Tamil Nadu, a state that was a pioneer in geriatric healthcare, has failed to implement provisions of the National Programme for Health Care of the Elderly or NPHCE that was launched seven years ago. According to a report by the Comptroller Auditor General, the state was supposed to have established geriatric units in five select districts which it has failed to do. It has also been the only major state in India that has not utilised any of the funds granted by the centre for this scheme between 2010 and 2015.
In 2010, the Ministry of Health and Family Welfare launched the NPHCE under the 11th Five Year Plan with the aim of providing affordable and accessible quality health services for people above the age of 60.
According to the census of 2011, there are nearly 104 million elderly people in India, 53 million of whom are women. Between 2001 and 2010, India saw a 35% growth in people above the age of 65. Around 71% of the elderly population resides in rural areas.
The 2004 round of National Sample Survey hd a comprehensive status health and healthcare for the aged, which found that occurrence of diseases as well as of hospitalisation are much higher in older people than the total population. About 8% of older Indians were confined to their home or bed. Among those above the age of 80, 27% of people are immobile or home bound.
Geriatric health experts point out that many older people take ill health in their stride as a part of “usual or normal ageing” and care of the elderly has been seen as the responsibility of their families – a possible reason why India did not have specific public health programmes for the elderly for a long time.
“The elderly face financial difficulties, emotional struggles and abuse from families,” said Dr Radha S Murthy, head of a Karnataka sub-committee examining NPHCE implementation and who has worked in the field of geriatric health for 20 years.
However, irrespective of socio-economic status, non-communicable diseases that need lots of health and social care are extremely common in old age. Disabilities resulting from these non-communicable and that affect daily living are frequent. Managing these diseases is also very costly.
“On the health front alone, geriatric health care has to look into multiple issues right from hypertension and diabetes to dementia,” said Murthy.
As India’s first national programme specifically for elderly healthcare, the NPHCE that aims to provide an easy access to services to promote health, prevent disease, and to cure and rehabilitate the elderly with ill-health. The programme is supposed to work based on a primary health care approach in conjunction with the National Rural Health Mission, Ayush and social justice programmes.
But the project has been slow to take off.
Tamil Nadu is not the only state lagging behind in implementing the NHPCE. As per government data, states have collectively used only 42% of the funds allocated for the programme between 2011 and 2015.
States like Assam, Madhya Pradesh and Rajasthan have used between 20% and 50% of their funds. Only Maharashtra, seems to have been more successful, using almost all the funds allocated under this scheme.
A senior official with the Ministry of Health and Family Welfare said that the union ministry can only issue advisories to states but not much more. “Ultimately, health is the state subject, and if the central government is providing funds then it is the state’s responsibility to utilise them for the betterment of their people,” he said. “If some of the states are not utilising the funds then they become ineligible for additional funds. If they utilise and do good work, then we give more.”
Structure of the NPHCE
Under the new NPHCE, states are required to set up regional geriatric centres at regional medical institutions. Each regional centre is supposed to have a separate geriatric out-patient department and a 30-bed geriatric ward for in-patient care. The regional geriatric centres are also tasked with setting up postgraduate courses in geriatrics to train more doctors in the field. Besides the regional units, each state also has to set up a certain number of district geriatric units under the programme. Each district geriatric unit is supposed to have a geriatric OPD and a 10-bed geriatric ward. Health authorities are supposed to organise bi-weekly geriatric clinics at community health centres and weekly clinics at primary health centres.
According to an August 2015 press release issued by the government, a total of 104 districts of 24 States and union territories and eight Regional Geriatric Centres have been covered under the programme. So far, 930 community health centres, 4,439 primary health centres and 28,767 sub-centres have set up geriatric facilities under the programme.
Under the 12th Plan, twelve more regional geriatric centres, geriatric units in 225 more districts and two National Institutes of Ageing were supposed to be to be established.
Delays in Tamil Nadu
Much before the NPHCE was drawn up, Tamil Nadu was the first state in the country to have a separate unit for geriatric health care in a government hospital in Chennai. Dr VS Natarajan, one of India’s first geriatric care specialists, set up such a unit at Madras Medical College in 1978, which is where the regional geriatric unit is now located.
The union government released around Rs 2.79 crore under the programme to the Tamil Nadu government for the year 2011-’12 and Rs 3.44 crore for the year 2012-’13, according to the said the CAG report which was tabled in the State Legislative Assembly on July 19. Tamil Nadu was supposed to have used these funds to set up district geriatric units in Coimbatore, Theni, Thoothukudi, Tirunelveli and Virudhunagar.
“Delays at various levels resulted in non-establishment of District Geriatric Units, despite availability of funds of Rs 7.96 crore,” claimed the audit report.
The NPHCE is supposed to be implemented by non-communicable diseases cells, where such cells have been set up. Funds for the programme are released by the union government to State Health Societies that pass required funds down to district health societies, community health centres and primary health centres.
Though the Tamil Nadu government was supposed to start implementing the geriatric health care programme in 2011, there was a long delay. The Project Director of the Tamil Nadu Health Systems Project had requested the state government to authorise the project’s non-communicable disease cell to implement the geriatric health care programme and waited till 2013 to get approval. Such approval was unnecessary, according to the CAG report.
“Since there was no need for seeking authorisation of Government of Tamil Nadu as per the Government of India’s guidelines, the delay of two years and eight months was avoidable,” said the report.
The principal secretary of Tamil Nadu’s Health and Family Welfare Department had responded to the auditors on October 2016 saying that the funds for the years 2010-’11 and 2011-’12 could not be utilised due to “non-availability of operational guidelines for the utilisation of funds”. According to the audit report, the principal secretary had said that the state government had not requested funds for the two years from the union government because they were not required. He had also added that the non-communicable disease control programme was being implemented in all the districts from 2011 onwards by the Tamil Nadu Health Systems Project.
To this, the audit report responded:
“The reply was not acceptable, as it was noticed that the Operational Guidelines for NPHCE were released by GoI in August 2011 itself...Moreover, the NCD control programme was implemented by GoTN for prevention and control of NCDs like diabetes, Hypertension, Cervix Cancer and Breast Cancer and was not a focused one, as in the case of NPHCE, which was meant to cater to the elderly people exclusively.”
Tamil Nadu’s Health Secretary, Principal Secretary and Director for Medical Education were unavailable for comment.
Slow implementation
According to the senior health ministry official, funds were being provided under the programme in two ways. State governments were allotted funds for acquiring equipment, hiring manpower to set up units in various districts. The union government was also giving funds directly to regional centres headed by medical colleges to set up research and training programmes in geriatrics.
“I don’t know about the audit report, but we have been using the funds in the college,” said Dr GS Shanthi, a geriatrician at Madras Medical College, which is a regional geriatric centre. “Eight beds were set up for intensive care units. The state is also starting a National Centre for Aging. The institute would start in a year. This will be a 200-bed hospital, with research on old age and training for doctors and health care.”
Rajasthan has a regional geriatric centre in Jodhpur. “The programme is very close to us, since we’ve been working for it to be implemented right from 2002,” said Dr Arvind Mathur, a retired professor and researcher at SN Medical College, Jodhpur. “Though I’m happy that it is going on, a lot more needs to be done.”
According to Mathur, there has been a certain amount of confusion in the states while implementing the scheme. While the centre allotted funds to hire geriatric doctors and staff for the various centres, they were expected to be hired on a contractual basis. However, the states did not find this to be practical.
“Because we have had to hire on a contractual basis, we do not have enough staff in the geriatric wards and there is no continuity in the way it is run,” said Mathur. “Not enough infrastructure has been created in various districts.”
Mathur also said that the regional centres have not been linked effectively with the district centres. While Rajasthan’s regional centres come under the Director of Medical Education as these were established in government medical colleges, the district programme is run by the Director of Medical and Health Services.
“There is still lot of confusion which is why funds have not been used effectively,” said Mathur. “We need to develop a proper feedback and monitoring system between the centre and the state.”