Almost all the youngsters of Ghisar village in Pune district are in Pune city, hunting for jobs or struggling to make a living. The same holds true of almost all the villages in Velhe taluk of Pune district.

One can see young faces only during the festivals. Surrounded by hills and infertile rocky land, agricultural income is often not sufficient. There is no other major livelihood opportunity in the vicinity.

With no young people around, the elderly had to change their lifestyle – they have to wait for proper medical care for weeks until the youth return and take them to a hospital. The primary health center in Pasli, 35 km away, caters to Ghisar village. But travelling to Pasli is not practical and commuting to the rural health center at Velhe, 21 km away, is an easier option.

However, higher referral centers ask for a referral letter from Pasli PHC for getting concession. As a result, it has become difficult for the elderly to seek proper healthcare during emergencies.

Changing demography

Unlike in high-income countries, Indian rural elderly rely are dependent on youngsters. Villages, once prosperous with people and culture, have a skewed population today. According to the 2011 Census data, 70.56% of the elderly are in rural areas, against 29.44% in urban areas.

This is more common in rapidly urbanising states: Maharashtra is third, after Tamil Nadu and Kerala, comparing Census data from 2001 and 2011.

However, in absolute numbers, Maharashtra ranks first, with more than 50 million people residing in urban areas. These urban centers have an increasing need for human resources, especially in the informal and semi-formal service sectors, which attract rural youth.

The youth in villages are frustrated, as they see no scope for their aspirations or development in their villages. Disheartened by lack of money and daily hardship, they move to cities in droves. There is also reverse migration of the elderly from cities to villages after retirement.

As there are no youngsters in the villages who can question and take up matters with officers, there is less pressure on government systems. Illiterate and under-confident, the elderly cannot run around to get the benefits of various schemes.

Often in many villages, PHCs suffer from lack of staff or medicines. Youngsters often cannot spare time to attend to the health needs of the elderly during their brief visits. “Our kids come here like guests. What all can we ask them to do? We have to plead [with] them for everything,” said an elderly lady.

Sakharam Dhendle and Pandurang Dhendle, residents of Ghasir, have severe mobility restrictions and spend a substantial amount on medicine. Credit: Abhijeet Jadhav/Village Square

When intervention cannot be avoided, they take the elderly to cities or private clinics, adding to the overall expenditure. This heavy expenditure adds to the emotional burden of the elderly. “My lower back operation cost Rs 6 lakh,” said a senior citizen. They are not aware of the national health insurance scheme for the poor. Enrolling in the scheme can prevent catastrophic health expenditure of many families.

Associated health risks

In 2011, the disability rate among the elderly – between 60 to 80 years of age – was 51.8 per 1,000, and 84.1 per 1,000 for the octogenarian population, which is high compared to high-income countries. Moreover, 76.19% of the disabled elderly are in rural areas.

These disability rates do not count impairments such as the inability to walk due to knee pain or vision impairment due to cataract. As per the Building Knowledge Base on Population Ageing in India research project 2011, 64.8% of the elderly suffer from some chronic disease or the other. Many elements, such as diabetes and hypertension, need monitoring, regular checkup and medication.

The non-availability of medicines is also a significant issue. All of this translates into excessive suffering, impairment, disability and low quality of life. Such life affects the psyche of the elderly, leading to excessive depression.

As per one study in rural northern India, 11.4% elderly had depression, and it was more among people with chronic diseases, disabilities and impairments. The BKPAI report also says that around three-fourths of the elderly are dependent financially on others and half of the elderly face some form of abuse.

Due to the state of primary health centres in villages, residents are forced to spend a lot on private healthcare. Credit: Abhijeet Jadhav/Village Square

Government schemes

The National Program of Health Care for the Elderly, started in 2011 in 100 selected districts, is meant exclusively for the elderly population. The program was expected to expand over some period. Under this program, infrastructure and healthcare delivery centres are to be built, from primary to tertiary health centre level with specialists and trained medical cadre.

Dedicated elderly clinics and camps are expected to happen at a certain frequency in the public health facilities at the grassroots with dedicated ward facility at district hospitals. However, there is inactivity and low fund utilisation. Most of the states have single-digit percentages of fund utilisation rate for this program.

The program is now managed by the Non-Communicable Diseases Cell, increasing further confusion. It is not clear how a senior citizen, whose children are away, can avail the program’s benefits. While the program document mentions outreach, there is no clarity about the related activities.

This vertical program is far from successful as the intended beneficiaries are completely unaware of it. Rashtriya Vayoshri Yojana, which gives free aids and assistive living devices to needy elderly, is another such scheme that is yet to reach rural areas effectively.

“Special clinic for elderly? First ask them to run the PHC. All such things are just empty talk,” said another senior citizen. Today, the average rural elderly are not aware of the program or the elderly healthcare centers around them.

Struggling in the city

For young men struggling in cities, staying away from their parents, wives and other family members is an additional source of stress. A village resident, speaking about her son, said, “His life is not easy. He has to work very hard in the city and manage the expenses on multiple fronts.”

The men cannot afford to take their newly married wives to cities, at least in the early phase of their career. This affects their relationship. Moreover, the women are burdened by the additional task of taking care of their elderly parents-in-law. “He left me here to work like a donkey. I have to manage everything here,” said a woman.

Migration of youth to cities for better education, employment and life is an unstoppable phenomenon. As our demographic dividend closes, the proportion of the elderly will keep increasing. By 2050, the proportion of the elderly in the total population – which is 8.7% at present – will be 19%.

It is also the year when our annual growth rate will be surpassed by the annual growth rate of the elderly. In the coming three decades, we will be grappling with the problem of a huge number of dependents needing medical care.

In order to ensure the health and well-being of the elderly, we require aggressive interventions in rural areas with a focus on outreach. There are multiple angles to be considered to build an effective intervention to improve health access of rural elderly, but proper implementation of existing programs could be a good start.

This article first appeared on Village Square.