Role of Government in Providing Healthcare and Economic Security for Older People

Constitutional obligation. Article 41 directs the State to secure the right to public assistance in old age, sickness and disablement; Article 47 makes raising nutrition and improving public health a primary duty of the State. Social security is a Concurrent List subject, so both Centre and States are answerable.

Market failure argument. Private insurance fails older people because premiums rise steeply with age, pre-existing conditions are excluded, and chronic and custodial care are not covered. Essentials makes exactly this point about long-term care insurance: it is affordable when bought young but becomes very expensive by age 75, when the need is greatest, and those who need it most may be ineligible because of prior conditions. Only the State can pool risk across the whole life course.

Demographic urgency. India’s 60+ population will rise from 10.5% (149 million) in 2022 to 20.8% (347 million) by 2050, the 80+ group will grow by 279%, and the elderly will outnumber children by 2046 — while over 40% of the elderly are in the poorest wealth quintile and 18.7% have no income at all.

The two problems are one problem. Older people are poor because they are sick, and sick because they are poor. Nationally, older adults spend about 17.4% of household consumption expenditure on healthcare, and treatment expenditure is demonstrably higher above 60 than in younger age groups, regardless of income level. Government action on health is action on economic security.

(i) Policy-maker / Steward — NPOP 1999, National Health Policy 2017, NITI Aayog Senior Care Reforms 2024; sets goals, targets and accountability.

(ii) Legislator — MWPSC Act 2007, Code on Social Security 2020, Section 144 BNSS; creates enforceable rights.

(iii) Financier / Purchaser — tax-funded programmes, PM-JAY, pensions, subsidies; pools risk and protects against catastrophic spending.

(iv) Provider — the public health system from Ayushman Arogya Mandir to Regional Geriatric Centre; old-age homes through IPSrC.

(v) Regulator — PFRDA, IRDAI, Clinical Establishments Act, drug price control (NPPA), minimum standards for old-age homes.

(vi) Capacity-builder and knowledge-generator — PG seats in Geriatric Medicine, training modules, LASI, National Health Accounts, research funding.

Direct service provision through NPHCE (2010). A five-tier ladder — Sub-centre/Ayushman Arogya Mandir → PHC (weekly geriatric clinic) → CHC (twice-weekly clinic + physiotherapy) → District Hospital (10-bedded ward with 2 respite beds) → Regional Geriatric Centre (30 beds) and National Centres for Ageing. The tertiary arm was renamed Rashtriya Varisth Jan Swasthya Yojana in 2016–17.

Financial protection through Ayushman Bharat. PM-JAY gives ₹5 lakh per family per year; the Ayushman Vay Vandana Card (October 2024) extends ₹5 lakh cover to every citizen aged 70+ irrespective of income, with no waiting period for pre-existing conditions and roughly 1,961 procedures across 27 specialties. This is India’s first universal, age-based (not means-tested) health entitlement.

Convergence with vertical programmes. The elderly are served by NP-NCD (with CBAC-based screening from age 30), NPCB&VI (cataract, refractive error), NPPCD (deafness/hearing aids), National Mental Health Programme (depression, dementia), the National Programme for Palliative Care, and free dialysis and free drugs & diagnostics initiatives.

Human resource development. NPOP 1999 promised that “facilities for specialization in geriatric medicine will be provided in the medical colleges” and that training in nursing care will include geriatric care — delivered through PG seats at RGCs, in-service training and caregiver training for families.

Evidence that public financing works — the strongest data point in this answer. National Health Accounts estimates released in September 2024 show out-of-pocket expenditure fell from 64.2% of total health expenditure in 2013-14 to 39.4% in 2021-22, while government health expenditure rose from 1.13% to 1.84% of GDP, with over ₹1 lakh crore of savings from PM-JAY alone. Per capita government health spending tripled from ₹1,108 to ₹3,169, government health spending as a share of total government expenditure rose from 3.94% to 6.12%, and Social Security Expenditure on health rose from 5.7% to 8.7%. Public spending on health has, for the first time, overtaken out-of-pocket spending.

Social assistance (tax-financed, for the poorest). NSAP delivers IGNOAPS (₹200/month for 60–79, ₹500/month for 80+ central share), IGNWPS, IGNDPS, NFBS and Annapurna (10 kg free foodgrain/month), supplemented by state top-ups and subsidised grain under the NFSA 2013.

Social insurance and pensions (contributory). EPFO runs EPF, EPS (minimum pension ₹1,000/month) and EDLI; government employees are covered by OPS (pre-2004), NPS (post-2004) and UPS (from 1 April 2025). Atal Pension Yojana extends a guaranteed ₹1,000–₹5,000 monthly pension to unorganised-sector workers.

Savings, annuity and tax instruments. SCSS at 8.2% paid quarterly (₹30 lakh limit), PMVVY, reverse mortgage, and tax relief through a higher basic exemption (₹3 lakh for 60–79, ₹5 lakh for 80+ under the old regime), Section 80TTB (₹50,000), Section 80D and Section 80DDB.

Legal enforcement of family support and welfare services. The MWPSC Act 2007 creates Maintenance Tribunals, makes abandonment punishable and allows property transfers to be declared void; AVYAY delivers old-age homes (IPSrC), free assistive devices under RVY, and Elderline 14567.

The unfinished agenda — six concrete gaps: Under-financing: government health spending is still only ~1.9% of GDP against the National Health Policy 2017 target of 2.5% by 2025, and OOPE at 39.4% remains above the 35% target, versus about 13% in the UK and Australia. The wrong thing is insured. Catastrophic spending in India is more common for outpatient care (47.8% of households) than for hospitalisation (43.1%), and medicines alone account for roughly two-thirds of out-of-pocket spending — yet outpatient care and medicines lie outside the flagship hospitalisation scheme. Tamil Nadu’s pooled free-medicines model is cited as a proven domestic remedy. This matters most for the elderly, whose costs are chronic and outpatient, not episodic. Unindexed benefits: IGNOAPS at ₹200–₹500/month and EPS at ₹1,000/month unrevised for over a decade. No long-term care system: no statutory LTC financing, no care-giver allowance, no LTC insurance. Fragmentation: delivery split across five ministries with no single accountable authority. The “missing middle”: roughly 400 million Indians remain uninsured — too rich for PM-JAY, too poor for private cover.

The ethical dimension the examiner is waiting for. Essentials warns that “older adults are prime targets for rationing efforts because they consume disproportionately large amounts of medical care and because they are seen as having already lived their lives.” It cautions that any measure using life expectancy is inevitably biased against the elderly, and that a measure relying on dependency as the outcome implies that those who are dependent no longer count — “by such logic, disability is equivalent to death.” It concludes that as advocates for their patients, geriatricians must be extremely vigilant to how such terms are used. Pathy’s makes the parallel point that the UK NSF’s Standard One was “rooting out age discrimination,” and that ageism leads older people to be denied beneficial investigations and treatments. A government’s role is therefore not only to fund and provide, but to protect older people from being rationed out of the system. Framework Table — Government Role Mapped to Instrument Role Healthcare instrument Economic security instrument Policy / Steward National Health Policy 2017; NPHCE guidelines NPOP 1999; NITI Aayog Senior Care Reforms 2024 Legislator MWPSC Act Chapter IV (medical care) MWPSC Act; Code on Social Security 2020; Sec 144 BNSS Financier PM-JAY + Ayushman Vay Vandana Card (70+); NSAP/IGNOAPS; EPS; UPS; APY; SCSS; tax reliefs free drugs & diagnostics Provider AAM-HWC → PHC → CHC → DH (10 beds) → RGC / IPSrC old-age homes; RVY assistive devices NCA Regulator Clinical Establishments Act; NPPA drug price control PFRDA; IRDAI; standards for old-age homes Capacity builder PG seats in Geriatric Medicine; staff training Elderline 14567; SACRED/SCOPE re-employment Knowledge generator LASI; National Health Accounts; HMIS Social Protection Data Pooling Exercise; e-Shram LATEST UPDATES (2023–PRESENT)

Public spending has overtaken out-of-pocket spending — a landmark. National Health Accounts estimates for 2020-21 and 2021-22, released 25 September 2024, show OOPE down from 64.2% (2013-14) to 39.4% (2021-22) and government health expenditure up from 1.13% to 1.84% of GDP, with NITI Aayog attributing more than ₹1 lakh crore of savings to PM-JAY. Per capita government health spending tripled from ₹1,108 to ₹3,169, and social security expenditure on health rose from 5.7% to 8.7% of total health expenditure. However, both National Health Policy 2017 targets — GHE of 2.5% of GDP and OOPE down to 35% — have been missed.

Universal age-based health entitlement (October 2024). The Ayushman Vay Vandana Card gives ₹5 lakh of free annual cover to every citizen aged 70 and above irrespective of income, with a ₹5 lakh top-up for seniors already in PM-JAY families. 9.67 million cards issued by 31 December 2025; by January 2026 nearly one crore cards, enabling about eight lakh elderly citizens to access free treatment, with 1.80 lakh Ayushman Arogya Mandirs operational.

Social protection coverage has doubled — ILO World Social Protection Report 2024–26. Coverage by at least one social protection cash benefit rose from 24.4% (2021) to 48.8% (2024), with nearly 920 million people (65% of the population) covered in cash or in kind, contributing a 5% increase in global coverage.

The legal architecture of economic security was rewritten (2025–2026). The four Labour Codes came into force 21 November 2025, consolidating 29 central labour laws; the Code on Social Security 2020 merges nine Acts and extends benefits to unorganised, gig and platform workers (Sections 113 and 114), with aggregators contributing 1–2% of turnover to a Social Security Fund. The Unified Pension Scheme took effect 1 April 2025 (50% of last 12 months’ average basic pay after 25 years, minimum ₹10,000/month, family pension 60%, AICPI-IW indexed), and EPS 2026 replaced EPS-95 with a 20-day claim-settlement rule carrying 12% penal interest.

Policy direction — what governments are being told to do next. NITI Aayog (February 2024) recommends strengthening geriatric healthcare within the existing system, extending comprehensive primary care through AB-HWCs, promoting health literacy among seniors and caregivers, expanding home health care, mental health services and Poshan Abhiyan for senior citizens, formal recognition of the care economy and care workers, especially women, a national portal for senior care, and a regulatory mechanism to set a viable base interest rate on senior-citizen deposits.

International benchmark. The UN Decade of Healthy Ageing (2021–2030) frames government responsibility under combating ageism, age-friendly environments, integrated care and long-term care. Its 2023 progress report found fewer than one-third of countries have adequate resources, with only about 1 in 4 having sufficient resources for integrated care and 1 in 3 for long-term care. The WHO ICOPE Handbook 2nd edition (January 2025) gives governments an operational tool — a four-step primary-care pathway screening six intrinsic-capacity domains.

“The government acts in six roles: steward, legislator, financier, provider, regulator and capacity-builder — and for older people all six are needed simultaneously.”

“Out-of-pocket expenditure fell from 64.2% in 2013-14 to 39.4% in 2021-22, so public spending on health has for the first time overtaken out-of-pocket spending — but both NHP 2017 targets have been missed.”

“India insures the wrong thing: catastrophic spending is commoner for outpatient care than for hospitalisation, and medicines are about two-thirds of out-of-pocket spending — precisely the elderly’s cost pattern.”

“Older adults are prime targets for rationing because they consume disproportionately large amounts of medical care and are seen as having already lived their lives.”

“By the logic of dependency-based outcome measures, disability is equivalent to death — geriatricians must be extremely vigilant to how such terms are used.”

NHA key numbers: OOPE 64.2% → 39.4% • GHE 1.13% → 1.84% of GDP • per capita ₹1,108 → ₹3,169 • GHE share of govt spending 3.94% → 6.12%.

NHP 2017 targets: GHE 2.5% of GDP and OOPE down to 35% — both missed.

Catastrophic expenditure: outpatient 47.8% of households vs hospitalisation 43.1%; medicines ~two-thirds of OOPE.

“Missing middle” = ~400 million uninsured Indians.

Elderly spend ~17.4% of household consumption expenditure on healthcare.

The ethical anchor: Essentials on rationing + Pathy’s NSF Standard One (“rooting out age discrimination”).