Nepal is a culturally complex, haphazardly urbanized and topographically varied country with over 100 different ethnic groups living within a territory of 14.5 million hectares of various ecological regions. The country is thickly populated with an average density of 181 persons per square kilometer. Over 50% of the population is concentrated in the southern Tarai region that serves as the bread basket for the country but covers only 17% of the country’s land mass. Though the economy is mainly based on agriculture, remittance contributes 26% of the gross domestic product (GDP). The low income patriarchal agrarian rural economy heavily suffers from lack of working manpower in the mid hills and mountain regions due to migration for jobs.  Low agricultural productivity and lack of employment opportunities in the rural areas have led to outflow of young and educated manpower to urban centers and foreign countries. Left in lurch in rural areas, elderly population is facing twin problems of sustaining agriculture without support of children and overcoming debts burdens of educating children. Added to these problems, the elderly are also facing the brunt of changing sociological conditions either due to absence of children or due to individualistic attitudes of their offspring once they marry and start family in new social environment. Here we have tried to analyze some of the problems faced by elderly people and review existing provisions the Government of Nepal (GoN) has implemented to ease the living conditions of the elderly. This will be followed by a longitudinal survey of literature on elderly care in various countries.  Finally, we suggest some steps to improve the living conditions of elderly in Nepal based on the social change theory and demographic characteristics.

The problems

Like other Asian countries, Nepal faces complex demographics structures coupled with many social issues such as gender imbalance within a varied topographic landscape ranging from 32 to 8808 meters elevation within 1.3 latitudinal horizontal distances. Dramatic changes in social structures after the decade-long (1996-2006) insurgency, eco-unfriendly development drive, and heavily influenced household economy from remittance all have synergistically affected living conditions of elderly people.  The historical practices of care giving to elderly people, the living arrangements with joint family and familial responsibilities toward elders that once centered around or within the patriarchal family network are changing in line with the Western culture, individualistic or emotionally-nucleated family systems. Over 1200 young people leave their natal homes each day for remittance and career goal purposes leaving the elderly in rural areas.  Despite investing on educations for their offspring, expected reciprocity by elderly during their old ages is decreasing.  Instead, elders are facing debt burdens of children education and little or no support for their living from their children at elderly age. The social change theories states that as offspring become associated with non-family institutions, such as schools, and drift away from family circle, they are less likely to involve in traditional life styles. With this shift in daily life style, a family starts becoming individualistic and emotionally nucleated, which decreases the amount of time the children should have spent with their parents. Research has revealed that individuals who lived closer to schools, health services and business areas often favor putting their ageing parents in adult care and rehabilitation centers. Such trends are found among educated people who often leave their natal homes for work or other opportunities, a contrary to the patriarchal social structure.  The altruistic model suggests that when children become more individualistic, parents get little support from their offspring and children even would not share and learn cultures from seniors and neighbors’ experiences. These developments are pushing Nepali culture close to western cultures. There has not been, however, a concurrent change in the country’s institutions to complement many of the new attitudes and behaviors to assist the living conditions of elderly people. With particular reference to the material support and care of older parents, young people have started living alone providing minimum support to their parents as compared to their predecessors. Many non-family institutions have replaced traditional familial support, and many elderly people live alone and receive little care from their non-resident children. Interestingly, the improvement in public health has expanded the life expectancy from 57 years to 65 for males and 62 for females in Nepal. Increase in the number of elderly people on the one hand and their solitary living conditions have led to severe frustrations among elders. These problems have drawn the attentions of researchers, social scientists and policy makers to devise systems to improve the living conditions of elderly so that the country would not have to deal with depressed elderly.

According to the 2001 census, Nepal’s elderly population constitutes 6.5 percent of the total population of the country. During the years 1991-2001, the annual elderly population growth rate was 3.39 percent as against the national population growth rate of 2.3%. According to the 2011 census, the percentage of elderly population has increased to 9.1 percent (male 4.6 and female 4.5%).  The sudden increase in elderly population has strained the family unit to provide support for the elders, and has led to a distressing situation for them for the lack of support. Despite such distressing conditions, the number of senior will increase because 54.7% of the total population is within the age group of 15-59, which is reproductively active.

Demographic theory states the elderly population increase either due to aging at the base or aging at the apex or both. Aging at the base results from a decrease in fertility; and then, subsequently, by a reduction in mortality among the elderly.  Records suggest that the main cause of population aging in Asian countries is due to the decline in fertility rather than a decrease in mortality. In Nepal, the decreasing fertility rate is attributed to the increase in education where many young couples favor to have family at the later age of the lifecycle.  As a result, the elderly population in the future would appear to increase at an even quicker pace which might reduce the doubling time. Similarly, an improvement in mortality also adds up the total number of elderly population.  Nepal’s elderly population has increased from 6.5% in 2001 to 9.1% in 2011. Over the same period, Nepal population has increased by 15% making the total population 26.6 million (48.56% males and 51.43% females) from 23 million of 2001.   Over 60% of the increased population is concentrated in the Kathmandu Valley making it the most congested among world’s cities.

Of the current total population, elderly population constitutes 2.4 million (4.6% male and 4.5% female) distributed across urban (24.2%) and rural (75.8%) areas. Among the rural areas, elderly population concentration is in the western hill (11.7%) followed by the hills of the eastern region (10.4%). Of the elderly rural population, 47.12% is economically active that includes 59.7% of males and 34.3% of females, but urban elderly population is economically inactive.

The above statistics suggests that like in many other Asian countries, many of the elderly in Nepal are living in rural rather than urban settings, both in terms of size and proportion. Most likely, this is due to a low level of urbanization (17% of the total population living in urban centers) and many elderly not willing to change their rural into urban lifestyles. Also, the elderly population prefers to live in a traditional rural society because of the presence of strong family ties. Intergenerational transfer of resources is a normal practice in the rural Nepali society. There are many sociological theories that deal with how intergenerational transfer of resources takes place and how do the flow of such resources impact on the living of elders. A survey of literature reveals that over 80% of elderly are living with their children (97.3% with sons and 2.7% with daughters) and over 60% of male elderly still head household in Nepal. Despite these familial attachments, elders in reality are either living with their daughter-in-laws or with paid workers at sons’ property while sons are away from home for work. Multiple motivations schemes are essential to improve the caring of elderly people, for example, tax break and paid leave for a few days for employees who take care of their parents.  The government and non-governmental sectors also have established service centers to take care of the elderly people, however, social welfare system is still lacking in Nepal. The first International Conference on Population and Development (ICPD) held in Cairo Egypt in 1994 recommended that the government develops social security systems to ensure greater equity and solidarity between and within generations to provide support to elderly people through encouragement of multigenerational families.

In order to set up a social welfare system, the GoN first needs to define what constitutes the elderly population. Population turning into a senior status is a time bound process that occurs over time and brings gradual changes in physical appearance, strength, mental conditions, immunity power, and mobility, however, this process varies among people based on nutritional standard and health facilities.   In line with the definition of the World Health Organization (WHO), Nepal Senior Citizens Acts 2006 identifies senior citizens as "people who are 60 years and above.”  However, this definition contradicts with the civil servant rules, where the retirement age varies for different disciplines; for example, for lower rank military and police, the retirement age ranges between 45 and 48 years, for higher ranks military and all other civil servants it is 58, for university teachers it, is 63, and for judiciary, it is 65 years. If universal pension system is to be implemented, it is essential to redefine what constitute senior citizen in line with the various retirement ages of government servants.
The Interim Constitution of Nepal 2006 and ILO convention of 1969 have provisions for the protection of rights and privileges of elderly people; however, these provisions have not been effective in Nepal. Government of Nepal from 1951 started providing $6 per month elderly age pension to people who are above the age of 75 years, and for widows of 60+ years. Since then the older age allowance is built up in the regular annual budget, which is disbursed to elderly individuals as per the Local Development Act 1995-96, article 233(2). Elderly Population Act 2006 and Elderly Population Rules 2008 have provisioned to reserve special seating arrangements for the elderly people in transportation and other public services. In addition to various provisions made by the government, elderly deserve welfare programs and respects as per the set international norms.

Concerns on the welfare of ageing population started after the Vienna 1982 Conference on International Plan of Action on Ageing. The Second World Assembly on Ageing held in Madrid, Spain in 2002 outlined an action plan at national and regional levels to develop and implement concrete plans of action to improve the living conditions of elders. Since then efforts are being made to expand the social security programs for elderly by the signatory countries. Nepal as one of the signatories of Madrid Assembly has taken some steps in this regard.

Provisions for Elderly Care in Nepal:

The minority Communist Government of the United Marxist Leninist in 1995 introduced a pension scheme for people of 75+ years of age and 60+ year old widows, which now amounts to $6.00 per month per person.  From the Ninth Five Year Plan (1997-2002), GoN started family-based security system to improve the living conditions of elderly.  GoN enacted Senior Citizens Policy and Working Policy 2002, National Action Plan for Senior Citizens 2005, Senior Citizens Acts 2007, Senior Citizens Health Facilities Program Implementation Guidelines, and Senior Citizens Regulation 2009 to implement the policies and programs that ensure the social security to the elderly.

The Senior Citizens Acts adopted by the Government has aimed to formulate policies to respect and utilize the knowledge, skills and experiences of senior citizens in nation development and social transformation. The provision made by the Senior Citizens Acts contradicts with the Civil Service Acts because the Civil Service Acts has obstructed the elderly people to be participated in the service. Nonetheless, GoN has: a) set up Senior Citizens Health Facilities Fund in each district to provide free treatment equivalent to a limit of $25 per person per year; b) made provision for free health services for heart and kidney patients of over 75 years of age; c) established “Aarogya Aashram” (Hospice Centers) in each of the five development regions; d) renovated Old Age Home established in 1976 in the premises Pashupati Nath (Pashupati Bridrashram) to accommodate the destitute elders; f) established charity fund to serve elderly people all over Nepal; g) initiated activities such as honoring families that provide the best care to their elders in their family; h) developed Senior Citizens Treatment Guidelines 2004 to provide treatments to sick and elderly people free of cost in hospitals having at least 25 beds.  The Old–Age–Allowance (OAA) is a step towards the fulfillment of the Directive Principle of the Constitution and the commitment expressed in the international forum on ageing.  Pensions are safe income for the remainder of life; however, a large bulk of the population in Nepal receives no pension and must depend on familial support and personal savings. Despite being small in amount, the pension has been a subsidy to purchase medicine, food, and/or clothing and has given strength to elderly people. Rural dwellers appreciate the pension more highly than the urban dwellers.

Survey of Contemporary Literature:

Different countries have various provisions to facilitate the living of elderly people. In India, the National Policy on Older Persons announced in January 1999 provides a framework for welfare of the elderly persons including improved financial security and increased access to health and nutrition services. Poor elderly citizen get $2 as pension per month. Additionally, the elderly gets health care services at primary, secondary, and tertiary levels. The Bangladesh government currently pays US$ 3 per month to extremely poor people aged 57 and above living in rural areas. This includes about a million (14% of the total population) of Bangladesh. Thailand has a similar scheme of providing allowances to senior citizens. The Chinese government provides five guarantees to elders: food, clothing, housing, medical care and burial expenses, who have lost the ability to work with no source of income and who are without any legal guardians to support for their living. The Chinese government has planned to offer comprehensive health coverage for elderly people and established a basic medical insurance system which combines the unified planning program with individual accounts for urban employees. Under this system, retirees do not have to pay the basic insurance premiums. The government subsidies the medical cost what is not paid by their former employers.  This supplementary medical care has reduced the burden of medical costs for the elderly.  Hong Kong, a Special Economic Zone of China, has Publicly Funded Comprehensive Social Security Assistance (CSSA), Old Age Allowance (OAA) for 65 years and older. Mandatory Provident Fund (MPF) schemes, and Voluntary private savings and investment are in the offing.  Indonesia revised the Social Assistance for the Elderly Law of 1965 and enacted Old Age Welfare Law of 1998 that guarantees services, such as religious/spiritual, health care, employment, education and training service. Special provisions have been made for “infirm” elderly and “able-bodied” elderly). Singapore assumes a family as the long-term care providers to the elderly. It encourages the traditional values system of caring for the older persons by way of policy initiatives, for example, making priority allocation of housing or allowing tax incentives to those children who take responsibilities of the care and maintenance of parents. There is legal obligation on children to care of their parents. Viet Nam has strengthened its nutritional, physical exercise and healthcare education programs for older persons. The Democratic People’s Republic of Korea, the Republic of Korea, and Japan encourage older persons to become more active through regular exercise routines and healthy life-styles. In the Philippines, the Department of Health formulated the Health Care Program for Older Persons (HCPOP) in 1998 to promote quality and productive life style of elderly.

In African country of Senegal and South Africa have provision of tested assistance systems for elderly, while Botswana, Mauritius, and Namibia have adapted universal pension systems. Mozambique operates a cash transfer system that targets households headed by chronically ill or disabled elders. Only three countries—South Africa, Namibia and Mauritius— provide an old-age pension system that is noncontributory and means tested.

Latin America countries of Brazil, Chile, Costa Rica, Cuba and Nicaragua provide pensions to poor who are 65 and older, but in Argentina and Uruguay only people of 70 and older deserve such pensions. Costa Rica is the only country in Latin America that provides a non-contributory universal pension to people aged 70 and older. Argentina has adopted a number of key initiatives to strengthen health and long-term care for older persons and ensure their right to an active life. The Ministry of Social Development has designed four educational programs to enhance the effectiveness of health professionals, social workers, community leaders, and caregivers to improve the living of elderly. Antigua and Bolivia offer a universal pension. In Australia, pensions are provided to elderly people whose disabilities require them to stay in nursing home.  People willing to stay in a community will get Community Aged Care Packages (CACPs) and Home and Community Care Program (HACC). The Commonwealth subsidies also cover about ¾ of the long-term residential costs.

In Sweden, responsibility for elderly care rests at national, regional, and local levels. At the national level the Swedish Parliament (Riksdagen) and the Government provides assistance to elderly people through legislation and financial control measures, whereas at the regional level, the 21 county councils are responsible for the provision of health and medical care. At local level Sweden’s 290 municipalities have a statutory duty to meet the social service and housing needs of the elderly. Under the Social Service Act, Sweden has means- tested social pension system, which is considered a politically stable pension. Anyone who has not earned an adequate pension through the public pension system is guaranteed a top-up guarantee pension. This compensation is financed via the central government budget.
The Older Americans Act (OAA) authorizes and funds the Administration on Aging and The Elderly Nutrition Program (ENP). They are administered by the U.S. Department of Health and Human Services Administration on Ageing. The OAA provides funding for two senior nutrition programs: congregate meals and home-delivered meals. Both of these services are offered to seniors at no cost. In Australia, the Commonwealth Seniors Health Card (CHSC) provides pharmaceutical concessions to non-pensioners elderly whose income is below the pension income cut off (around A$ 22 000). New Zealand provides broad-based support to family care-givers, which typically consisted of counseling and coping, training on caring skills and respite services.

The above accounts reveal that different countries have adapted different services to elderly citizens. The main goal is to improve the living conditions of elders. Nepal could follow examples of low income countries that have similar socio-demographic conditions to Nepal and are sustainably maintaining the living conditions of senior citizens.

Suggestions:

This study suggests that Nepal’s existing social pension programs do not provide adequate income or coverage to elderly people as in other countries, and needs to be expanded with health care and nutritional packages. Offering old age pensions adds financial burden to a country. However, different mechanism can be implemented to alleviate these burdens. These include but not limited to general taxation, special levies on specific activities or sectors, or the imposition of an earnings-based “solidarity” tax or contribution by those participating in employment pension programs.  Incentives should be provided to those couples who provide unconditional cares to their parents. These incentives could be in the form of appreciation letters with some annual financial and health coverage packages, discount in transportation costs, free participation in skill learning vocational workshops, reduction in annual land revenues, agricultural subsidies, and tuition fee subsidies to children of caring couples.

Demographic studies suggest that each day over 1200 young people leave Nepal in search of jobs. The remittance sent by these people contributes 26% of the total GDP of Nepal.  Leaving Nepal by working age population is a loss of human capital and brain drain. This adds frustrating and depressing to elders, however, reality cannot be ignored. Overseas remittances, rural-to-urban migration, and increased entrepreneurial activities in agriculture have alleviated the poverty and improved the lackluster economic growth of Nepal. In addition, these activities have helped reduce poverty from 41.7% in 1995 to about 30.9% in 2003 and to 25% in 2011.  Today Nepal’s poverty incidence seems to be lower than India’s (35.1%) and Bangladesh (36.3%).  Although these trends were partly driven by the lack of opportunity in local economies and by conflict/civil war, and have directly impacted on the living conditions of elderly, remittance and rural-to-urban migration should be taken as a forward steps to alleviate poverty.  Nepal needs to bring social changes in elderly lives. Though the Maoist insurgency (1996-2006) brought social changes with revolutionary ideas in rural areas, not much has been done to elevate the living conditions of elderly. It could be a cultural taboo in the Nepali community to propose the implementation of western culture; however, studies have shown that ever married elderly couples have maintained their sustained happiness than the widowers.  Probably, the establishment of elderly meeting centers and allowing them to interact with others and possibly finding partners for widowers might be a creative way to restore happiness among elderly.  Lately, widow marriage has been widely accepted in Nepal and GoN has provisioned to provide incentives for such marriages. Probably, this step will not only help to restore happiness among widowers, but also it might reduce the incidences of marrying younger females under various pressures by elderly males. Such a revolutionary step might help to balance gender ratio among elderly population.

(Nimisha Bhattarai is a pre-medical student and Meena Bhattarai is a graduate student in social gerontology at the University of Central Missouri. Their emails respectively: This e-mail address is being protected from spambots. You need JavaScript enabled to view it , This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

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