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National Programme for Health Care

of the Elderly(NPHCE)
CONCEPTS AND DEFINITIONS

Elderly or old age: ages nearing or surpassing the average lifespan


of human beings. Changes in activities or social roles.

Senior citizen or elderly: above 60 years of age (according to


Government of Indias National Policy on Older Persons, 1999)
Gerontology: Medical study of the ageing process.

Geriatrics : the study of diseases that afflict the elderly.


Life expectancy: Expected number of years of life remaining at a
given age.

Old age dependency ratio: number of persons in the age-group 60


or more per 100 persons in the age-group 15-59 years.
AGEING: GLOBAL SCENARIO

FIGURE: CHANGES IN TOTAL FERTILITY RATE AND LIFE EXPECTANCY AT


BIRTH
FIGURE: POPULATION PYRAMID OF THE WORLD, 1950-2050
FIGURE: OLD AGE DEPENDENCY RATIO IN INDIA, 1961-2001
HEALTH PROBLEMS OF THE AGED

Above 60 years of age:


Almost 8% -impaired mobility/were confined to homes
Around10% are hospitalized

Both proportions rising with age

Above 70 years of age: More than 50% suffer from one or


more chronic condition

Health problems of the aged may be:


Problems due to the ageing process itself
Problems associated with long term illnesses
Psychological problems
FIGURE: NUMBER OF PERSONS AGED 60 YEARS OR ABOVE REPORTING A
CHRONIC CONDITION (PER 1,000 POPULATION)
FIGURE: NUMBER OF DISABLED PER 100,000 ELDERLY PERSONS FOR
DIFFERENT TYPES OF DISABILITIES

6.4%
FEW MILESTONES

1930s - Interdisciplinary geriatric appeared first in Great Britain


1982 - 1st World Assembly on Ageing at Vienna, Austria
1983- WHO scientific group on epidemiology of ageing, Geneva.
1998- WHO had declared year 1999 as International Year of Older
Persons (IYOP)
1999- Theme of World Health Day (April 7th) was Active Ageing
1999- Government of India announced the National Policy on
Older Persons.
2000- Government of India announces year 2000 as National Year of
Older Persons
2002- 2nd World Assembly on Ageing, Madrid, Spain.
2007- Senior citizens (Maintenance, Care and Protection) Act
2012- WHO Day theme- Adding life to years- focus on healthy ageing
NATIONAL POLICY ON OLDER PERSONS, 1999

Aim- Safeguard their interest in terms of financial security,


health, legal, social and psychological security and their special
needs.
NPOP broadly provides for the following:
Financial security: through coverage under Old Age Pension
Schemes, better returns on earnings/savings

Health security: recognizing special health needs of older persons


and providing facilities for same.

Shelter, basic need- earmarking 10% of houses/housing sites in


urban/rural areas for elderly in lower income groups.
NPOP (1999)

Protection of life and property of elder persons: encourage


family members to care for older persons

Education /information needs of older persons

Welfare and institutional care: create infrastructure in


partnership with NGOs/Voluntary orgaizations to provide for
poor, destitute and neglected elderly.

Training of Human Resource to care for Older Persons

Promote research in this field


NPHCE: VISION AND OBJECTIVES

VISION:
To provide accessible, affordable, and high-quality long-term,
comprehensive and dedicated care services to an Ageing population;
To build a framework to create an enabling environment for "a Society
for all Ages";
To promote the concept of Active and Healthy Ageing;

Convergence with National Rural Health Mission, AYUSH and other line
departments like Ministry of Social Justice and Empowerment.
OBJECTIVES:
To provide comprehensive health care to the elderly by preventive,
curative and rehabilitative services.
Train health professionals in geriatrics, including supportive care and
rehabilitation.
Develop scientific solutions to specific elderly health problems by
research into geriatrics and gerontology.
NPHCE: CORE STRATEGIES

Community based primary health care approach: domiciliary visits


by trained health care workers.
Dedicated services at PHC/CHC level
Dedicated facilities at District Hospital with 10 bedded wards
Strengthening of 8 Regional Medical Institutes
To provide dedicated tertiary level medical facilities for the elderly

Introducing PG courses in Geriatric Medicine, and

In-service training of health personnel at all levels.

Information, Education & Communication (IEC) using mass media,


folk media, etc.
Monitoring and evaluation of the programme and research in
Geriatrics and implementation of NPHCE.
SUPPLEMENTARY STRATEGIES

Promotion of public private partnerships in Geriatric Health


Care.

Mainstreaming AYUSH and convergence with programmes of


Ministry of Social Justice and Empowerment in the field of
geriatrics.

Reorienting medical education to support geriatric issues.


ORGANIZATIONAL STRUCTURE

NATIONAL NCD CELL

TERTIARY REGIONAL GERIATRIC CENTRES


STATE NCD CELL
LEVEL GERIATRIC WARD (30 BEDS)

DISTRICT NCD DISTRICT DAILY GERIATRIC CLINIC


HOSPITAL GERIATRIC WARD(10 BEDS)

GERIATRIC CLINIC ON
CHC/PHC FIXED DAYS

HOME BASED
SUB-CENTRE CARE
COVERAGE DURING 11TH FIVE YEAR PLAN

Department of Geriatric at 8 Super Specialized Institutions:


All India Institute of Medical Sciences, New Delhi
Institute of Medical Sciences, BHU, Uttar Pradesh
Sher-e-Kashmir Institute of Medical Sciences, Srinagar, J & K
Govt. Medical College, Tiruvananthapuram, Kerala
Guwahati Medical College, Guwahati, Assam
Madras Medical College, Chennai, Tamil Nadu
SN Medical College, Jodhpur, Rajasthan; and
Grants Medical College & JJ Hospital, Mumbai, Maharashtra.
Geriatric Units at 100 district hospitals
Rehabilitation Units at CHCs Falling Under 100 Identified
Districts
PACKAGE OF SERVICES

SUB CENTRE:

Health education related to healthy ageing


Domiciliary visits to home bound / bedridden elderly persons
Training to care providers in family
Arrange for suitable callipers and supportive devices from the
PHC to the elderly disabled persons to make them ambulatory.
Linkage with other support groups and day care centres etc.
operational in the area.
PRIMARY HEALTH CENTRE:

Weekly geriatric clinic run by a trained Medical Officer


Maintain record of the elderly using standard format during
their first visit
Conducting a routine health assessment of the elderly persons
(eye, BP, blood sugar, etc.)
Provision of medicines and proper advice on chronic ailments
Public awareness on promotional, preventive and rehabilitative
aspects of geriatrics during health and village sanitation
day/camps.
Referral to higher centres as needed
COMMUNITY HEALTH CENTRE:

First Referral Unit (FRU) for the Elderly from PHCs and below.
Geriatric Clinic - twice a week.
Rehabilitation Unit for physiotherapy and counselling
Domiciliary visits by the rehabilitation worker for bed ridden
elderly and counselling of the family members on their home-
based care.
Health promotion and prevention
Referral of difficult cases to District Hospital/higher health care
facility
DISTRICT HOSPITALS:

Regular Geriatric Clinic / OPD services


Facilities for laboratory investigations
10 bedded Geriatric Ward for in-patient care
Services from existing specialities like General Medicine,
Orthopaedics, Ophthalmology, ENT,etc.
Provide services to referred in patients from CHCs/PHCs etc
Conducting camps for Geriatric Services in PHCs/CHCs and other
sites
Referral services for severe cases to tertiary level hospitals
REGIONAL GERIATRIC CENTRES:

Specialized Geriatric Clinic


30-bedded Geriatric Ward for in-patient care (apart from other
specialities)
Laboratory investigation required for elderly with a special
sample collection centre in the OPD block.
Tertiary health care to the cases referred from medical colleges,
district hospitals and below.
INSTITUTIONAL FRAMEWORK FOR IMPLEMENTATION OF NPHCE

PROGRAM STRUCTURE - INTEGRATION WITH NRHM:


Financial Management Group established under NRHM will be
responsible for financial management

STATE HEALTH SOCIETY (SHS):


Under NRHM framework societies for different National Health
Programmes have bee merged to form a common SHS.
Chairperson-Chief Secretary/Development Commissioner
Vice-chairperson-Principal/Secretary (Health &Family Welfare)

DISTRICT HEALTH SOCIETY (DHS):


District level program societies merged into single DHS.
Chairperson Governing body: Chairman of ZP/ District collector
Chairperson Executive body: District collector
NATIONAL NCD CELL:

Constituted at central level for implementation and


monitoring of NPCDCS and NPHCE.
Main functions:
Preparation /dissemination of technical & operational guidelines.
Plan for capacity building of health functionaries
Development of IEC strategy & prototype IEC material
Coordination and liaison with all stakeholders.
Monitoring and review of programme activities at each level
Release of funds and monitoring of expenditure under NPHCE
Organizing External evaluation and coordinating Research in
geriatrics and NPHCE
STATE NCD CELL AND DISTRICT NCD CELL

STATE NCD CELL:


Constituted under NPCDCS will also implement & monitor NPHCE
at state level
Guided by State Programme Officer (SPO-NCD)
Other contractual staff:
Programme Assisstant
Finance cum Logistics Officer
Data Entry operators
DISTRICT NCD CELL:
District level planning, implementation, monitoring, etc.
Guided by District Programme Officer
NPHCE AND 12TH PLAN:

Health care facilities at district: At present 100 districts


covering 21 states, plan to extend to 540 more districts
covering all states/UTs.
Geriatric services at district hospital
Strengthening current services
All district will have 10 bedded geriatric ward and a geriatric OPD on
a daily basis
4-10 bedded multipurpose medical intensive care & stroke unit
Drugs/ Consumables/ Rehabilitative appliances, Transport

District programme for health care of elderly:


At CHC, PHC and subcentre level: strengthening of services.
Developing geriatric department in medical college of each
state:
12 additional Regional Geriatric Centres across country
With 2 PG seats for MD in Geriatric Medicine
Video conferencing units

National Institute of Aging (NIA): at AIIMS, New Delhi &


Madras Medical College, Chennai.

Human Resource Development: PG and certificate courses

Research: special project on Alzheimer's Disease


EXPECTED OUTCOMES OF THE NPHCE

FROM 11TH PLAN FROM 12TH PLAN

8 Regional Medical Institutions 20 Regional Medical


Institutions
16 post graduates in geriatric
medicine 40 postgraduates i.e. MD
Geriatric Medicine
Videoconferencing units
Additional 6400 beds in
District geriatric units in 100 District Hospitals& 1000 beds
district hospitals in Medical colleges
Rehabilitation Units in CHC Geriatric clinic in 640 DH&
2000 geriatric clinic in
Sub-centres provided with
PHC/CHC
community outreach services
Free aids/appliances to elderly
population
REFERENCES:

National Program for Health Care of the Elderly (NPHCE) : Towards active and healthy
ageing. Operational Guidelines. Director General of Health Services, MOHFW, Government
of India.
Situation Analysis of The Elderly In India, June 2011. Central Statistics Office, Ministry of
Statistics & Programme Implementation, Government of India
Rajan SI. Population ageing and health in India. The Centre for Enquiry into Health and
Allied Themes (CEHAT), Mumbai. July 2006.
National Policy on Older Persons (1999). Ministry of Social Justice and Empowerment,
Government of India, Shastri Bhawan, New Delhi.
Morbidity, Health care and the Condition of the aged. NSSO (64th round)Jan-June 2004,
National Sample Survey Organization, Ministry of Statistics and Programme
Implementation, Government of India, March 2006.
Two years (2009-2011) Achievements and New Initiatives. NRHM, Ministry of Health and
Family Welfare, Government of India.
Ingle GK, Nath A. Geriatric Health in India: Concerns and Solutions. Indian J Comm Med,
2008; 33 (4); 214-18.
Prevention & Control of Non-Communicable Diseases (NCDs): Proposal for the 12th Plan,
Report of the Working Group on Disease Burden: Non-Communicable Disease (NCDs),
Director General of Health Services, MOHFW, Government of India.
Planning Commission. 11th five year plan (Draft), Government of India; Accessed on
27/02/2012 at URL:http://www.planningcommission.nic.in
Title of the Scheme National Programme for Health Care of the Elderly (NPHCE)
Brief Description Division Non-Communicable Division
Beneficiaries & Eligibility
Criteria All elderly (60
Years)

Funding Pattern of Scheme The Centre will bear 75% of the total budget and the State Government
will contribute 25% of the budget, for activities up to district level.

Keeping in view the National Policy on Older Persons as well as the states obligation under
recommendations made in the the Maintenance & Welfare of Parents & Senior Citizens Act 2007,
The MoHFW launched the NPHCE during the year 2010-11, in the
11thplan period, to address various health related problems of elderly
people.
Types of Benefits Free, Specialized health care facilities exclusively for the elderly people
through the State health delivery system.

How to Avail Benefits The State Government/Union Territory should furnish programme
Implementation plan in the prescribed format to avail the facility for
implementation of the programme as per the guidelines and terms and
conditions.

Validity of the Scheme 2016-17


NPHCE,, NCD, National National Programme for Health Care of the Elderly
Health Mission
INTRODUCTION
Population ageing is global phenomena at present.
The population over the age of 60 years has tripled in last 50 years in
India.(Census 2001, 7.7% of the total population, increased to 8.14% census 2011.
projections for population over 60 years in next four censuses are: 133.32 million
(2021), 178.59 (2031), 236.01 million (2041) and 300.96 million (2051). Are the
result of changing fertility and mortality regimes in last 40-50 years.
an end product of a decline in both birth and mortality rates and increase in life
expectancy at birth and older ages.
The expectancy of life at birth during the year 2006-2011 was 65.65 and 67.22
for male and female respectively
projected expectancy of life at birth 2011-2016 will be 67.04 and 68.8 years for
males and females respectively.
Irrespective of socio-economic status, the non-communicable diseases (NCDs)
requiring large quantum of health and social care are extremely common in old age.
Disabilities resulting from these NCDs are very frequent, which affects the activities
of daily living. The management of these chronic diseases is also very costly,
especially for cancer treatment, joint replacements, heart surgery, neurosurgical
procedures etc.,

it out of pocket for elderly persons.


The 60th round of NSS provides a comprehensive status report on older
persons. According to this survey, the prevalence and incidence of diseases
as well as hospitalization rates are much higher in older people than the
total population. It also reported that about 8% of older Indians were
confined to their home or bed.
The proportion of such immobile or home bound people rose with age to
27% after the age of 80 years. Women were more frequently affected
than males in both rural and urban areas. The survey revealed that a good
or fair condition of health was reported by 55-63% of people with a
sickness and 77-78% of people without one. In contrast about 13-17% of
the survey population without any sickness reported ill-health.
It is possible that many older people take ill health in their stride as a part
of usual/normal ageing.
This observation has a lot of significance as self-perceived health status is
an important indicator of health service utilization and compliance to
treatment interventions.
INTRODUCTION
However, very little effort has been made to develop a model of health and social
care in tune with the changing need and time. The developed world has evolved
many models for elderly care, e.g., nursing home care, health insurance etc., As no
such model for older people exists in India, as well as most other societies with
similar socio-economic situation, it may be an opportunity for innovation in the health
system development, though it is a major challenge. The requirements for health-
care of the elderly are also different for our country. India still has family as the
primary care giver to the elderly and scope for training this lot provide support to
the program. Presently, the elderly are provided health-care by the general health-
care delivery system in the country.
As the elderly population is likely to increase in the future, and there is a definite
shift in the disease pattern, i.e. from communicable to non-communicable, it is high
time that the health care system gears itself to growing health needs of the elderly
in an optimal and comprehensive manner. There is a definite need to emphasize the
fact that disease and disability are not part of old age and help must be sought to
address the health problems. The concept of Active and Healthy ageing needs to be
promoted among the elderly, which includes preventive, promotive, curative and
rehabilitative aspects of health.[4]
VISION AND OBJECTIVES OF THE NATIONAL PROGRAM FOR
THE HEALTH-CARE FOR THE ELDERLY (NPHCE)
The NPHCE is an articulation of the International and national
commitments of the Government as envisaged under the UN
Convention on the Rights of Persons with Disabilities, National Policy
on Older Persons adopted by the Government of India in 1999 and
Section 20 of The Maintenance and Welfare of Parents and Senior
Citizens Act, 2007 dealing with provisions for medical care of
Senior Citizen. The Vision of the NPHCE are: (1) To provide
accessible, affordable, and high-quality long-term, comprehensive
and dedicated care services to an ageing population; (2) Creating
a new architecture for Ageing; (3) To build a framework to create
an enabling environment for a Society for all Ages; (4) To promote
the concept of Active and Healthy Ageing.
SPECIFIC OBJECTIVES OF NPHCE
To provide an easy access to promotional, preventive, curative and
rehabilitative services through community based primary health-care (PHC)
approach
To identify health problems in the elderly and provide appropriate health
interventions in the community with a strong referral backup support
To build capacity of the medical and paramedical professionals as well as
the care-takers within the family for providing health-care to the senior
citizen
To provide referral services to the elderly patients through district hospital
regional medical institutions
Convergence with National Rural Health Mission (NRHM), Ayush and other
line departments like Ministry of Social Justice and Empowerment.
STRATEGIES TO ACHIEVE THE
OBJECTIVES OF THE NPHCE
Community based PHC approach including domiciliary visits by trained health-care
workers
Dedicated services at PHC/Community Health Center (CHC) level including provision
of machinery, equipment, training, additional human resources, Information,
Education and Communication (IEC), etc.
Dedicated facilities at the district hospital with 10 bedded wards, additional human
resources, machinery and equipment, consumables and drugs, training and IEC
Strengthening of 8 Regional Medical Institutes to provide dedicated tertiary level
medical facilities for the elderly, introducing PG courses in geriatric medicine, and in-
service training of health personnel at all levels
IEC using mass media, folk media and other communication channels to reach out to
the target community
Continuous monitoring and independent evaluation of the Program and research in
geriatrics and implementation of NPHCE
Promotion of public private partnerships in geriatric health-care
Mainstreaming Ayush revitalizing local health traditions and convergence with
programs of Ministry of Social Justice and Empowerment in the field of geriatrics
Reorienting medical education to support geriatric issues.
THE FOLLOWING ARE THE EXPECTED
OUTCOMES OF NPHCE
Regional geriatric centers (RGC) in eight Regional Medical Institutions by setting up
RGCs with a dedicated geriatric out-patient department (OPD) and 30-bedded
geriatric ward for management of specific diseases of the elderly, training of health
personnel in geriatric health-care and conducting research
Post-graduates in geriatric medicine (16) from the eight regional medical institutions
Video Conferencing Units in the 8 Regional Medical Institutions to be utilized for
capacity building and mentoring
District geriatric units with dedicated geriatric OPD and 10-bedded geriatric ward
in 80-100 District Hospitals
Geriatric clinics/rehabilitation units set up for domiciliary visits in
community/primary health centers in the selected districts
Sub-centers provided with equipment for community outreach services
Training of Human Resources in the Public Health-Care System in geriatric care.
PACKAGE OF SERVICES UNDER
NPHCE
In the program, it is envisaged providing promotional,
preventive, curative and rehabilitative services in an
integrated manner for the Elderly in various Government
health facilities. The package of services would depend on
the level of health facility and may vary from facility to
facility. The range of services will include health promotion,
preventive services, diagnosis and management of geriatric
medical problems (out- and in-patient), day care services,
rehabilitative services and home based care as needed.
Districts will be linked to RGCs for providing tertiary level
care. The services under the program would be integrated
below district level and will be an integral part of existing
PHC delivery system and vertical at district and above as
more specialized health-care are needed for the elderly.
Packages of services to be made
available at different levels under NPHCE
In the program, it is envisaged providing promotional, preventive,
curative and rehabilitative services in an integrated manner for the
elderly in various Government health facilities. The package of
services would depend on the level of health facility and may vary
from facility to facility. The range of services will include health
promotion, preventive services, diagnosis and management of
geriatric medical problems (out- and in-patient), day care services,
rehabilitative services and home based care as needed. Districts will
be linked to RGCs for providing tertiary level care.
The services under the program would be integrated below district
level and will be an integral part of existing PHC delivery system
and vertical at district and above as more specialized health-care
are needed for the elderly
Institutional framework for the
implementation of NPHCE
Financial Management Groups (FMG) of Program Management support units at the
state and district level, which are established under NRHM, will be responsible of
maintenance of accounts, release of funds, expenditure reports, utilization
certificates and audit arrangements. The funds will be released to States/UTs
through the State Health Society (SHS) to carry out the activities at different levels
as envisaged in the operational guidelines. Funds release from SHS to District
Health Society (DHS) would inter alia include funds for CHCs, PHCs and sub-centers
to cover the entire District.
Funds from this program will be released to the SHS by the Government of India.
SHS will retain funds for state level activity and release grant-in-aid to the DHSs.
NPHCE would operate through NCD cells under the program constituted at State
and District levels and also maintain separate bank accounts at each level. Funds
from Health Society will be transferred to the Bank accounts of the NCD cell after
requisite approvals at the appropriate stage. This system will ensure both
convergence as well as independence in achieving program goals through specific
interventions. It is envisaged to merge the program at State and District into the SHS
and DHS respectively in order to ensure sustaining the current momentum and
continued focus [Table 1].
Although, the NPHCE addresses most of the health problems in an
institutional health-care system, but it completely neglects the home based
care of an elderly person in families. It would have been better to focus on
awareness among families and make them prepare for possible
eventualities rather than treating when it happened. Other than having a
national vision, the policy should have a decentralized vision that can make
the policy demand driven rather than an autocratic state driven system. As
in the case of most of the national programs or policies, it also fails to focus
on regional issues that are different in different regions. The policy can be
a failure in addressing how to generate an incentive for families to treat
and care for their elderly, which is so necessary in a poor country like
India.[5]
The NPHCE is a good and new initiative to take care of a fast ageing
population. It requires more attention in the implementation and
coordination so that the program would not only be on paper like many
other programs of the country.