Findings of the study are organized under eight themes as follows: 1) Demographic characteristics 2) Disease burden and access to healthcare, 3) Financial hardship, 4) Living arrangements, 5) Economic dependence, 6) Physical immobility, 7) Perception towards own health, 8) Change in the health status of elderly from 2014 (71st Round NSS) to 2017-18 (75th Round NSS).
1. Demographic characteristics. The average age of the elderly population in India was 67.5 years (see Table 1). Out of total elderly population (60 years or above), 66.1% were in the age group of 60-69 years, 25.9% in (70-79), and 8% were aged 80 years or above. 67.1% of India’s elderly live in rural areas. Proportion of female (50.9%) is higher than male (49.1%). In terms of the social group, 6.2% elderly belong to ST category, 17.4% SC Category, 42.3% to OBC, and 34.3% belongs to general category. More than half (54.1%) of elderly people are illiterate, and 20% belongs to those households where casual labour was the main household occupation. 4.3% of the elderly in India did not have a surviving child (see Table 1).
2. Diseases burden and access to healthcare:
Outpatient care. Proportion of elderly person (PAP) who reported ailments in the last 15 days was 27.7 per 100 out of which, population who reported chronic conditions in the last 15 days was 22.4% whereas for acute ailments it was 5.7% (see Table 2). PAP was significantly higher in population subgroup 80 years or above (36.7%), urban areas (34.0%), widowed (30.8%), general category (33.2%), regular wages (31.5%) and richest economic quintile (rural-36.8%, urban-43.8%, see Table 2) compared to their counterparts and it was statically significant (see Table 3). The logistic model also shows that chances of reporting ailment in last 15 days was 1.43 times higher in 80 years and above compared to 60-69 years, 1.40 times in higher in urban areas compared to rural areas, 1.1 times higher in male compared to female, 2.27 times higher in general category compared to ST category, 1.32 times higher in primary level educated elderly compared to illiterate, 1.16 times higher in casual labourer compared to regular wages employee, and 2.23 times higher in richest economic quintile compared to their poorest counterparts ( see Table 3).
Cardiovascular conditions including hypertension (32.0%), endocrine conditions including diabetes (22.5%), musculoskeletal conditions (13.9%), infectious diseases (10.0%), and respiratory ailments (7.3%) were the top-five conditions for seeking outpatient care in the last 15 days (see Table 4). In terms of seeking care, 33.6% of the elderly went to a public provider in the last 15 days. Cancer (55.8%) and eye problems (47.5%) were the top two major ailments for which half of the elderly patients went to a public provider (see Table 4). Public healthcare utilization was higher in rural areas (39.7%), ST category (43.5%), casual labourer (50.3%), illiterate (37.7%), never married or divorced (47.6%) and poorest economic quintile (rural-45.3%, urban-41.6%) population (see Table 2).
Inpatient care. Hospitalization rate in elderly was 8.5%, and it was highest in 80 years or above (14.3%) age group. Hospitalization rate was significantly higher for male (9.5%), urban areas (10.1%), never married/divorced (8.8%), with no surviving children (21.3%), general category (10.0%), regular wages employee (9.2%) and richest income quintile (rural-11.2%, urban-11%) population compared to their counterparts and it was statistically significant (see Table 2 and Table 3). For instance, hospitalization rate was 1.26 times higher in age group 80 years of above compared to 60-69 years, 1.21 times higher in urban areas compared to rural areas, 1.2 times higher in general category compared to ST category, 1.1 times higher in primary educated elderly compared to illiterate, 1.38 times higher in financially dependent compared to independent, 2.1 times higher in living alone compared to living with significant others, 1.3 times higher in elderly with health insurance compared to no insurance, and 1.68 times higher in the richest quintile compared to poorest quintile (see Table 3).
Cardiovascular disease (18.1%), infectious diseases (16.6%), eye ailments (8.4%), psychiatric or neurological conditions (8.2%), and injuries (7.9%) were top five reasons for hospitalization in last 365 days (see Table 4).
Out of the total hospitalization episodes, 39.8% services availed from a public provider. It was higher in rural areas (44.5%), elderly with no surviving children (46.0%), ST category (64.0%), illiterate (46.1%), and poorest income quintile (rural-51.0%, urban-47.7%, see Table 2). Share of the public sector was higher in cancer (52.8%), skin (50.3%), infectious diseases (48.3%), and blood diseases (46.8%) whereas the share of the private sector was higher in most of the other conditions. For instance, 72.2% of genito-urinary, 63.2% of psychiatric and neurological conditions, and 63.1% of injury patient went to the private sector for hospitalization (see Table 4).
3. Financial risk protection
Publically funded health insurance (PFHI) coverage and provisioning of tax based subsidized public provisioning are two major strategies used by the government for providing financial risk protection in India [17].
Health Insurance. Overall insurance coverage in the elderly population of India was 18.9%, whereas PFHIs covered 14.3% population. PFHIs only cover inpatient care in India, whereas CGHS (2.1%) and ESIS (0.7%) also cover outpatient care, although to a lesser extent. Private insurance (1.8%) also provided coverage, but for inpatient care alone [13]. PFHI coverage was higher in rural areas (16.6%), ST category (20.7%), illiterate (16.6%), casual labourer (18.2%), and poorest rural quintile (12.8%) in India. Insurance coverage in urban areas was more equitable compared to rural areas, since PFHI coverage was higher in poorer quintile compared to richer quintile in urban elderly. In the rural areas, PFHI coverage was higher in top two quintiles compared to the bottom two quintiles (see Table 5).
Outpatient care. OOPE under public sector for outpatient care was Rs. 390 per visit whereas under private sector it was Rs. 852 (see Table 5). OOPE was significantly higher in 80 years or above age group (public: 430, private: 1039). OOPE was almost the same under rural and urban India. OOPE was higher for male compared to the female gender in the public sector, whereas under the private sector it was nearly the same. OOPE was higher in ST category population compared to general category population in the public and private sector. The public sector was more equitable compared to the private sector. For instance, under public sector, OOPE was Rs. 371 for the poorest income quintile against 564 in the richest quintile. On the other hand, under the private sector, OOPE was Rs. 995 for poorest quintile and Rs. 916 for the richest quintile.
Inpatient care. Average OOPE was Rs. 6209 under public sector and Rs. 38709 under private sector. OOPE was significantly higher for male, urban areas, never married or divorced, elderly without children, ST category, above secondary literate, and richest quintiles compared to their counterparts (lower quintiles). For instance, OOPE for poorest rural quintile was Rs. 5084 in public and Rs. 19410 in private provider whereas it was Rs. 7949 and Rs. 39683 in the richest rural quintile, respectively (see Table 5).
CHE-10 and CHE-25 were calculated to understand the impact of OOPE on the households. Out of total households who went for hospitalization in the last 365 days, 23.2% faced CHE-10 in public whereas 64.9% faced under private sector. Similarly, CHE-25 was 9.1% under public and 37.0% under private sector. CHE-10 and CHE-25 was higher among 60-69 years age group, rural areas, male gender, never-married individuals, ST category, casual labourer, and poorest income quintile compared to their counterparts (see Table 5). Chances of facing CHE-10 and CHE-25 was statistically higher for rural areas, male gender, elderly without surviving children, poorest quintile, non-insured population, private provider and elderly living alone. For instance, chances to facing CHE-10, and CHE-25 was 2.38 and 2.29 times higher in elderly who were living alone compared to elderly living with spouse or another family member (see Table 3). Similarly, chances of facing CHE-10 and CHE-25 was 8.17 and 7.5 times higher, respectively, under the private sector compared to the public sector.
4. Living arrangements:
In India, 4.2% of the elderly population was living alone, whereas 14.1% of the elderly were living with spouse only (see table 6). 50.3% of the elderly lived with spouse and other members whereas 31.5% elderly were living without a spouse but with children or relatives. Population living alone was higher in rural areas (4.4%), female gender (6.6%), never married or divorced individuals (22.2%), elderly without any surviving child (16.1%), illiterate population (5.0%), and richest income quintile (rural-7.0%, urban-6.5%). Also, the population living with their spouse were higher in top two income quintiles compared to the bottom two quintiles. Chances of living alone was higher in 60-69 years age group, rural areas (OR: 1.35), female (OR: 1.24), widowed (OR: 2.4), general category (OR: 1.45), and richest income quintile (OR: 1.87), and it was statistically significant (see Table 3).
5. Economic dependence
47% of elderly in India were wholly dependent on others financially, whereas 30.1% were independent, and 22.9% were partially dependent (see table 6). In other words, 70% of India’s elderly were, partially or entirely, dependent on others. Complete financial dependence was higher in 80 years or above age group (70.8%), female (67.1%), widowed (62.8%), illiterate (55.5%), and poorer quintiles. Chances of being economically dependent were higher in 80 years or above (OR: 3.36), female (OR: 9.5), general category population (OR: 1.20), elderly not living alone, and poorer quintiles and it was statistically significant (see Table 3).
6. Physical immobility:
Physical mobility is one of the proxy indicators for locomotor disability. In India, 7.6% of elderly were either completely (bedridden) or partially immobile (on a wheelchair or restricted within the home). It was considerably high in 80 years above group (27.5%), female gender (8.9%), widowed (11.9%), illiterate population (8.7%), and poorer income quintiles. However, immobility increases steeply for the richest quintile (rural-8.3%, urban- 9.5%) compared to other quintiles (see Table 6).
7. Perception of self-health
In India, one in five elderly (19.6%) felt their current health was poor and a similar proportion felt (21.0%) that their health condition had deteriorated compared to the previous year (see table 6). Perception of health being poor was higher in the 80 years or above age group, rural areas (21.4%) and widowed elderly (26%). Perception towards the current state of health across income quintiles was mixed. However, the proportion of elderly who felt that their health got deteriorated compared to the previous year was considerably higher in poorest urban quintile (20.4%) compared to richer quintiles (see Table 6).
8. Change in the health status of the elderly in NSS 75th Round, 2017-18, compared to NSS 71st Round, 2014
Hospitalization rate among elderly decreased from 10.9% in 2014 to 8.5% in 2017-18 (see Table 7). Also, PAP fell from 30.3 in 2014 to 27.7 in 2017-18. Share of the public sector in outpatient care increased from 28.3% in 2014, to 33.6% in 2017-18, whereas its share in inpatient care it increased from 35.9% to 39.0%. OOPE under public sector decreased from Rs. 547 (in 2014) to Rs. 390 (in 2017-18) for per outpatient visit and from Rs. 7177 to Rs 6209 for per hospitalization visit. On the other hand OOPE under private sector increased from Rs. 802 to Rs 852 per outpatient visit and Rs. 31,875 to Rs. 38,709 per hospitalization visit (see table 7).
Proportion of elderly population living alone almost remains the same, whereas proportion of the elderly population being dependent on others decreased marginally from 71.7% (in 2014) to 69.7% (in 2017-18). Self-perception of having poor health decreased from 22.4% (in 2014) to 19.6% (2017-18). Similarly, elderly population who felt their health has deteriorated compared to last year dropped from 25%, in 2014, to 21%, 2017-18 (see Table 7).