Addressing health equity for senior citizens in India

“You need an ECG,” the clinician told 72-year-old Narayan. Panicking, his son quickly googled nearby facilities, finding only private clinics. Unaware of any public health options, and with time more critical than cost, he paid Rs. 500 to get it done.

As India’s population ages, healthcare for senior citizens becomes increasingly important. In a significant move, the government has recently extended health coverage under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) to all senior citizens aged 70 and above, regardless of income. This step is critical to addressing the health inequities faced by the elderly population.

AB PM-JAY offers Rs. 5 lakh per family annually for secondary and tertiary hospital care, covering all family members. Under the new provision, families with elderly members aged 70 or above will receive an additional Rs. 5 lakh annually. However, if two elderly members are part of the same family, this top-up will be divided between them.

With around 9.1 crore senior citizens between the ages of 70-79, this group will be the primary beneficiaries of the expanded scheme. While this extension is a positive step, it excludes a significant portion of the senior population aged 60-69, totaling approximately 16.24 crores. Given India’s average life expectancy of 69 years, many seniors under 70 still face substantial health and financial risks. Excluding them from coverage leaves a gap in care for crores of elderly citizens who also need financial support to access healthcare.

Out-of-pocket expenditure: A major challenge

In India, out-of-pocket expenditure (OOPE) covers half of all healthcare costs. Like Narayan, who had recently enrolled in the PM-JAY senior citizen scheme, many still pay from their own pockets for timely care due to limited public health infrastructure.

OOPE is regressive health financing, as it affects poorer households disproportionately. OOPE forces many families to reduce spending on basic needs such as food and clothing and limits their access to healthcare services due to cost. OOPE are incurred while accessing both inpatient and outpatient care. 

Reducing OOPE was one of the primary goals of AB PM-JAY when it was launched. However, the scheme only covers inpatient care. The outpatient care is not currently covered under AB PM-JAY. To pay for their healthcare expenditures, senior citizens have to use their consumption budget (e.g. food, housing, clothing, phone) that may affect their quality of life. A seventy five year old Asif said, “I have to choose between mobile recharge and buying medications this month”.

The burden of OOPE is especially heavy on the poorest, who spend twice as much of their consumption budget on healthcare compared to the wealthiest seniors. While the new AB PM-JAY provisions help reduce the OOPE for hospitalisation, outpatient care remains a significant financial strain. 

Around 75 per cent of elderly individuals suffer from chronic conditions, with many also having disabilities. Medications and routine tests dominate their healthcare expenses. For instance, 67-year-old Shilpa spends over Rs. 10,000 monthly on medical care, even with generic medications.

Also, studies show that senior citizens primarily depend on outpatient consultations to access healthcare for lack of knowledge and/or access to public health facilities. Six years after the launch of AB PM-JAY, these outpatient costs remain uncovered, leaving seniors with significant healthcare expenses.

Low health insurance penetration, lack of pensions, and below poverty line living conditions limit spending on outpatient expenditures and access to healthcare. Importantly, 71 per cent of the elderly live in rural areas, where  inadequate medical infrastructure exacerbates the problem of low healthcare utilisation. This is a problem for specialty care. Swapnil’s father is 68 years old, an oral cancer patient, and has to travel 100 km to Pune for his oncologist appointments.

Consequently, many households with elderly struggle financially, with 90 per cent of them perceiving their economic status as average or worse. Swapnil confided, he has spent more than Rs. 30 lakhs for his father’s cancer. His oncologist has advised immunotherapy, which will cost Rs. 10 lakhs.

The way forward for equitable senior care

OOPE is pushing a significant portion of the elderly population below the poverty line further into extreme poverty, creating a generational poverty trap for many. The AB PM-JAY scheme, though well-intentioned, exacerbates this economic divide by not covering outpatient care, which is a large component of elderly healthcare expenditure. AB PM-JAY is the world’s largest publicly funded health assurance program, aimed at achieving universal health coverage. Extending the scheme to cover outpatient services for seniors would help bridge the gap in healthcare equity. This could include covering the cost of routine medications and tests for seniors suffering from chronic conditions or disabilities.

To ensure the success of this expanded coverage, following measures could be considered – (i) increasing the allocated budget. By further increasing the number of beneficiaries without increasing budget allocation is going to deprive more people of care now defeating the purpose of achieving universal health coverage, (ii) focus should be on increasing public health infrastructure and controlling privatisation, (iii) shift from facility-based care to home-based care covering the expenditure through senior citizen scheme, (iv) raising awareness among senior citizens about their entitlements under the scheme and simplifying the documentation process are essential steps, (v) encourage the private sector to contribute to senior care through corporate social responsibility (CSR) initiatives, helping reduce the financial burden on the elderly.

India’s senior citizens deserve equitable healthcare, and AB PM-JAY can play a pivotal role in ensuring that no one is left behind. By making the scheme more comprehensive and accessible, we can better meet the healthcare needs of our aging population.

(All names changed to protect privacy)