This study primarily aims to decompose the differential in the elderly and non-elderly age groups in the occurrence of disability in India. Adding to that we tried to measure the contribution demographic and socio-economic factors to explain the above-mentioned differential in the occurrence of disability. The prevalence of disability among the elderly and non-elderly is 84 and 16 per thousand population, viz. The study supports the fact that the elderly is facing a significant health disadvantages due to degenerative and chronic morbid conditions much more than the non-elderly. The increase in the prevalence of diseases related to disability is significant and extensive among the elderly in low-and-middle-income countries (Sousa et al., 2009). This indicates that the focus on disability as well as geriatric care, in particular, has not been strengthened in the existing healthcare system in India. Healthcare must address the need of population as elderly in developing countries have a greater chance to suffer from chronic diseases and related disabilities (28).
Socio-economic conditions become precursors to the incidence of disability as it promotes barrier in the major dimensions of life. The risk difference in disability prevalence across demographic and socio-economic determinants predicts that those factors develops a higher risk of disability among elderly (29). A larger set of socio-economic factors determines participation of an individual. Being from rural areas, currently married, belonging from a reserved community, no educational achievements, lower wealth quintile, and smaller household size represents higher disability prevalence in India. Globally, better education and wealth status act as a modifier for health behaviour, practices and purchasing power of health services among individuals. Inadequate public health infrastructure, higher medical expenses at the private health sectors and lack of adequate rehabilitation facilities at the primary healthcare centres are probably few important reasons that results into a higher disability prevalence among the lower category of MPCE. Disabled individuals are more prone to suffer from physical inaccessibility in different services and facilities (30). Moreover, reduction in the functional capacities at the older ages significantly deteriorate the scope to access healthcare facilities and other services (31). Therefore, it contributes towards the disability burden, which is squarely manifested as a reason to limit the barrier-free infrastructural inclusivity in the facilities.
Few types of disability are more common in India, for instance, locomotor, hearing, and visual disability proclaims a top most share in total disability. The elderly shows a higher share of disability in the particular categories in compared to the non-elderly. Results demand a higher focus on the reduction of burden of morbidities that causes the disabling conditions. It is noticeable, that disability in speech and language, mental retardation, and mental illness are sharing a sizeable proportion of disability among non-elderly. Developmental disorders, due to nutritional deficiency in relation to maternal and child health, in the younger age-groups continue to persist in the population (12). It is to be mentioned, transitions in disease pattern is negatively associated with the social gradients. Studies already showed the speed of growing incidence of non-communicable morbid conditions like diabetes, cardiovascular diseases etc., among higher wealth quintiles in India. A higher disability prevalence and risk difference among educational categories predicts that the impact on disability is much severe among elderly in the selective categories. Study shows non-elderly age-groups have a growing disability burden from a range of conditions that includes communicable diseases, NCDs and injuries (13). Besides, the trend in the incidence of injuries, atrocities in childhood, malnourishment at the early ages, and violence among children and younger age adults are also seeking an attention in the context of India for upcoming decades.
Decomposition analysis supports that males are potential contributor to the gap in disability. Being elderly male is likely to pronounce the chance of occurrence of disabled conditions at older ages. Gender attributes 11.3 percent of the gap in the disability prevalence. Males are more exposed to outer environment and shows more severe incidence of fatal chronic diseases like stroke, hypertensions, injuries etc. However, policy analysts suggest that varying gender roles exposes them to various morbid conditions and injuries. The implication on health utilization is biased towards males in the resource-poor developing countries (32, 33). Under representation of female in the society might be a cause of concern as it under-reports the health complications and increases the incidence of disability in the later ages in such setups. Easier and accessible approach to the health centres must be fortified with the local community health workers to address the unmet needs of population (28). This study shows that marital status acts as a negative factor for decompositions. Being widowed and divorced uplifts the gap in disability between elderly and non-elderly. The longer life expectancy of elderly females and early demise of spouse becomes critical to the health and economic conditions, since, loss of financial security is likely to intensify the deprivation at later ages (33, 34). Major informal caregiving for the disabled is provided by the family members, for older ages the importance of the family and kin has been highly emphasised in India. Being disabled in older ages seeks an intensive care and support from its caregivers. It can also derive that introduction of elderly specific agendas in policies, and activities of non-governmental organizations is far reaching to safeguard the well-being of the widowed or divorced. Higher education contributes positively to the disability gaps due to a remarkable contribution of NCD related morbid conditions across better socio-economic groups. At older ages, absence of an adequate healthcare infrastructure at the community level and inaccessible financial protections, and distressed financing can deteriorate the extent of disability, too. It is important to mention, access to healthcare at primary health facilities becomes critical (35, 36), as rehabilitation facilities are more concentrated in the bigger cities and private facilities in India. Moreover, interventions for disabilities in mental health at community-level is needed to be strengthened since, individuals suffers from heightened barriers like stigma, avoidance, lack of care-receiving and discrimination against healthcare (37). Availability and accessibility of treatment and assistive devices in low cost can be easily achieved if community-based interventions are offered. It would complement a better participation by reducing the barriers.
Disability is a long-term phenomenon that brings permanent damage to health. This diverse consequence of disability can be addressed by integrating to a multidimensional approach not only in the health policy but policies that are intended for the socio-economic development like, financial inclusion and offering satisfactory social safety nets. Previous research on inequality in the health-seeking behaviour and health financing would be helpful to explain the fact on unaffordable healthcare cost in private hospitals, skewed utilisation of benefits to the upper socio-economic groups at the expense of disadvantageous one, growing size of lower socio-economic groups in the elderly population with adverse health conditions as individuals, especially from lower wealth quintile, tries to avoid treatment (32, 38, 39). Besides, lack of community-level health facilities is reiterated to generate an inevitable barrier among population.
A larger household size shows a negative contribution to the disability gaps explains that the presence of more number of members in the family can escalate the chance of support and caregiving. It has been clear that the disintegration of the families in the Indian context induces a higher chance of being disabled at older ages in the absence of traditional caregiving and support. Thus, promoting a provision for caregiving to the disabled, and more importantly, to the elderly disabled, can enhance the health utilization and reduce the vulnerability caused by disability. Lack of support from the close network members at the household level can be correlated with the occurrence of mental retardations and multiple disabilities. Dearth in cognitive and social capital can alleviate the chance of disability by keeping an individual less active and poorly informed, as reported in a study (33).
Relative deprivation negatively affects health behaviour in developing countries. States with higher social and income inequality can have more unsatisfactory health outcomes in terms of disability. Our study shows that Southern region of India has the highest prevalence of disability, followed by Central regions of India. A higher value for risk difference presented by the population living in the Central part of the country (76.8 per 1000 people). It explains the fact that being elderly in the Central region of India has a higher likelihood of disability than the rest of the regions. However, at a same level of disability prevalence, there remains a wide heterogeneity in risk difference across the states in India. Decomposition shows in the Eastern and North-eastern regions of India; elderly population is more prone to be disabled than non-elderly. Besides, a better healthcare infrastructure does not ensure the lesser prevalence of disability and a low-risk difference. For instance, despite Kerala and Odisha are two states ranking far away in terms of health indicators in India, they secure same position in graph at the high-high region; and explaining a higher disability prevalence and risk difference. Higher horizontal inequality of the elderly in terms of healthcare utilization can explain the socio-economic inequity in the country (40). Lesser utilization, as a matter of inequity, can intensify the morbidities and disabilities in a population. The extent of disability among the elderly is fatal in the states designated as high-high in Fig. 3.
Besides, states like Punjab, Rajasthan, Karnataka are yet to finish the demographic transitions, also explain lesser share of the elderly population and are facing a threat of worsen health outcomes among the elderly than non-elderly population. It should also take into consideration that low-high states of Chandigarh, Assam, and Arunachal Pradesh needs to be focused on geriatric care and rehabilitation, even though it shows a lower disability prevalence. It accelerates a thought that lack of disease preparedness in the health system would worsen the experience of ageing among the population, if not acted now. The promotion of healthcare demands a priority for the non-elderly in the high-low set of states like West Bengal, Himachal Pradesh, and Andhra Pradesh. The positive correlation suggests for promoting the healthcare to be geriatric-centric, although a large chunk of the population still need a non-elderly care. Strengthening of the preventing measures for chronic diseases is suggested in the developing countries, which can serve to elderly and non-elderly by mitigating the risk factors (36, 41). Joe et al. (2015) suggests that moderation in no-need driven factors for healthcare utilization like, education and wealth through investing in social and economic dimensions is an equivocal policy approach for both the elderly and non-elderly population. In that context, a meagre amount of disability pension and lack of consistency in pension delivery across states must be considered to promote health equity. To achieve an optimal health, it is suggested to promote universal access to primary healthcare and population specific interventions, in respect to health promotion in the infrastructure as well as in home and community care (12, 28). Elderly in Indian context occupies a remarkable position in regard to health and well-being. In next few decades, the elderly will grow at a significant rate with a decline in potential support ratios and increase in a health burden (42). To cater the tumultuous challenge, it is necessary to promote the disability inclusive component as a vital component of universal health coverage in India. Through this study, we support the importance of building a framework that reduces the inequality between different demographic and socio-economic gradients and finally, to provide preventive, curative, palliative and rehabilitative care to the disabled population affected due to a varied health conditions (3).