Healthcare Between Two Countries

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My background is in public health. I have been a part of teams who screened for viral hepatitis, the COVID-19 sheltering, and response team, and most recently coordinating efforts for the 2022 outbreak of MPOX (formally known as monkeypox). Moving to India for the AIF’s Banyan Impact Fellowship was not my first introduction to public health in India, as I had completed two internships prior to being accepted for this fellowship. However, this was the first time I would be focused on elderly care and healthcare systems in India.

Someone who is 60 years or older is considered elderly. Globally, the elderly population accounts for 13.4% of the world’s population; by 2050, this number is expected to grow to 21.3% (3). In 2019, the US elderly population accounted for 16% of the population. By 2040, the number is expected to be 21.6%, which is 10 years earlier than the global 2050 estimate (7). In 2020, India’s elderly population was 8.6% of their population and is expected to have exponential growth over the next few decades (3). The reality is, the elderly population is growing quickly around the world, and it is important to know whether our healthcare system and care infrastructures can respond to people living longer.

If I were to ask someone what families in the United States do when their elderly family members reach an age where they need support vs what families in India do, I am very confident what their answer would be. Families in the US put their families in assisted living or healthcare facilities and are cared for by professionals, while families in India continue to take care of their families in their homes. And while some may believe that this is a difference in values, it also speaks to our healthcare systems.

According to data provided by the World Bank, in 2019, the US spent about 16.7% of the GDP on healthcare, while India spent 3.01% (1).

In 2019, 99% of elderly individuals in the United States were covered by insurance, either through private or government-based plans (7). Medicare, a form of government-sponsored health insurance, applies to individuals 65 or older; in 2019, 94% of those who qualified for Medicare were covered (7). 96% of those on Medicare also reported that they had a regular place to receive medical care (7).

In comparison, India has a more fragmented insurance structure, but could potentially cover over 70% of the population through current plans (6). In 2018, the Government of India initiated “Ayushman Bharat” which created a form of public health insurance, primarily in rural India and job-specific fields in urban areas. It was expected to provide coverage to about 40% of the total population in India (5). Other forms of insurance include Social Health Insurance (SHI) and Private Voluntary Health Insurance (PVHI), but cover another 30% of the total population (6).

In the US, healthcare expenditures among elderly individuals were 13.6%, with total population spending 8.2%. In India, healthcare expenditures are harder to compare, but with the disparities in insurance coverage, more individuals pay for healthcare out of pocket, increasing their chances of being left with extraordinarily high bills and few options for paying them (2).

The proportion of individuals who received long-term care at home was 15% in the United States, while the rest of the care was provided in institutions (4). According to the Organisation for Economic Co-operation and Development (OECD), the US ranked much lower than other countries in terms of home-based care. In comparison, India has always relied more heavily on intergenerational households and family care; while this is changing, it is still overwhelmingly preferred over professional caregiving or institutional care (8).

As an outsider, I think it’s easy to assume that our two cultures vary greatly in values which leads to these differences in care, but our healthcare systems are also vastly different. Insurance coverage impacts the decisions people make around care. While India has provided family care for their elderly in the past, things are changing, more people are entering the workforce and family dynamics are shifting, where family care becomes harder to maintain. Values are one part of the picture. Even as things change, if families don’t have the financial ability to hire professional care or to move their older family members into nursing facilities, then their choices are limited.

I am not an expert by any means, and these topics are very complex, but I offer the experiences of what I’ve seen over the last few months. I’ve only been in my fellowship for 4.5 months working at my host organization, Life Circle Health Services, which is a home healthcare company. While this industry is still new in India, it is growing, but probably it will take years before it can meet the market demands. However, I think it is a critical aspect of elderly care in India. I have seen the value that families have in being able to bring caregivers into their homes to care for their aging family. The ability to allow the older generation to age in their homes while receiving the care they require and providing respite to their family caregivers is the happy medium in maintaining their values and shifting to the realities of today.

Looking towards the United States, I am interested in seeing where our growth occurs. Home-based care is much more established in the country, and I wonder how things will shift as the elderly population grows beyond what the current healthcare system, such as hospitals, clinics, and nursing homes, can handle.

References:
1. “Current Health Expenditure (% of GDP) – United States, India.” Data, World Bank, https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=US-IN

2. Deol, Taran. “India’s Persistently High out-of-Pocket Health Expenditure Continues to Push People into Poverty.” Down to Eart, 22 Sept. 2022, https://www.downtoearth.org.in/news/health/india-s-persistently-high-out-of-pocket-health-expenditure-continues-to-push-people-into-poverty-85070. Accessed 9 Jan. 2023.

3. Dumka, Neha1; Mangat, Seerat1; Ahmed, Tarannum1; Hannah, Erin1,; Kotwal, Atul2. Adding health to years: A review of the National Programme for Health Care of the Elderly (NPHCE) in India. Journal of Family Medicine and Primary Care 11(11):p 6654-6659, November 2022. | DOI: 10.4103/jfmpc.jfmpc_765_22

4. Grabowski, D.C. The future of long-term care requires investment in both facility- and home-based services. Nat Aging 1, 10–11 (2021). https://doi.org/10.1038/s43587-020-00018-y

5. Keshri VR, Gupta SS. Ayushman bharat and road to universal health coverage in India. J Mahatma Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Jan 9];24:65-7. Available from: https://www.jmgims.co.in/text.asp?2019/24/2/65/267010

6. Kumar Anurag, and Sarwal Rakesh. 2021. “Health Insurance for India’s Missing Middle”

7. “Profile of Older Americans.” ACL Administration for Community Living, May 2021, https://acl.gov/aging-and-disability-in-america/data-and-research/profile-older-americans

8. Sharma, R. “Emerging need for care in place support system in India for older adults.” Journal of Gerontology & Geriatric Research 10 (2020): 532.

About the Author:
KayLynn Gesner (she/her) served as an American Indian Foundation (AIF) Banyan Impact Fellow at Life Circle Health Services in Hyderabad. For her fellowship, she will be focused on learning about the current experiences in the home health aide program to inform a plan for changes prior to scaling of the program into new communities. In 2021, she graduated from University of Alabama at Birmingham with a Master’s in Public Health, & a graduate certificate in Global Health. She received her B.A. in Social Sciences from Portland State University. Since her undergraduate, she has been active in the nonprofit and public health sectors, including interning at Special Olympics Oregon & The Cupcake Girls, Portland. Her first visit to India in 2017 was for a fellowship working at an NGO that integrated sustainability practices into school curriculum. Her passion continued when in 2020, she completed a remote internship with another India-based NGO, where she researched the impacts of COVID-19 on students & developed course curriculum integrating life skills and reproductive health. Locally, KayLynn has spent over 5 years working with the houseless community, including operating emergency shelters and doing outreach to individuals for viral hepatitis and HIV screening. When COVID-19 hit, she began managing two COVID-19 isolation & quarantine motels. Her most recent position involved taking on the role of Operations Section Chief for the ongoing COVID-19 pandemic and the 2022 hMXV (monkeypox) outbreak for her home county.