the poor income class usually access the public healthcare for any health requirement while, the middle-income class is comparatively more relied on the private health sector and therefore, they borne more healthcare related cost than the poor. Thus, middle-income class faces higher OOPE which in turn, prevents them to healthcare access. Second, the middle-income class is also more concerned about their moderate life condition which push them for higher savings and left little money to spend on other heads including healthcare. Hence, high OOPE and higher family responsibility and financial obligation makes the middle-income class more vulnerable to healthcare access.

The healthcare access of SC-ST group is better than others. It is due to the reason that there are several health schemes available for SC-ST group. The ‘Tribal relief fund’ and Ambedkar Medical Aid Scheme are few of them. There is no such specific health support to the other backward group and hence, the poor healthcare access is highly observed among them. Religion wise the cases of unmet need is higher among the Hindus. However, the Hindus are comparatively wealthier than others [15, 16] and hence, financially, their healthcare access is greater than others. But, in our findings, higher cases of unmet needs among Hindus indicate other socioeconomic factors significantly contribute to their non- access to healthcare, and therefore, such factors need to be explored.

As far as education is concerned, there is a positive correlation between health status and education level [17, 18]. A similar result is also observed in our findings. Hence, better education may lead to high healthcare access and health condition among the poor. The other factor like the gender gap is not found to be significant to unmet needs in our study.

The case of ‘ignorance of illness’ is more prevailed among the rich. There is a psychological reason of it. Rich class is financial affluent and therefore, they have strong financial resources to meet any health exigency, if arises. Early prevention of disease or early treatment of any illness is widely suggested Leonard [19] & Kisling, et al. [20]. Apart from the health benefit of such early initiatives, the financial cause is also prominent. Early treatment leads to huge savings of medical and treatment expenses. People from the poor and middle-income class are very much concerned of their financial position and perhaps, it is the major cause that they seek healthcare soon. In contrast, the rich-class has sufficient financial back up and therefore, financial constraint to healthcare is not significant for them. Hence, they often ignore the illness, although it is not good.

Conclusion

The elders face several physical and social challenges in their life. With ageing, their capability of doing the work gets reduced. They turn out to be highly vulnerable to both communicable and chronic diseases. Psychological issues also arise. At an older age, their source of income is either seized or limited. Overall, the phase of the ageing period, especially after the age of 60, becomes very challenging. The absence of family support, financial support and the public health system makes their lives not better than a hype of burden. Assuring better healthcare access is one of the several contributory factors that lead to a dignified life for elders. The unmet need across socioeconomic determinants shows that elders from the middle-income class and OBC group are more likely to have unmet needs and therefore, the government health policy and schemes should also incorporate these two factors for better health intervention. Apart from it, the common approach to prevention and treatment also needs to be rectified. Government should run Health Awareness Program on large scale. people should be aware of the long-term benefit of early prevention and treatment. It will not only reduce the financial burden, but also ensures a better life in later age.