Old age security: Doing the right thing for our elders

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It is estimated that India has around 90 million elderly and by 2050, this number is expected to rise to 315 million. The life expectancy in India has increased from 42 years in 1960 to over 65 years at present. Longevity is laudable as an achievement in developing countries but it leads to social and economic pressures on formal and informal care network along with the government. Governments around the world have a herculean task at hand of providing for pensions, housing, medical services and a dignified life for seniors.

Elderly care is gaining more importance in India owing to the changing demographic mix and increased awareness. Even though the proportion of elderly in India might be low as compared to the developed countries, the sheer size of the population would make this a mammoth task. There is a clear need which is emerging for a comprehensive solution for elderly care which encompasses their overall security.
Poor and economically dependent senior citizens in the rural and urban areas have an urgent need for support in terms of UHC which will provide for both inpatient and outpatient treatments across secondary and tertiary care.
The economically independent elderly would need support across the five elements of Financial, Emotional, Social, Physical and Family security for a comprehensive support system.

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Old age security: Doing the right thing for our elders

  1. 1. Old age security: Doing the right thing for our elders kpmg.com/in
  2. 2. Table of contents Introduction - current status and prominent trends of elderly 02 Initiatives taken by the Government and Government agencies 08 Global overview 13 Way forward 17 Next steps 22 Appendices 24
  3. 3. ASSOCHAM - Foreword With increasing life expectancy and decreasing fertility the population pyramid is slowly inverting leading to a narrower base and a heavier burden. Add to this a change in disease pattern and a change in the social fabric - leading to the break down of the joint family system, and the problem of how to take care of our elderly looms large over us. In this changing environment, Old Age Security will no longer be ensured by only providing monetary support, there are physical, emotional and social factors that will need to be considered. Apart from taking care of the health care requirements, there is a need to provide the elderly with physical security in terms of a fully furnished and serviced accommodation and concierge services to support. Besides this, provision of emotional and social security, by creating an environment where they may build and sustain social networks is crucial. They are also in need of legal advice and estate planning services to be able to manage their funds better. While, we work towards creating a robust framework for elderly care, we also need to ensure the young know of their choices and start planning early. Initiatives such as a single view of retirement funds, which will help them understand their current corpus and plan for the future, and a retirement planning helpline that would guide them in their choices would go a long way in ensuring overall success of the program. However, this solution cannot be worked upon in isolation by any one entity, there is a need for different stakeholders like Government, Insurers, Financiers, NGOs, and Health Care Providers to come together and work in collaboration to achieve a total security solution. There will be structural changes in policies and a central agency required to ensure implementation of the various schemes. This report is a first step in defining the challenge and a possible solution, we hope for this to be the starting point to stir a larger debate and discussion, culminating in the development of a new framework for Old Age Security. Dr. P Nandagopal . Chairman - ASSOCHAM National Council on Insurance, MD & CEO - IndiaFirst Life Insurance
  4. 4. ASSOCHAM - Message Social security is a basic human right. The object of social security is to provide livelihood to those who cannot earn their livelihood by work for chronic or temporary reasons. The older persons need social security as they cannot work and earn due to age factor. The eligibility criteria of the National Old Age Pension Scheme need to be liberalized, the quantum of benefits under the scheme needs to be enhanced. The subsidized insurance schemes need to be enlarged to cover all sections of the unorganized sector linked to welfare funds and rationalized in so far as the subsidy element is concerned. Thus the system of social security in India would consist of a multi-tiered structure. Indeed, there is already such a structure though in a rudimentary form in the first tier there is the National Social Assistance Programme and other social assistance programmes. In second tier there are the social insurance schemes namely the ESI Scheme, the schemes framed under the EPF Act, the Employers' Liability Schemes and such others. In the third level are the numerous Voluntary Health Insurance and Old Age Pension Schemes, which are being run by LIC, GIC, the UTI and other Financial Institutions. Adequate arrangements should be made for institutional care of those who have no families or who cannot be taken care of by their families. At the same time concerted effort should be made to preserve and strengthen the traditional family system, as the alternative to institutional care cannot be a satisfactory substitute for family care of the elderly. ASSOCHAM in partnership with KPMG brings to you this knowledge report on “Old Age Security-doing the right thing for our Elders” with a light on prominent trends, healthcare sector and key drivers in Old Age Security. ASSOCHAM acknowledges the hard work of KPMG and ASSOCHAM team in shaping this knowledge report for easy understanding and a ready reference book. I am sure this report will give a rich insight and adequate knowledge to all the stakeholders. Your valuable suggestions / comments are welcome. D.S.Rawat Secretary General ASSOCHAM
  5. 5. Foreword As per KPMG in India's experience, few societies have truly faced up to the magnitude of long-term elderly care crisis. If this system fails it will have devastating consequences for elderly individuals, their families, the economy and wider society. Without swift action, such a gloomy outlook is probable rather than possible. It is estimated that India has around 90 million elderly and by 2050, this number is expected to rise to 315 million. The life expectancy in India has increased from 42 years in 1960 to over 65 years at present. Longevity is laudable as an achievement in developing countries but it leads to social and economic pressures on formal and informal care network along with the government. Governments around the world have a herculean task at hand of providing for pensions, housing, medical services and a dignified life for seniors. Global Age Watch Index (GAWI), developed with UN fund for population and development, ranks India 73rd out of 91 countries in elderly care which includes key areas across income security, healthcare, employment, education and enabling environment. The elderly face a lot of challenges in terms of their health and well-being. Most of the people above 60 years of age do not have a steady stream of income and have to depend on their family for financial expenditure as well as physical and emotional support. Also, with changing family structure increasing number of senior citizens are not staying with their children and living alone. This issue is more daunting for senior people below the poverty line in rural areas as most of the old-age homes, institutional support and medical care are currently focused on urban areas. Moreover, senior citizens are more prone to chronic illness and disabilities. Without the safe, secure and dignified status, the elderly are finding themselves vulnerable. A comprehensive security coverage is required to ensure the overall care of the elderly. Such a framework needs to address financial, physical, emotional, social and family security for the elderly. Compared to other areas of healthcare, long-term elderly care has received very little attention. Further, the healthcare system at various levels in our country so far has largely been designed for the population at large. Most hospitals do not have a special geriatric facility. Similarly, the nursing and other para-medical staffs are not formally trained in providing care for elderly patients. While several policy initiatives have been taken to promote welfare of elderly and Central and State Governments have implemented various schemes for the elderly, people below poverty line are largely uncovered or inadequately covered. It is also pertinent to consider the capacity of this segment to afford ever increasing healthcare expenditure. India must prepare for surge in elderly population who may be far poorer than their counterparts in the West. This report attempts to capture the prominent trends of elderly in India, initiatives taken by the Government for this segment and outlines a possible roadmap for the long-term care of the elderly. Can we look at India as a country where our elders are well taken care of? Our aim is to stimulate wider dialogue between governments, private and non-profit stakeholders, to inspire innovation and change in attitudes and policies. Shashwat Sharma Partner Financial Services KPMG in India
  6. 6. Old age security: Doing the right thing for our elders | 1 Introduction That is no country for old men. The young In one another's arms, birds in the trees —Those dying generations—at their song, The salmon-falls, the mackerel-crowded seas, Fish, flesh, or fowl, commend all summer long Whatever is begotten, born, and dies. Caught in that sensual music all neglect Monuments of unageing intellect. An aged man is but a paltry thing, A tattered coat upon a stick, unless Soul clap its hands and sing, and louder sing For every tatter in its mortal dress, Nor is there singing school but studying Monuments of its own magnificence; And therefore I have sailed the seas and come To the holy city of Byzantium. Sailing to Byzantium - W B Yeats Old age is a relatively recent phenomenon and until the second half of the 20th century the few that survived beyond 60 were typically cared for by family members. Ageing of population is affected with downward trends in fertility. With improvement in nutrition and healthcare, average life expectancy had increased to over 60 years in developed regions, reaching 75 years by 20001. The life expectancy continues to increase and the gap between the developed and developing countries is gradually reducing. Though longevity is a positive measure of healthcare development in the developing countries, it brings with it a whole lot of social, economic and healthcare challenges for the elderly and puts pressures on the society. Not many countries, including India, have woken up to the fact that this stratum requires inclusive policies which can potentially reduce stress on governments in terms of pensions and healthcare expenditures as the younger generation may not be willing or may be unable to provide for senior people in the future. Golden age or second innings is becoming a major concern for the policymakers all over the world. Second innings should not be stressful for the elder generation if they are prepared for their life after retirement in terms of healthcare expenditure, pensions, housing and above all a secured community living to interact with like-minded people. Elderly care refers to the fulfillment of special needs and requirements of the senior citizens. It entails a broad spectrum of services, such as assisted living, adult day care, long-term care, nursing homes, hospice care and home care. 1 KPMG Global report on ‘An uncertain age: Reimaging long-term care in the 21st century’ Many people suffer from complex and multiple chronic conditions like cancer, heart disease, diabetes, hypertension among others. An integrated approach to care should anticipate the recipient’s needs and manage his or her journey by bringing together specialists, family doctors, home care nursing, and social care. New roles could potentially emerge in the future, such as care coordinators, who facilitate people’s journeys through the health and social care system, and help people to be at the right place and at the right time for early diagnosis.
  7. 7. 2 | Old age security: Doing the right thing for our elders Prominent Trends Increasing life span With the rapid advancement in medical science and technology it has now become easier to control various dreaded diseases which were the cause of high mortality earlier. This has resulted in a steady increase in life expectancy. United Nations predict that by 2050, average life expectancy will be almost 80 years in developed regions and more than 70 years in less developed parts of the world.2 Globally, the number of persons aged 60 year or above is expected to more than triple by 2100, increasing from 841 million in 2013 and close to 3 billion in 21003. In the developed regions, population above 60 years will be increasing at 1.0 per cent annually before 2050 and 0.11 per cent annually from 2050 to 2100. In the less developed regions, population above 60 years will increase at a faster pace—it is projected to increase by 2.9 per cent annually before 2050 and 0.9 per cent annually from 2050 to 2100.4 Population above 60 years in million 2,500 1,600 554 287 2013 2050E 2100E Developed Countries Hence, for a developing country like India, the ageing population poses mounting pressures on various socio economic fronts including pension outlays, healthcare expenditures, and fiscal discipline. Disintegrated ‘extended family concept’/ less pool of caretakers According to a 2012 survey by HelpAge India, less than 40 per cent of Indians live with their extended families. The trend is similar in rural India as well, where younger generation is moving to urban cities for better employment opportunities and thus diminishing the concept of extended families. Countries such as China and Mexico are facing a similar situation. High divorce rates and single-parent families are no longer a taboo and one can see them mushrooming everywhere. In a scenario where there are fewer care-takers in the family, elder generation is often left to fend for themselves. Also, due to a tilt in the pyramid, less working age population i.e. population in the labour force has to support more and more elders and children who are not in the labour force i.e. dependent population. According to the World Bank in 2012, the ‘dependency-ratio’6 was close to 50 per cent for the United States and 60 per cent for Japan. For India, the dependency ratio was 53 per cent in 2012 and has been hovering between 50-55 per cent since 2010. 440 417 It is also worthwhile to note that in the period 1970-75, average length of life was only 48 years and 59 years in rural and urban areas respectively. However, with availability of healthcare improving, the life expectancy has increased as well as the rural – urban gap has considerably reduced in the last 30 years.5 Developing Countries Source: United Nations June 2013 report on ‘World Population Prospects Economic and Social Affairs The 2012 Revision’ On the contrary, India would have 30.2 per cent of the population above 60 years by 2100 which is relatively less as compared to other nations. However in India, though per centage wise greying is not very rapid, but due to its mammoth size, planning for the elderly is a huge challenge for the policy makers. Per cent of population above 60 years (medium variant) 41.1 39.9 46 35.2 18.3 23.2 32.3 19 9.5 2013 2050 Japan India UK France 8.3 19.7 2100 35.5 15.6 8.6 USA 24.1 27.7 25.9 Mexico 27.1 13.9 Germany Brazil Australia World 21.2 11.2 China 19.8 11.7 Canada 21.2 30.7 32.8 28.9 27 30.2 Russia 31 30.7 27.6 32.2 28.5 39.4 42.7 39.6 27.5 27.8 15.8 South Africa 34.3 38.4 Singapore 35.4 35 35.5 Source: data.worldbank.org 2 KPMG Global report on ‘An uncertain age: Reimagining long-term care in the 21st century’ 3 United Nations June 2013 report on ‘World Population Prospects Economic and Social Affairs The 2012 Revision’ 4 United Nations June 2013 report on ‘World Population Prospects Economic and Social Affairs The 2012 Revision’. For developed and developing regions definition, please refer the terminology at the end of this report 5 Situation Analysis ‘The elderly in India’ by Government of India in June 2011 6 Age dependency ratio is the ratio of dependents--people younger than 15 or older than 64--to the working-age population--those aged between15-64.Data shown in the graph is the proportion of dependents per 100 working-age population.
  8. 8. Old age security: Doing the right thing for our elders | 3 Age dependency ratio (per cent of working age population) 52 52 47 55 52 54 54 53 54 54 49 2010 2011 Mexico 2012 36 54 54 Singapore 39 56 Japan UK France Germany 57 54 52 India 54 52 China 36 Canada Brazil 44 36 World 39 USA 45 48 36 55 36 Australia 54 49 40 58 Singapore 47 48 54 50 45 36 48 53 Russia Federation 49 60 56 Source: data.worldbank.org A concept of ‘newly aged poor’ is also becoming more prominent where people in their 50s are taking up early voluntary retirement schemes (VRS) or forced retirement due to lack of jobs and skills. This further increases the burden on health and welfare schemes as well as pension schemes by the government. Retirement homes/ Communities The elderly are concerned about their safety and well-being. With a diminishing joint family concept and kids moving ahead in their career in different countries/ cities, elder population has to take care of their-day-to-day activities. Alternatives such as retirement homes or communities with assisted living are being preferred by the elderly generation rather than staying alone. In countries such as USA, retirement villages like Beacon Hill Villages and Community without Walls offer homes close to medical care, community services and entertainment. Elder residents and volunteers are recruited to help each other with basic services7. ‘Community without Walls’ in New Jersey is a village that works with a local non-profit organisation and relies mainly on informal volunteers. There is an annual fee of USD 30 to join the community, with a charge of USD 300 for a higher level of assistance. Other services are available for an additional cost. In 2012, Japan introduced a new Integrated Community-based Care System that aims to provide various support services, including welfare, healthcare, long-term care and preventative measures within existing communities, and accessible within 30 minutes. As a first step, there is a 24-hour home visit service, which can be reimbursed under the national long-term care insurance scheme7. Care homes provide the elderly the benefits of being part of a community of like-minded individuals. Care homes provides housing, support services and personalised care for elderly individuals who may need help with daily activities, hygiene maintenance and health & medication management. Doctors who provide check - ups and give wellness tips, nursing staff that administer medicine and provide wheel chair assistance, care givers who assist in daily personal grooming, availability of pharmacy, ambulance, convenience stores, railing supports, ramps for wheel chairs and security controls translates into peace of mind for the entire family. In India, assisted-living complexes such as retirement resorts at Lavasa - Pune and Bhiwadi - NCR developed by Ashiana builders are generating interest from the elder population. Demand for retirement homes is on the rise and lots of projects are coming up in cities such as Coimbatore, Goa and Dehradun.8 A report by JLL in 2013 estimates the current demand for retirement housing in India at approximately 3 lakh units.8 7 KPMG Global report on ‘An uncertain age: Reimagining long-term care in the 21st century’ 8 http://articles.economictimes.indiatimes.com/2013-07-08/news/40443288_1_retirement-housing-projects-senior-citizens
  9. 9. 4 | Old age security: Doing the right thing for our elders Our survey findings A quick dipstick KPMG in India's survey of the elderly from diverse economic, social and demographic background highlighted that financial problems, health problems and fear of living alone emerged as top three fears of the surveyed elderly. The level of prominence of problems was different for rural and urban areas. While health problems and fear of living alone were more prominent among urban elderly, financial problems were more fearful for elderly in rural areas. It clearly indicates more health consciousness among urban elderly while a weakening social fabric in urban areas. Further, it was found that most of the elderly belonging to middle class in urban areas were dependent on their savings while those from rural areas were dependent on their children or Government for their healthcare needs. In terms of housing, a large number of respondents preferred living with their children given the large joint family base in India followed by a preference to shift to a senior citizen housing project. Increasing awareness about such projects coupled with the weakening social fabric is expected to help community living as a preferred option for many elderly. 31% 15% 8% 15% 8% 15% 31% 8% 8% 15% 15% 23% 46% 8% Top Rank Second Rank 15% 8% 8% 15% 15% 15% 38% 15% 38% 23% 15% 38% 23% 15% Third Rank Fourth Rank Closeness to a metro/city Construction as per elderly requirements such as absence of stairs Easy access/physical assistance for medical facilities Source: KPMG in India Analysis 15% 54% 38% Fifth Rank 23% Sixth Rank Need for intervention 38% 31% 69% 31% 31% 23% 8% 8% 15% Top Rank 38% 23% 8% 15% Second Rank 62% Third Rank Fourth Rank Clubs/Old age homes Public transportation Free medical check-up Social protection Source: KPMG in India Analysis Important parameters in a senior living society 15% In case of an option to live in a community, 38 per cent of seniors have ranked easy access to medical facilities as their top priority while choosing a community living society followed by 31 per cent who have ranked living with like minded people as their top priority. Security has emerged one of the top concerns especially from urban elderly population while rural elderly are more concerned about easy access to healthcare facilities. 8% 15% Seventh Rank Expenses to be incurred for moving out of current location and to a new home Like minded group Security Support for household chores More than half the elderly surveyed (69 per cent) have ranked social protection as the top most priority where they need intervention. The worries of most of the respondents on basic facilities, such as health and finances point to a lack of institutional support for the elderly. By comparison, most of the developed countries, especially Scandinavian countries have a highly evolved and institutionalised model of elderly care, which puts the onus on the entire community, rather than the individual families. Financial security and fear of living alone figured among the top three fears voiced by surveyed elderly. Need for social protection emerged as the main concern where intervention was needed. Overall, the survey highlighted the need for security on five varied dimensions — financial, physical, emotional, social and family security.
  10. 10. Old age security: Doing the right thing for our elders | 5 Supply and demand gap in healthcare With the increasing number of senior people who are prone to chronic illnesses, the demand for long-term care will increase in the coming years but long working hours and low wages in the field of geriatrics prevents talented people to enter this field. Also, most of the skilled people find better job opportunities outside India. Around one-fifth of doctors practicing in Organisation for Economic corporation and Development (OECD) countries are immigrants or contractors from abroad. India is a major source of doctors for Australia, Canada, New Zealand, the UK and the US while the Philippines is the single largest supplier of nurses.9 Further, the problem is aggravated by the infrastructure gaps which continue to remain substantial in India. The hospital bed density in India is currently 9 beds (2005-2012) per 10,000 population which is significantly lower than the WHO global number of 30 beds per 10,000 population10. Increasing health expenditure The current government expenditure on healthcare is only 1.2 per cent of the GDP and it is planned to increase it to 2.5 per cent by 2017 and 3 per cent by 202211. To provide for better coverage/ care to the citizens insurance could be an alternative. OECD nations such as the US, Mexico, Spain and Austria offer preferential incentives such as tax deductions, tax credits and allowances to encourage citizens to buy insurance policies to ease strain on public expenditure. Some of these benefits are available in India too but the Indian insurance market still remains under-penetrated as compared to some of the other international markets. Senior people face chronic illnesses and most of the people below poverty-line do not even consider insurance as an option. Insurance companies have an entry age limit and senior people may not have their life and medical expenses covered when they need it the most. Insurance penetration** for FY12 (Life + Non Life) Ageing society puts a burden on healthcare expenditure by the government. For most of the countries, healthcare expenditure as a per cent of GDP is minuscule when compared with the growing population. Amongst the BRICS nations, the public and private spending on healthcare in India is the lowest—3.9 per cent of GDP on healthcare as compared to Brazil and South Africa which spend in the range of 8.5-9 per cent. 11.3% 12% 8.9% 8% 8.2% 6.7% 4.8% 4.0% 4% 3.0% Health expenditure as a per cent of GDP in 2011 0% UK 2.7 Indonesia Australia 9 South Africa 8.5 France USA Germany Malaysia India China Source: IRDA Annual Report 2012-2013; ** Penetration is expressed as GWP as % of GDP All countries data pertains to the calendar year except India 6.2 Russia Insurance density* for FY12 (Life + Non Life) 8.9 Brazil 5.2 China 5000 UK 9.3 Japan Premium per capital in USD 3.9 India 9.3 Canada 11.2 Germany 11.1 4,350 4,047 4000 3,543 2,804 3000 2000 1000 514 53 11.6 France 17.9 United States 0 5 10 15 Source: World Bank 9 KPMG report on ‘An uncertain age: Reimagining long-term care in the 21st century’ 10 WHO Health Statistics 2013 11 HLEG (set up by Planning Commission) Report 20 179 India China 0 UK France USA Germany Malaysia Source: IRDA Annual Report 2012-2013; *Density is defined as GWP per capita. All countries data pertains to the calendar year except India Currently, a vast population of India does not have any health insurance or any other medical cover. The Government of India has been discussing policies towards universal coverage. The Planning Commission, in its 12th five year plan for India, visualises a comprehensive health reform for the aged. Positioning the health of the elderly in a broader framework of universal access and affordability of universal health coverage has potential to transform the structural conditions that hamper the well-being of the aged.
  11. 11. 6 | Old age security: Doing the right thing for our elders Considering the fact that the insurance penetration and density in India is extremely low at the moment, and Governments’ policies for healthcare expenditure is not sufficient, out-ofpocket healthcare expenses for individuals is the only way out. The graph below gives out details about out-of-pocket healthcare expenditure by individuals. USA and South Africa has the minimum out-of -pocket expenses for individuals due to the insurance cover and strong Government policies for senior population. Out-of-pocket healthcare expenditure as a per cent of private expenditure 92.0 86.0 87.9 82.0 78.8 63.0 57.8 53.1 32.1 87.8 92.2 82.0 20.9 53.1 51.4 13.8 13.9 2010 Russian Federation Mexico Japan India United Kingdom 22.7 France Germany China 32.2 United States 49.0 Brazil Australia 86.0 77.2 57.8 Canada 59.4 South Africa 51.4 48.6 2011 Source: World Bank In 2012, India was ranked third in the World Health Organization's latest list of "countries with highest out- of-pocket expenditure on health" in the south-east Asia region.12 Even amongst the developing countries, India has the highest out-of-pocket expenditure only next to Mexico and Russia. As in July 2012, the healthcare inflation in India was 15 per cent13. Due to the increase in medical inflation, cost for various treatments for senior people has been increasing. The cost of treatment like Angiography, Cholecystectomy (Gall Bladder removal), TURP among others has increased by almost 50 -60 per cent in 2007 – 2012.14 While the technology has reduced the time taken for certain medical procedures, the expertise to use such technology is limited. The cost of super specialty and robotics is also passed to patients. Disease Management In India, healthcare is generally reactive, with little pro active steps being taken for managing health such as regular medical checkups. Until there is a need, people avoid visiting a doctor. Due to lack of customer demand, there has been limited growth in service providers who cater to disease management and preventive care. Disease Management is all about proactive and disciplined health management where patients’ self efforts are of high significance. The goal for disease management is to educate the patient about his condition and ensuring that he follows his unique care plan designed by a dedicated care manager tuned to his specific needs and possibilities. Disease management ensures better compliance with the treatment plan, thus ascertaining better outcomes and thereby reducing overall cost of treatment compared to reactive treatment which can be very expensive for a chronic condition. 12 ‘Out of Pocket Expenditure’ of Health Care Services in India: Factors, Consequences and Solution-Journal of Global Economy (ISSN Print-0975-3931, Online -2278-1277), Volume 9 No 2, June, 2013 In India, the concept of disease management is in its nascent stage. The concept of wellness and overall physical well being is not very common with a lot of people associating wellness services with beauty services and spas rather than fitness centers. However, awareness about fitness and preventive care is gradually picking up. There have been a few entrants in the disease management space, though they have a very small footprint currently. A few large corporate such as Apollo Hospitals and other health insurance companies are also introducing concepts related to wellness and preventive care. Aetna Inc. has bought Indian Health Organization (IHO) with an objective of providing preventive medical tests, dietician programs among others. However, given the complex healthcare system in India, rolling out disease management and wellness programs will remain a challenging task. Perception about Elderly Most of the younger generation feels that elder generation should retire after 60 years as they cannot cope with the stress and work but if the elder generation is healthy and willing to work, the perception needs to change. Everyone has a right to a dignified life and with some help in honing the elderly genrations' skills and making them technology-savvy, the younger generation could benefit from their experience. Though the Constitution of India mandates the well-being of elderly generation under Article 41 but if the elder generation does not get adequate help from the extended family, society, and take charge of their own life, the pension schemes run by the Government would not be adequate to sustain this generation. 13 http://m.businesstoday.in/story/rise-in-medical-costs-should-be-covered-inhealth-insurance/1/185680.html 14 http://www.jagoinvestor.com/2012/09/health-insurance-inflation-in-india.html
  12. 12. Old age security: Doing the right thing for our elders | 7 A Government pension scheme for the poor “Indira Gandhi National Old Age Pension Scheme (IGNOAPS)” was introduced in 1995 for elder population below poverty line. Under this scheme, INR 200 per month is given by the Central government to people above 60 years who live Below the Poverty line (‘BPL ’). The Central Government has also urged the State Government to contribute INR 200. Recently, the government has approved a bill to increase the pension to INR 500 a month to those over the age of 80.15 Considering the medical inflation, and out of pocket expenditure of individuals on healthcare, this amount may be meager for individuals whose survival depends on it. In 2007 the Maintenance and Welfare of Parents and Senior , Citizens Bill, that protects the rights of senior citizens, and provides a system where the elderly could petition the administration to seek maintenance from their family was cleared by the parliament. Despite rapid and consistent economic growth in India, it will have a huge ageing population who may be far poorer than their counterpart in the West. In India those who have worked in Central and State Government sectors get pension and other retirement benefits after the age of 60 years. But for others, the Government of India and the State Governments, at present, have very nominal old-age pension coverage. But much is to be done as at the old age the medical expenses go up and dependency on children / relative also increases for physical, mental and economic support. The various initiatives undertaken by the Government to address the healthcare challenges for the elderly are discussed in detail in the next section. 15 http://gulfnews.com/life-style/general/why-india-s-youth-are-abandoning-their-elderly-parents-1.1136422
  13. 13. 8 | Old age security: Doing the right thing for our elders Initiatives taken by the Government and Government agencies During the last two decades, aging population has become a cause of worry for the policy makers all over the world — both developed and developing countries alike. The proportion of elderly (above 60 years of age) is expected to increase from 8.3 per cent in 2013 to 18.3 per cent by 2050 and to 30.2 per cent by 2100). Therefore, the formulation and successful implementation of welfare policies for senior citizens pose a challenge to the Central and the State Government. This section highlights significant policies initiated and implemented by various governments (center/state) in the post-independence era. The Constitution of India mandates governments to provide public assistance to the elderly. Although some small steps were taken before, a stronger foundation was laid only during the third Five Year Plan (1961-66) that recognised the requirements of the old people who had no one to support them. A host of legislation and government initiatives — employees provident fund scheme, employee pension scheme for employees in the central and state government sectors — were undertaken for the welfare of older people between 1952 and 1976. In 1969, the public provident fund (PPF) scheme was introduced for those in private sector as well as for self employed. However, these initiatives were mainly aimed at ensuring income security and were applied to segment of elderly with relatively good condition. As the initiatives taken by the Government before 1990s proved to be inadequate, the Central Government initiated a new wave of welfare programs for the senior citizens. Some of the prominent ones include the National Policy for Older Persons, IGNOAPS and the National Programme for the healthcare for the elderly. The objectives and current status of these schemes/ policies are discussed below: Integrated Programme for Older Persons (IPOP) With a view to improve the quality of life of the elder generation, the Ministry of Social Justice & Empowerment launched a flagship scheme called the IPOP since 1992. This scheme provides basic amenities like shelter, food, medical care as well as entertainment opportunities to encourage productive and active ageing. About 350 NGOs are being supported every year for running and maintaining around 550 projects under IPOP Keeping in view . the rising cost of living, and the cost norms of various projects, the Government revised the scheme in April 2008.1 Now, NGOs are provided with the financial assistance of up to 90 per cent of the project cost to establish and maintain old age homes, day care centers among others while the remaining 10 per cent is borne by the concerned organisation/institution. 1 Department of Social Justice and Empowerment, http://socialjustice.nic.in/pdf/report-nationalconferenceonageing.pdf, accessed on 11 December 2013
  14. 14. Old age security: Doing the right thing for our elders | 9 National Policy on Older Persons (NPOP)2 The Ministry of Social Justice & Empowerment announced the NPOP in 1999 to ensure financial security, healthcare and nutrition, shelter, education, welfare protection of life and property of older people. Among others, the policy recognised the role of NGOs in providing user friendly affordable services to complement governments’ endeavors to create a healthcare system for elderly. In pursuance of the NPOP the National , Council for Older Persons (NCOP) was constituted in 1999 to oversee the implementation of the policy. However, the policy has failed to deliver even after more than thirteen years since its announcement. Keeping in view the changing demographics, socio-economic patterns, technological advances and other relevant factors, the Government assessed the status of various issues concerning senior citizens and drafted a new National Policy on Older Persons in January 2010. The new draft policy has been circulated in 2011 to all State Governments and Union Territories Administrations seeking their comments/suggestions. However, nothing has been done to implement the new policy as well. National Rural Health Mission (NRHM)3 Launched in 2005 by the Ministry of Health and Family Welfare, the National Rural Health Mission (NRHM) aimed to provide accessible, affordable and quality health services in rural areas with a special emphasis on elderly care. The NHRM involved building infrastructure and healthcare staff with a female accredited social health activist (ASHA) in every village. NRHM has helped significantly reduce the incidences of several diseases by increasing the number of health facilities, care providers (ASHAs, doctors, nurses and paramedic staff) and community education. The NRHM has been quite successful in achieving several of its projected targets. However, administrative constraints, governance issues, inadequacy in human resources and sub-optimal investment in public health services and misuse of funds have been some key constraints during the implementation of NRHM. 2 Ministry of social justice and empowerment 3 nrhm.gov.in 4 Department of Social Justice and Empowerment, http:// socialjustice.nic.in/pdf/reportnationalconferenceonageing.pdf, accessed on 11 December 2013 5 National Programme for Health Care of the Elderly, Press Information Bureau, http://pib.nic.in/newsite/ erelease.aspx?relid=94453, accessed on 11 December 2013 6 No takers for geriatric project , The Hindu, http://www.thehindu.com/ todays-paper/tp-national/no-takersfor-geriatric-project/article4464688. ece, accessed o 11 December 2013 Maintenance and Welfare of Parents and Senior Citizen Act 2007 Maintenance and Welfare of Parents and Senior Citizen Act 2007 is considered to be a landmark development for senior citizens. It aimed to ensure need based maintenance for parents and senior citizens, protection of the rights and welfare from their children. It contains penal provisions for the abandonment of senior citizens, provides for the establishment of old age homes for indigent senior citizens, and envisages protection of the life and property of senior citizens.4 However, the level of implementation of the Act by states and union territories (UTs) seems to be neither uniform nor satisfactory primarily due to the lack of adequate awareness about the provisions of the Act among the civil society. National Programme for the Health Care for the Elderly (NPHCE) The Ministry of Health and Family Welfare initiated NPHCE in June 2010 with an objective to provide promotional, preventive, curative and rehabilitative services to the elderly persons at various level of healthcare delivery system. The first phase (2010-12), NPHCE was planned to cover 100 districts of 21 states/UTs across all verticals of healthcare set up viz. primary level, secondary level and tertiary level. The second phase (201217) plans to extend the program to the remaining 540 districts in the country. As on April 2013, only 25 districts hospitals (out of the planned 100 districts) have started geriatric clinics.5 Further, the implementation has not even started in many of the states. During 2011-13, an amount of INR 2,880 million was allocated to the NPHCE. However, the utilisation of the amount remained poor. As an example, Kerala, the state with one of the largest elderly population in the country, had utilised only 8 per cent of the INR 87 million it received till January 2013.6 .9
  15. 15. 10 | Old age security: Doing the right thing for our elders Indira Gandhi National Old Age Pension Scheme (IGNOAPS)7 Launched in 2007 by the Ministry of Rural Development, IGNOAPS covers individuals who are 65 years or above and belong to the BPL families. While the Central Government provides INR 200 per month as pension, it has urged states to make at least an equal contribution to the scheme from their resources.8 As stated above in the prominent elder trends, for elder generation above 80 years, the pension amount has been raised from INR 200 at present to INR 500 per month.9 It was a step taken in the Union Budget 2011-12. Also, the eligibility for pension was reduced from 65 years to 60 years. The total number of beneficiaries under IGNOAPS was approximately 21 million as of 2011-1210. Rashtriya Swasthya Bima Yojana (RSBY) or National Health Insurance Programme Recognising the absence of affordable health insurance, the RSBY was launched by the Ministry of Labour and Employment in 2008 for poor people in India. RSBY aims to shield low-income households from the burden of major health expenses. The scheme provides health insurance cover of INR 30,000 per annum (including INR 1,000 towards transportation expenses) for five members of a BPL family. As there is no age limit for the eligibility, elderly population is also covered under the scheme. The beneficiary family has to pay a registration fee of INR 30 at the time of enrolment for accessing empanelled hospitals across the country. The premium is subsidised by the Central and State Government. There is also a provision for the State Governments to top up the coverage amount beyond INR 30,000. The scheme only covers in- patient treatment and excludes out-patient expenses. RSBY was originally limited to BPL families but was later extended to building and other construction workers, street vendors, beedi workers, sanitation workers, auto rickshaw drivers and taxi drivers among others. Under RSBY, each district is administered by only one insurance company who has won the competitive bidding process at district level. As of April 2013, 15 insurance companies (public as well as private) along with 25 third party administrators (TPAs) are involved in RSBY scheme. Insurance companies are incentivised to enroll as many people as possible for each additional person enrolled. The premium for RSBY is different in different districts. The insurance premium is contributed by the Central and State Governments in the ratio of 75:25, except for the North-East region and Jammu and Kashmir where it is 90:10. As on April 2013, 468 districts in 28 states and UTs have been selected for RSBY implementation, many running into second year of operation. The number of families that are enrolled in RSBY has gone up from 4 million in 2009 to 37 million in 2013.11 .5 More than 11,800 hospitals are selected across the country which makes it one of the largest health insurance schemes in the world. The shortcomings of RSBY include high transaction costs due to insurance intermediaries (fee for service), and lack of coverage for primary health and outpatient care. The RSBY also does not take into account state specific variations in disease profiles and health needs. With criticism of focus on inpatient treatment only, RSBY scheme is now expanding into outpatient care, with pilots in Gujarat, Odisha, Andhra Pradesh and Punjab. Rajiv Aarogyasri or Aarogyasri Health Insurance Scheme The Government of Andhra Pradesh (AP) launched Rajiv Aarogyasri Health Insurance Scheme in 2007 to improve access of poor people to quality medical care. The scheme has been implemented in all districts in the state and is one of the best examples of public private partnership. The AP Government selected Star Health and Allied Insurance Company via a competitive bidding process to implement the scheme. Under this scheme, hospital bills of the insured persons are paid by the insurance company which in turn is paid by the AP Government. People do not have to pay anything under this scheme. The AP Government set the premium at INR 210 per household annually for tertiary coverage of up to INR 150,000 per family annually during the first phase of the scheme. Within the state, the premium is same across all districts and the amount reimbursed per procedure to any network hospital is also the same. The scheme covered 19.83 million families out of total across 22.91 million families (87 per cent) across all the districts of the state.12 Pension Fund Regulatory and Development Authority (PFRDA) and National Pension Scheme (NPS) The Government established the PFRDA in 2003 with an objective to develop and regulate the pension market in India. Further, the Government introduced the NPS in 2004 to provide retirement income to all the citizens. Initially, NPS was introduced for the new government recruits (except those in armed forces). From May 2009, NPS has been extended to all citizens including those in the unorganised sector on voluntary basis. As on 31 March 2013, NPS had 4.8 million subscribers with assets under management of INR 298.52 billion.13 Additionally, to inculcate the habit of saving for retirement, the Central Government launched a co-contributory pension scheme for people from unorganised sector, ‘Swavalamban’ in 2010-11. Under this, the government will contribute a sum of INR 1,000 to each eligible NPS subscriber who contributes a minimum of INR 1,000 and maximum INR 12,000 per annum. This scheme is presently applicable up to 2016-17 During 2011. 12, the scheme had 640,000 subscribers. A budget provision of INR 1.1 billion in 2011-12 and INR 2.2 billion in 2012-13 has been made for the scheme.14 7 Formally known as National Old age pension scheme which was launched in 1995 8 http://rural.nic.in/sites/downloads/our-schemes-glance/SalientFeaturesNSAP .pdf 9 Ministry of rural development, http://nsap.nic.in/nsap/NSAP-%20About%20us. pdf 10 http://www.academia.edu/2948934/National_Social_Assistance_Programme_ NSAP_2013-14 accessed on 17 December 2013 11 Rashtriya Swasthya Bima Yojana(RSBY)-Highlights, Press Information Bureau, http://www.pib.nic.in/newsite/erelease.aspx?relid=94269, accessed on 11 December 2013 12 Health Insurance in India, http://www.iosrjournals.org/iosr-jhss/papers/Vol8issue1/B0810714.pdf, accessed on 13 December 2013 13 NPS Trust, PFRDA, http://www.pfrda.org.in/indexmain.asp?linkid=184, accessed on 13 December 2013 14 http://financialservices.gov.in/pensionreforms/swavalambanscheme.asp
  16. 16. Old age security: Doing the right thing for our elders | 11 Select Municipal Corporation Schemes In order to provide health protection to senior citizens, a few municipal corporations provide health cover to senior citizens. The Gwalior Municipal Corporation (GMC) and Indore Municipal Corporation (IMC) initiated a special healthcare scheme providing health insurance cover for hospitalisation expenses (secondary care) of up to INR 20,000 targeting senior citizens from financially weak backgrounds (aged 60 – 80 years). The premium payment is fully subsidised by GMC/ IMC. It is a cashless scheme with co-payment of INR 500. However, due to limited involvement of civil society organisations, slow enrolment process, limited hospital network along with inadequate coverage of INR 20,000 without any critical care cover curtails the efficacy of this scheme. Universal Healthcare (UHC) The results of various schemes and initiatives discussed above have been only marginal and inadequate. One of the key issues is the lack of coordination among various government departments/agencies running these schemes. Hence, a strong need was felt to introduce a comprehensive UHC system. In October 2010, a High-Level Expert Group (HLEG) was constituted to provide recommendations to ensure impartial, affordable, appropriate, accountable and quality healthcare services - regardless of income level, social status, gender, caste or religion. Key recommendations from HLEG include• ncrease in public expenditure on health to at least 3 per cent I of GDP by 2022 from the current level of 1.2 per cent of GDP as of 2011.15 • Expenditures on primary healthcare, should account for at least 70 per cent of all healthcare expenditures and cover. • Use general taxation as the principal source of healthcare financing. • Develop a national health package that offers essential health services as part of the entitlement of every citizen • Increase the numbers and skills of health workers. • Avoid any kind of fees for use of healthcare services under the UHC framework. • Establish new medical and nursing colleges in underserved states and districts. • Establish district health knowledge institutes to coordinate and conduct training of different categories of health workers. • Strengthen the role of civil society and non-governmental organisations. • Establish National Health Regulatory and Development Authority (NHRDA) a, National Drug Regulatory and Development Authority (NDRDA) and a, National Health Promotion and Protection Trust (NHPPT). Broadly, the recommendations of HLEG revolve around management reforms, community participation, better financing for healthcare along with improved access to medicine and healthcare services. Positioning elderly health in a broader framework of universal access and affordability, UHC has the potential to transform the structural conditions that hampers the well-being of the aged. It is estimated that India has around 90 million elderly and by 2050 this number is expected to rise to 315 million16. People become more susceptible to chronic diseases, physical disabilities and mental incapacities in their old age. The illness of the elderly are multiple and chronic in nature. Keeping in mind the higher risk in the group, a higher coverage limit along with tertiary care is desirable for this segment with a fully subsidised UHC package to effectively provide for better health coverage. It is also critical to focus on disease management for this segment by creating a special fund which will pay for the healthcare expenditure. Under this framework it is envisaged to provide guaranteed access to an essential health package covering primary, secondary and tertiary care without using any independent agents. We propose that the primary care can be continued to be provided through the existing public health facilities while access to secondary and tertiary care can be provided through insurance mechanism. The use of insurance would help in expanding coverage and large scale of operationalisation. Multiple schemes, both public and private, are running in parallel in a fragmented manner, however, they suffer from inadequate coverage in terms of population and health cover provided. There is a situation where certain sections of the society are covered for some level of benefits, a few others have a larger coverage (such as employees under Central Government Health Scheme (CGHS) and Employees' State Insurance Scheme (ESIS). However, majority of the population is still uncovered and the coverage is inadequate. Moreover, there is no coordination among various schemes. To facilitate effective reach of UHC, especially the senior citizens, it is critical to identify different segments within this group. The key is to identify segments which need subsidisation by the Government to bring them under the ambit of UHC on priority. Majority of elderly reside in rural areas and belong to low socio economic section. Also, merely 10 per cent of the elderly receive some form of retirement benefits such as pension benefits16. This is due to the nature of work participation which is concentrated in the informal and unorganised sector. In addition, only 1.5 per cent of the elderly hold a valid policy16. 15 High Level expert group report on Universal Health Coverage for India – Nov 2011 by Planning Commission 16 Report on the Status of Elderly in Select States of India, United Nations Population Fund, November 2012
  17. 17. 12 | Old age security: Doing the right thing for our elders Selective subsidisation can be offered to certain segments of the population such as BPL, people working in vulnerable occupations and other informal sector, senior citizens belonging to economically weaker sections of the society. Following are the recommended segments which will require specific strategy to provide health cover: Senior citizens living in rural areas: It has been estimated that around 75 per cent of the elderly live in rural areas17. More than 65 per cent of the rural elderly are dependent (partially/ fully) on others for their maintenance18. • oor/ Economically Dependent Senior Citizens: These people P can be provided full subsidy by the Government for providing UHC package. • conomically Independent Senior Citizens: Most of the E people in this category work as labourers, farmers, in informal sectors among others. It will be important to create awareness in this group to encourage voluntary enrolment. For people working in informal sector, efforts need to be made to include all vulnerable groups under various welfare trusts and boards. These boards will act as facilitators between the beneficiaries and the insurance companies empanelled for UHC enrollment in particular districts. As this segment will be funding the premium through self, it is important that the UHC package should be designed in such as manner so as to make it affordable for this segment. 17 Report on the Status of Elderly in Select States of India, United Nations Population Fund, November 2012; Situation Analysis of The Elderly in India, Ministry of Statistics & Programme Implementation, June 2011 Senior citizens living in urban areas: Similar to rural elderly, almost 65 per cent of the elderly in urban regions are dependent (partially/ fully) on others. • Economically Dependent Senior Citizens: These people can be provided full subsidy by the Government for providing UHC package. • Economically Independent Senior Citizens: For those working in organisations employing more than 20 employees can be provided the base level UHC cover through premium payment by means of Provident Fund (PF) benefits as provided by the employer. A small portion can be deducted for premium amount towards the basic health cover while deducting EPF amount during salary disbursements by the employer. The premium amount so deducted can be parked in a separate fund which is utilised for providing health insurance benefits to the employees. • Alternatively, a group health cover may be mandated to be provided by organisations through employee-employer contribution. The use of insurance would help in expanding coverage of UHC. The managerial, technical and operational capacity of insurance industry can be leveraged. The actuarial capability of insurance industry can bring in reasonable cost of care, higher efficiency and controls. Moreover, consolidation of fragmented purchasing will help in improving the quality of the care provided. With larger population coming under the ambit of UHC, it will make the healthcare insurance affordable to the self-paying section of the population. The concept of UHC is in its planning phase and has already attracted attention and criticism. 18 Situation Analysis of The Elderly in India, Ministry of Statistics & Programme Implementation, June 2011 Role of NGOs in elderly care Is enough being done? NGOs have helped in bringing to the forefront the issues related to elderly belonging to lower income, disadvantaged or unprivileged sections of the society. NGOs have played an important role in creating awareness, imparting information, partnering and implementing schemes and training of support staff. Presently there are many NGOs working for the cause of the elderly in India. They have played a key role in a number of areas including residential care, day care, geriatric care, medical camps and geriatric counseling, mobile medical units and homecare, hygiene and sanitation promotion, medical and psychiatric care, recreation, financial assistance and counseling. The Government of India is a signatory to many of the national and international plans, such as the UN Proclamation on Ageing 1992, the Madrid Plan of Action (MIPAA), United Nations Principles for Senior Citizens 2002, the Shanghai Plan of Action 2002, and Macau Outcome document 2007 adopted by the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP). The Government has also recognised the NGO sector as an important institutional mechanism to provide user friendly and affordable services to complement its efforts in elderly care. In many cases, NGOs have been more effective in delivering elderly care on account of the NGOs better connect with the people. The Government has implemented many of its schemes through NGOs, which are given grant-in-aid (GIA) for the purpose. With the number of schemes and plans and the success of RSBY and AarogyaSri, the situation of elderly in India has improved, but yet much is to be done. From KPMG in India's perspective, we have noted that the healthcare system in India suffers from many structural problems, such as various ministries working independently without any nodal agency, poor capacity in public health management, and weak regulatory systems for drugs as well as medical practice. Indian healthcare system also suffers from inadequate funding. Further, a robust healthcare system also needs the active participation in preventive and promotive healthcare.
  18. 18. Old age security: Doing the right thing for our elders | 13 Global Overview In the past, delivery of healthcare services was driven primarily by regulatory and policy initiatives without much consideration for the cost of delivery. However, increasing cost along with a higher proportion of elderly and technology advancement has led to increased costconsciousness in the health systems worldwide. Therefore, the modern day healthcare delivery systems focus on providing mix of services and allow choices by consumers on where to obtain health care based on the efficiency of services. Integrated care with reduced cost has been a hallmark of modern day healthcare delivery models. These models coordinate the work done by various healthcare providers, such as primary care physicians, specialists, hospitals, pharmacies and laboratories. Integrated care helps improve care quality, makes care delivery more convenient for members, and increases communication among various care providers. At the same time, these enable to find efficiencies that reduce costs, improve or maintain quality, and allow for innovation. One of the most widely used models has been Kaiser Model. The model provides a useful framework to manage the healthcare needs of people who need long-term care. Kaiser pyramid Evercare & Pfizer model Case manage Highly complex patients High risk patients Kaiser model Disease management Supported self care 70-80% of people with chronic Population wide prevention Source: “A review of UK and International frameworks, Institute of Innovation ” and Improvement, University of Birmingham, accessed on 16 December 2013 The bottom of the pyramid shows that most (approximately 70-80 per cent) people with long-term conditions can care for themselves and thus, need minimal input from health and social services. High risk patients, which are represented in the middle layer, need more active disease and care management from professionals. Patients with highly complex needs, which are represented by the top layer and form a small proportion, account for a large number of emergency admissions to hospital. They would require a trained health care professional (for example a nurse) to actively manage their case.
  19. 19. 14 | Old age security: Doing the right thing for our elders Kaiser model focuses on integrating organisations and disciplines. Most of the healthcare infrastructure, including doctors, facilities, nurses, pharmacists, laboratory technicians and radiology staff, are shared between primary and secondary care. Beneficiaries requiring long-term care are classified according to need, with intensive management targeted at those at highest risk. Information technology also pays a significant role in enabling Kaiser Model. It helps gather and share information, track outcomes and systematically identify innovations that improve patient care. The model uses information systems, such as reminders on patient notes, monitoring systems and online discharge summaries, to target the whole spectrum of chronic care. The model focuses on developing partnerships between clinicians and managers while employing high proportion of doctors in leadership roles. More emphasis is paid on patient education and integrated and proactive management. Healthcare programs based on Kaiser Model could help reduce hospitalisation and improve co-ordination of various agencies providing health care. For example, in the California, US, this model has helped improve quality of life and reduce hospital admissions and days spent in hospital in California, US. Kaiser Model can prove to be very effective in extending the healthcare coverage to the elderly. The model could be aligned with the UHC services to extend to the elderly population, especially in rural areas which lack medical facilities. Majority of people with long-term conditions could be catered to with the supported self care. In this section, we have also attempted to study the commonly used healthcare models across the world and their applicability in the Indian context. Elderly health care in select countries The elderly are disproportionate users of healthcare. Healthcare of the elderly is multi-sectoral, involving the individual himself, the family, the community, certain non-profit organisations, the commercial sector, and the government. Different countries world over have adopted different approaches to serve the needs of the elderly. The following section provides an overview of the structure of elderly health care in four countries — Brazil, Indonesia, Singapore and Sweden. Brazil1 In Brazil, the Unified Health System (SUS) is publicly funded universal free access to healthcare to the whole population. SUS is decentralised at three levels — federal government, state government and municipal authorities. It includes the model of foresight system, which provides care in Basic Health Units (BHUs) for spontaneous demand or patients referred by other services. The organisation and provision of services are based on risk groups or specific conditions. The second model of Primary Health Care (PHC) is based on Family Health Strategy (FHS) and offers participative and comprehensive care in a system of centralised coordination. The FHS began in the poorest areas without coverage of PHC and since then has been implemented gradually replacing the traditional model of care. The model aims to insert the individual in the system, providing a primary person-centered care, with priority to prevention and health promotion followed by curative medicine. Coverage is universal, geographically circumscribed and referral to other levels of care are allowed when necessary. The management of chronic diseases in Brazil takes into account not only the prevalence but also the population aging and the burden of disease. The guideline recommends easy access to SUS with priority attention and frequency of assistance according to the presence of risk factors and health status throughout life, tracking changes and stages of aging, integrating promotion, prevention, treatment and rehabilitation at all levels of complexity of the healthcare system. PHC model of care reiterates the role of FHS in health care for the elderly and also shows that the FHS contributes to higher quality of life. 1 Biomedcentral.com Indonesia2 According to the United Nations, the per centage of Indonesians aged 60 or older are expected to rise from 7-8 per cent of the population in 2002 to 13 per cent in 2025. The intensity of this demographic change could be gauged from the fact that a comparable shift took 50 and more than 100 years in the Great Britain and France, respectively. The Indonesian Government plans to introduce one of the biggest health care schemes — National Social Security System (SJSN) — in 2014 by setting up an insurance fund to cover all 240 million of its citizens. The aim is to provide free health care at the point of use. The key highlights of the scheme are as follows. • Five separate programmes: Five separate social insurance programs would be established — Jaminan Kesehatan (Health Insurance), Jaminan Kecelakaan Kerja (Work Accident Insurance), Jaminan Hari Tua (Old Age Insurance), Jaminan Pensiun (Pension Insurance) and Jaminan Kematian (Life Insurance). The first program under SJSN to be rolled out is the health insurance program by January 2014 followed by the other four programs by 2015. • Four administrators: The four existing Perseros (profitoriented limited liability state enterprise) would be responsible for administering the five new social insurance funds. • National Social Security Council: The council is a policymaking body responsible for running the SJSN system. It has 15 members — five from government ministries, two from employers, two from workers, and the remaining six are appointed experts. • Contribution structure differs between formal and informal sector: Under the SJSN law, the burden of financing the various social insurance programs is allocated among workers, employers, and the government as per the following scheme. 2 'Preparatory studies on National Social security system in Indonesia' by Asian Development Bank 2007 and International Institute of Social Studies Point . of view "A study of the shift towards Universal Social policy in Indonesia", December 2012
  20. 20. Old age security: Doing the right thing for our elders | 15 –– Formal sector workers and their employers contribute towards the social insurance programs. Costs are shared equally between employers and workers. –– Contributions for informal sector workers are a nominal amount while the Government pays for the rest of the contributions. Those in the informal sector who are not poor must pay their own contributions. Singapore Elderly in Singapore (aged 60 and older), which comprise 15.8 per cent of the population, utilise much higher proportion of public sector primary care and hospital services. Based on the increased numbers of elderly and assuming the same utilisation rate, there is expected to be a four-fold increase in the utilisation of health resources by 2030. Ministry of Community Development and the Ministry of Health are the government bodies responsible for elderly care. The Ministry of Health, Singapore provides various schemes and subsidies to support the elderly. It has instituted schemes such as ElderShield, Interim Disability Assistance Programme for the Elderly (IDAPE), Seniors' Mobility and Enabling Fund to provide affordable insurance to those who can pay/ financial assistance to needy elderly. Also, the government’s strategy is to make Voluntary welfare organisations (VWOs) as the main service providers for elderly care. The government’s policy is to provide the direction and to encourage and support VWOs to provide the majority of these services rather than doing it itself, primarily due to the following two reasons. • Anything provided by the government is considered a ‘right’ by the people which invariably leads to more being demanded by the people. • These services often require a level of motivation and compassion by caregivers for which money cannot harness. 3 “Health Care of the Elderly in Singapore, Singapore Home Nursing website, ” http://www.singaporehomenursing.com/elderly-health-care-singapore.html, accessed on 20 December 2013 Government’s assistance to VWOs3 • Assistance of up to 90 per cent for capital expenditure and for cyclical maintenance costs for existing building • Up to 50 per cent for operating/recurrent expenditure • Up to 100 per cent rental subsidy for use of government premises or state land • 100 per cent rebate for input GST along with manpower (doctors and nurses and permits for foreign medical experts) Types of health services provided by VWOs3 • Community hospitals: Community hospitals are for patients, especially elderly patients, who require longer inpatient care, but who do not require the high technology and sophisticated care of acute hospitals. The patients admitted should also have rehabilitation potential. There are currently four hospitals providing a total of 426 community hospital beds. • Chronic sick hospitals: Chronic sick hospitals admit long stay patients who have no rehabilitation potential but require medical and nursing care. Two such hospitals are currently in place, with 218 beds. • Nursing homes and hospices4: Nursing homes provide primary nursing care with little or no medical care. There are 47 nursing homes with 4,705 beds, with 23 homes being run by VWOs (3,241 beds) and 24 homes by the commercial sector. • Day Care Centers: These are rehabilitation centers for the elderly suffering from senile dementia, the terminally ill and frail elderly. Seventeen day rehabilitation centers provide 700 places for frail and sick elderly, while three day care centers provide 86 places for elderly with senile dementia. • Home care: There are home nursing services, home medical and home help services available to the home-bound elderly. About 4 per cent of the elderly in Singapore receive some form of help care services. 4 Hospices are for the terminally ill and they provide medical and nursing care as well as social support (religious support and bereavement counseling)
  21. 21. 16 | Old age security: Doing the right thing for our Elders Sweden5 Scandinavian countries, such as Sweden, have always had a high public expenditure towards care for the elderly. The Scandinavian model is based on community living and allows the elderly to live a normal and an independent life. This is basically construed as living in their own homes with various forms of support, such as safety alarms, meal service, transportation service, medical and social services delivery, at home. The Swedish Parliament has defined the following objectives for national policy for the elderly. Older persons shall: • Be able to live an active life and have influence over their everyday lives • Be able to grow old in security and retain their independence • Be treated with respect • Have access to good healthcare and social services Within this framework, the responsibility of care for the elderly rests at three levels: • Level 1: The central government realises policy goals through legislations and financial grants • Level 2: The regional councils are responsible for health and medical care 5 Improving care for people with long-term conditions by NHS and University of Birmingham 2006 • Level 3: Local municipalities are responsible for social service and housing needs of the elderly Together, these three authorities work towards providing support and facilities for elderly living. It is important for India to imbibe the key learnings from different models and adopt an approach most suitable to the needs and vagaries of the elderly in India. Some of the key aspects based on the different approaches that are essential for developing a successful strategy for providing holistic care to the elderly are: • Joint governance by way of Government bodies, various agencies such as insurance companies, healthcare providers, both public and private and other bodies to create a responsive ecosystem for elderly care • A senior citizen requires care which is all encompassing viz. financial, health, emotional etc., health care is of primary importance and the Government will soon need to take measures towards making UHC a reality • Moreover, elderly need support and care and there needs to be a strong focus on building an infrastructure which caters to social and emotional aspects of elderly by institutionalising support for old age homes/ community living In the next section, some of these ideas have been detailed out to highlight their applicability in the Indian context.
  22. 22. Old age security: Doing the right thing for our elders | 17 Way Forward Elderly care has gained more importance in India owing to a changing demographic mix and increased awareness. The planning and implementation is a mammoth task due to the sheer size of the population. The country witnessed a number of changes, both from the Government as well as the private sector in this area during the last two decades. However in view of the lack of an effective social security scheme and a large unorganised sector, much more needs to be done. As per KPMG in India, we believe there is a clear need emerging for a comprehensive solution for the elderly care which encompasses their overall security. It is also important to analyse the needs of senior citizens which are to be prioritised to effectively deliver comprehensive care. These needs may vary for elderly in urban and rural areas. Poor/ Economically Dependent Senior Citizens in Urban and Rural Areas Almost three-fourths of the elderly population resides in rural areas. Those who are working are primarily in the unorganised sector, where both productivity and pay are low. The workforce participation of senior citizens in rural areas indicates economic compulsion. Though the number of years spent in the labour force is considerable, pension or retirement benefits are not available to a large majority. Though this segment runs a high risk of poor health, financial insecurity remains one of the key reasons for not seeking treatment. Similarly, approximately 65 per cent of senior citizens in urban areas are dependent for their daily needs on others. Hence, it is the need of the hour wherein this segment of senior citizens of the society is provided a basic level of health cover. This segment will gradually be covered under the ambit of UHC which will provide for both in-patient and out-patient treatments across secondary and tertiary care. They should have access to the primary care through public facilities at no cost. The rising healthcare expenditure is one of the primary reasons of poverty for people with limited means and it is critical to reduce the burden of healthcare expenditure on elderly. In our view, for the poor/ economically dependent senior citizens, the Government should provide full subsidy of the premium towards the UHC cover. A large number of senior citizens are working and some of them are economically independent. In the rural areas elderly working in informal sector is more prevalent. As some of them would be associated with welfare trusts and boards, we understand that for such elderly the basic coverage can be provided through these trusts and boards. They will act as facilitators between the beneficiaries and the insurance companies empanelled for UHC enrolment.
  23. 23. 18 | Old age security: Doing the right thing for our elders Economically Independent Senior Citizens in Urban Areas We have discussed below the 5 Spoke Security Framework for the elderly wherein it is essential to address each of the spoke to ensure a comprehensive solution for the elderly in urban areas. 5 Framework Emotional Security 4 Social Security 3 Source: KPMG in India analysis and ASSOCHAM • Emotional Security - To feel a part of things and to be able to form meaningful relationships and feel part of the community • Family Security – To get legal advice especially relating to property planning Financial Security Physical Security • Physical Security – To feel safe and free from threat, harm, and discomfort • Social Security - To have goals and to have the opportunity to engage in purposeful activities, this leads to active ageing 1 Family Security • Financial Security – To ensure independence or reduced dependency for healthcare needs 2 In this section, we have attempted to examine a range of structural, technological and industry –led change catalyst which will enable in achieving the objective of the security framework. Structural changes like long-term care and facilities will provide the much needed physical and emotional security which coupled with technological innovation will further improve the care and the experience. Moreover, NGOs, bank and other entities are geared and involved to provide the emotional, social and family security. Finally, none of this can be achieved without changes to structures and policies, innovation in retirement planning products and a collaborative approach to deliver the model which will provide financial security. The collected effect of these change catalysts should support in meeting the objective of overall security for the senior in the urban and rural areas.
  24. 24. Old age security: Doing the right thing for our elders | 19 As per KPMG in India's study on the sector, we have made the following observations and recommendations 1. Long-term care and facilities Long-term care includes a bouquet of services to meet the medical and non-medical needs of disabled or chronically ill patients. These services can include social, medical/nursing as well as community services. Providing long-term care has become utmost important in view of the increased life expectancy and improved medical facilities. However, the country lacks adequate geriatric care facilities and trained personnel to provide quality care. Measures need to be taken in this regard to build capacity to serve the elderly people. Key Driver Likely future direction Increase in supply of geriatric facilities Most of the available geriatric care facilities are urban based while as mentioned above an estimated 75 per cent of the elderly reside in rural areas. Therefore, there is an urgent need to focus on facilities providing geriatric care at various levels.1 • At primary care level, geriatric healthcare must be made a part of the healthcare services at an affordable price. Specially trained medical practitioners in geriatric medicine should be deputed at primary healthcare centers. • At the secondary and tertiary care levels, separate geriatric wards should be set up in medical facilities to provide OPD and in-patient services to the geriatric population. Hospitals should make adequate provision for screening services along with curative and rehabilitative services to ensure long-term care. Super specialty and medical college hospitals should have a multidisciplinary team to meet the needs of the geriatric population. These hospitals should also have a provision to provide reasonably priced medical facilities to elderly patients from poor and low income strata. • There is a discussion going on to bring in a standard protocol for treatments to bring in uniformity in the cost of various treatments. A step in this direction will make the health cover products affordable to the end customers and at the same time will not adversely affect the bottom line of service providers. Training • Peripheral health workers and community health volunteers need to be trained to identify and assist elderly patients for timely and proper treatment. The task force project, ’Health Care of the Rural Aged,’ conducted by the Indian Council of Medical Research (ICMR) in the primary health center area found the services of trained health workers and community health volunteers to be beneficial. • Health providers known as ‘Community Geriatric Health Workers’ can be trained to provide home care to the disabled elderly population. This model has worked successfully in a community based project ‘Urban Community Dementia Services’ in Cochin, in providing home-based care as well as care in day care centers. Research and • Promote research in the areas of Geriatrics and Gerontology. These areas may include the professional courses evaluation of the nutritional and functional status of the elderly, chronic and neuro-degenerative disorders, ageing process, pharmacokinetics and pharmacodynamics of drugs, health system research and research in alternative medicine. • Professional courses in Geriatrics and Gerontology need to be promoted in Indian universities and other academic institutions. More emphasis should be given to geriatric medicine in undergraduate medical as well as paramedical courses. Preventive care • Preventive care packages offered by various NGOs could be very effective in improving the quality of life of elderly. These packages comprise knowledge and awareness about disease conditions, steps for their prevention and management, good nutrition and balanced diet and physical exercise. Various grants and aids provided to the NGOs will be utilised to provide health cover to the economically weaker sections of the senior citizens segment. 1 “Geriatric Health in India: Concerns and Solutions, Indian Journal of Community Medicine website, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2763704/ ”
  25. 25. 20 | Old age security: Doing the right thing for our elders 2. Leveraging Technology The incredible innovations in technology, over the past 20 years, have transformed the way that humans and organisations exist. In areas like information aggregation and management, communications and human-machine interfaces, technology has enabled new paradigms. Future promises an increase in the rate of technology innovation. Technology is also expected to play a role in providing improved medical care and long-term care to elderly. Key Driver Improved medical devices Likely Future Direction • For people requiring long-term care, technology can be useful in doing daily chores and in providing physical safety. • Social robots, which can help elderly patients with daily chores and provide comfort and companionship, are approved as a medical device and are being used in a number of eldercare centers around the world. Moreover, many technology concepts, such as telemedicine, can become more effective if accompanied with improvement in physical infrastructure. High powered computing engines and mass storage • The Government authorities should develop a community database of diseases suffered by the elderly. Sophisticated data analysis tools to analyse all types of trends –by demographic or geographical profiling, multiple economic segments and gender. This could be based on a comprehensive baseline morbidity survey and functional assessment in significant health areas. The database can provide significant insights for effective implementation of elderly care and help in allocating finances accordingly. • In the future, massive data stores will enable Government and companies to collect, collate and manage the huge volumes of data that will be generated through devices and other customer interaction Single view of the retirement funds • With retirement savings scattered across instruments, customers have little idea about their savings. This is the key reason for significant under penetration of pensions in India. The retirement savings through accumulated gratuity, compulsory provident fund, New Pension Scheme Account and various retirement plans purchased from life insurance cannot be integrated into one single account. Integration helps the customer to have a total view of his retirement savings and the portfolio allocation to take any course corrections for better alignment with his needs IT enabled management and integration for UHC • IT enabled system with standard coded data exchanges, and portability of cover across levels/ providers/ locations will lead to better management • There is a need to implement Electronic Medical Records (EMR) standards and seamless health data capture at the source 3. Structure and Policies Significant improvement in the quality-of-life of the elderly can come by adopting a holistic approach and concerted efforts by the health and health-related sectors. Key Driver Collaborative models Likely Future Direction • Greater coordination among various ministries and State Governments running multiple schemes for elderly care. There should be a central nodal agency responsible for driving, coordinating and monitoring these schemes leading to better results. The central nodal agency can potentially enable the implementation of the Central Government’s ambitious comprehensive UHC. • A National Health Regulator needs to be set up and there should be an oversight by Health and Insurance regulators with effective governance at joint level to oversee the adoption of UHC • Increased co-ordination with non-governmental organisations (NGOs) and charitable organisations is required to augment the Government’s efforts to reach out to elderly population in far flung areas. Such organisations can organise screening camps and mobile clinics to reach out to the elderly population.
  26. 26. Old age security: Doing the right thing for our elders | 21 4. Industry-led innovation Key Driver Delivery models Likely Future Direction • NGOs and private sector can provide various convenience services to the elderly population which can include payment of utility bills, home service for household equipments and other services. For example, a private player in Chennai provides for servicing of kitchen and home products at the door step for a fee and approximately half of its enrolled members belong to elderly group.2 • Banks have an existing trust-based relationship with many elderly being their customers for various banking and health insurance products. Further, given their outreach and in many cases, a long relationship, banks could emerge as healthcare provider. For example, in Indonesia-based Bank Tabungan Pensiunan Nasional, in association with Grand-Aides Foundation, provides health services in its branches to its elderly customers. Physicians, who are paid for by the bank, provide health checks and advice besides handling inbound calls from sick clients four days a week. This has been implemented on a pilot basis and the bank plans to scale this model. • Community living – The country could witness the establishment of specific community living for elderly. These could be funded or run by NGOs and charitable organisations and provide various facilities catering to the needs of elderly population. For example, Tamaraikulam village in Tamilnadu which is managed by HelpAge India and NDTV. Besides these, private players are also expected to establish residential societies suited for seniors. 5. Retirement Planning Products Currently, the long-term retirement planning in India is constrained both from the supply and demand side. On the supply side, the country lacks institutional and product framework to promote retirement planning. There are no specialist players and packaged products catering to the needs of people who wish save for their silver years. On the demand side, retirement planning is not a top priority for most Indians despite the fact that the country has one of the highest savings rate. According to a survey conducted by HSBC in 2009, 35 per cent of the savings goes towards saving for children typically for their marriage and education while retirement funds account for only 12 per cent savings. Further, retirees are only achieving some of their retirement aspirations highlighting the strong need for retirement planning.3 However, the demand for organised retirement planning is expected to increase significantly in near future. There is a growing awareness about retirement planning/ savings products. Changes in the social milieu are expected to result in a decline in joint families and extended community support post-retirement will lead to an increasing significant need for individual retirement planning. Following is a brief discussion on the key drivers and the likely future trends in retirement planning in India. Key Driver Retirement Products Likely Future Direction • The Central Government intends to set up an authority to regulate retirement funds. Fund managers will have to provide different fund options (with different risk profiles) and offer at least one product with an assured minimum return to protect investors from market volatility. This will allow foreign companies to manage pension funds and provide investors with more options to grow their savings. • The Government also plans to allow foreign investment of up to 26 per cent in pension funds with an option to increase it to 49 per cent in case the limit goes up in the insurance sector. This will allow foreign companies to manage pension funds and provide investors with more options to grow their savings. Retirement Planning Helpline • Managing savings and diversifying this into a variety of asset requires guidance – hence, the need for professional, unbiased advice similar to the UK Government’s pension advisory scheme Disease Management Programs • Insurance companies could develop solutions focusing on helping individuals manage their long-term therapy regimes through regular assessment and advice which will lead to lowering of expenses while ensuring quality of healthcare delivery. • Through this offering, periodic monitoring and counseling could be provided focusing on preventive measures. Diet management, access to multidisciplinary providers focusing on wellness could be offered at preferential rates. 2 “Health care issues, The Hindu, 7 October 2012, via Factiva, accessed 10 ” December 2013 3 “The Future of Retirement - It’s time to prepare, 2009, HSBC ”
  27. 27. 22 | Old age security: Doing the right thing for our elders Next steps as recommended by KPMG in India and ASSOCHAM A healthy, prosperous and empowered population is a pre-requisite for India to gain its rightful place in the world economy. A number of change catalyst discussed in the previous section like increase in supply of geriatric facilities, greater co-ordination between various implementing bodies, use of innovative delivery models for ensuring elderly care and improved medical devices are expected to change the approach to elderly planning and care and provide a comprehensive solution for the overall security of the elderly. Moreover, with increasing medical cost, changing demographics and social fabric, and an ad-hoc approach of investment concentrated in a few low-yielding assets, retirement planning is expected to be transformed into a methodical approach by professionals with investments spread across a variety of asset classes. There are multiple industries today which are slowly bringing out products for elderly care. Life Insurance companies have pension and annuity offerings, health insurance companies are coming out with special plans for the elderly and real estate players have started offering special senior living apartments. However, each player is limited in their role as of now. There is a need for an aggregator to combine all these services from different players and offer it as one package to the elderly to enable single window solution for elderly care. In addition, the aggregator would be required to play a pro active role in managing the different aspects of elderly care such as: • Infrastructure for senior citizen living: Refurbishments required in existing housing such as improving accessibility, anti skid flooring or moving to an altogether new house within senior living societies or care homes • Healthcare financing: Taking care of daily medications, hospitalisation requirements, medical checkups among others • Support system for taking care of day to day needs like Utilities payments
  28. 28. Old age security: Doing the right thing for our elders | 23 Banks/Pension funds Corpus accumulation and management Real estate firms One time payment making adjustment to housing / shifting to senior living societies Aggregator Health Insurance companies Healthcare financing needs of the elderly Pension/Insurance funds Providing annuity for meeting day to day financial needs of the elderly Source: KPMG in India analysis However, this requires the key stakeholders like PFRDA, IRDA and Finance Ministry to approach the elderly care and retirement planning in a more focused way along with the intervention from the Government by way of regulations and tax benefits under sections 80C, 80CCD and 80D. One who always serves and respects elderly is blessed with four things: Long Life, Wisdom, Fame and Power. An industry forum needs to be established to further co-ordinate and research the efforts in this direction. A final recommendation report that will provide the future road map will be presented by this forum in a time frame of about 6 months. Manusmriti Chapter 2:121 Improving the quality-of-life of the elderly calls for a holistic and more coordinated approach among various stakeholders and which goes beyond the standalone work done by many schemes of different agencies.
  29. 29. 24 | Old age security: Doing the right thing for our elders Appendices Appendix 1: Terminology • Developed countries comprise of all regions of Europe plus Northern America, Australia/New Zealand and Japan. • Developing countries comprises of all regions of Africa, Asia (excluding Japan), Latin America and the Caribbean as well as Melanesia, Micronesia and Polynesia. The least developed countries (also included in developing countries), as defined by the United Nations General Assembly in its resolutions included 49 countries in June 2013: 34 in Africa, 9 in Asia, 5 in Oceania and one in Latin America and the Caribbean. Those 49 countries are: Afghanistan, Angola, Bangladesh, Benin, Bhutan, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Comoros, Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Haiti, Kiribati, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Myanmar, Nepal, Niger, Rwanda, Samoa, Săo Tomé and Príncipe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sudan, Timor-Leste, Togo, Tuvalu, Uganda, United Republic of Tanzania, Vanuatu, Yemen and Zambia.
  30. 30. Old age security: Doing the right thing for our elders | 25 Appendix 2: List of abbreviations ASHA Accredited Social Health Activist BHU Basic Health Units BPL Below Poverty Line BRICS Brazil, Russia, India and China CCM Chronic Care Model CGHS Central Government Health Scheme DM Disease Management ESIS Employees' State Insurance Scheme FHS Family Health Strategy GDP Gross Domestic Product GIA Grant-In-Aid GMC Gwalior Municipal Corporation HLEG High-Level Expert Group ICMR Indian Council of Medical Research IGNOAPS Indira Gandhi National Old Age Pension Scheme IMC Indore Municipal Corporation IPOP Integrated Programme for Older Persons IRDA Insurance Regulatory and development Authority MIPAA Madrid Plan of Action NCOP National Council for Older Persons NDRDA National Drug Regulatory and Development Authority NGOs Non Governmental Organisations NHPPT National Health Promotion and Protection Trust NHRDA National Health Regulatory and Development Authority(NHPPT NPHCE National Programme for the Healthcare for the Elderly NPOP National Policy on Older Persons NPS National Pension Scheme NRHM National Rural Health Mission OECD Organisation for Economic corporation and Development OPD Out Patient Department PFRDA Pension Fund Regulatory and Development Authority PHC Primary Healthcare PHM Public Health Model PPF Public Provident Fund RSBY Rashtriya Swasthya Bima Yojana TPA Third Party Administrators UHC Universal Healthcare UHS Unified Health System UNESCAP United Nations Economic and Social Commission for Asia and the Pacific UTs Union Territories VRS Voluntary Retirement Schemes
  31. 31. 26 | Old age security: Doing the right thing for our elders About KPMG in India KPMG in India, a professional services firm, is the Indian member firm of KPMG International and was established in September 1993. Our professionals leverage the global network of firms, providing detailed knowledge of local laws, regulations, markets and competition. KPMG in India provide services to over 4,500 international and national clients, in India. KPMG has offices across India in Delhi, Chandigarh, Ahmedabad, Mumbai, Pune, Chennai, Bangalore, Kochi, Hyderabad and Kolkata. The Indian firm has access to more than 7 ,000 Indian and expatriate professionals, many of whom are internationally trained. We strive to provide rapid, performance-based, industry-focused and technology-enabled services, which reflect a shared knowledge of global and local industries and our experience of the Indian business environment. KPMG is a global network of professional firms providing Audit, Tax and Advisory services. We operate in 155 countries and have 155,000 people working in member firms around the world. Our Audit practice endeavors to provide robust and risk based audit services that address our firms’ clients’ strategic priorities and business processes. KPMG’s Tax services are designed to reflect the unique needs and objectives of each client, whether we are dealing with the tax aspects of a cross-border acquisition or developing and helping to implement a global transfer pricing strategy. In practical terms that means, KPMG firms’ work with their clients to assist them in achieving effective tax compliance and managing tax risks, while helping to control costs. KPMG Advisory professionals provide advice and assistance to enable companies, intermediaries and public sector bodies to mitigate risk, improve performance, and create value. KPMG firms provide a wide range of Risk Consulting, Management Consulting and Transactions & Restructuring services that can help clients respond to immediate needs as well as put in place the strategies for the longer term.

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