Policy Interventions to Address Academic Burnout in the Indian Student Population

What is Academic Burnout?

Academic Burnout, or the “burnout syndrome” is characterized by a “combination of exhaustion, depersonalization, and reduced personal accomplishment caused by chronic work stress”. 1 The amalgamation of these emotions often lead to the feeling of prolonged sadness, low self-esteem, ineffectiveness, and an overall disassociation from one’s work or success over time. Studies, akin to the ones conducted by Ioanna V. Papathanasiou prove that academic burnout is an antecedent to depression and other mental health problems.2 Information from the Diagnostic and Statistical Manual of Mental Disorders (DSM) illustrates that depression is a precursor to suicidal thoughts and actions.

According to the latest available data from the National Crime Records Bureau, a student commits suicide every hour in India. 3 This highlights a prominent problem in student demographic. Thus, it is essential to investigate why suicide rates are constantly increasing in India as opposed to the rest of the world.4 Moreover, it is imperative to find a solution for the same. This article attempts to explore how incorporating policies aimed at reducing academic burnout in educational institutes will help lower the suicide rates in India.

To ensure effective policy change, it is essential to have a thorough understanding of the causes of academic burnout in Indian institutions.

Social and Economic Background for Academic Burnout

India spends about 0.07%of its GDP on the provision of mental health services in the country.5 6 This stands in stark contrast to developed countries like Denmark that spend at least 4% of their annual GDP on mental health services.7 By spending on mental health provisions, the State ensures that there are mental health professionals in the country- these could be in the form of counselors, crisis hotline workers, psychiatrists, and psychologists. In India, due to the lack of funding for these provisions, there is a dearth of mental health professionals and services in the country.8 The Mental Health Act passed 2017 outlines the allocation of finances for mental health professionals in the state and aims to safeguard the rights of people with mental health disorders.9 However, the Act does take into account other means of mental illness prevention like creating awareness. Moreover, the Act does not mandate educational or commercial institutions to create a safe atmosphere. This is further reflected in the education system where publicly funded universities and schools do not have mental health professionals on campus – therefore, students do not have access to these facilities when they need help.10

The language that surrounds the mental health culture in India is extremely toxic. As a result of this, people are uncomfortable while expressing their problems and this apprehends students from seeking help. Seeking mental health assistance is extremely difficult due to the social stigmas attached to the issue; if a person is going to therapy, they are called “weak or paagal”.11  Another corollary for the same is the narrative around academia in households and educational institutes, where students are meant to ‘just deal with it’.

The Indian education system is built on a punitive and test-score driven method as opposed to holistic development.12 For example, if a child is not performing well, they are often shamed or defamed in front of the class. The students can’t even find comfort at home because often parents are extremely strict and demanding when it comes to academics.

Research conducted by the World Economic Forum revealed that households are not a safe space where students can voice their concerns and apprehensions about their education.13 Moreover, due to the high emphasis that is put on a “successful career”, children are often pushed towards subjects that they are not comfortable with or even keen on doing; this is because intelligence is mostly measured through technical subjects and not music, arts, sports, etc. 14 15 This creates a discord in the student’s schemas – a schema is a cognitive framework or concept that helps organize and interpret information 16– if they are unable to perform well in subjects deemed important by the society. As a result, students start building a negative narrative for themselves. They start seeing themselves as failures and this often leads to depression, which in turn could lead to suicide.17 Countries like Finland and Denmark that focus on the core strengths of students are reported to have a happier student population.18

Lastly, one of the most important contributors to the student suicide crisis is the glorification of stress. In the Indian academic world, overworking and high workloads are often considered to be markers of “productivity”.19 Students often brag about the all-nighters that they’re pulling in order to manage the workload they have- this often comes in the forms of classwork, extracurriculars, student government, competitions, etc. The idea of being a part of everything on campus is seen as a paradigm for an “exemplary student”. Hence, students themselves refuse to take a break or acknowledge that their academic stress is unhealthy.

Thus, the academic burnout problem can be seen as a silent epidemic in India that needs to be addressed at an institutional level to ensure pro-active measures. Policy changes would allow for early and systematic intervention.

Policy Solutions to tackle Academic Burnout:

  1. Educational life is supposed to ready students for the work-life, thus, especially in universities, the teaching atmosphere imitates the work environment. One of the first policy change that needs to be addressed is the acceptance of long working hours in Indian society. This promotes the ideology of “not having a life outside work” and thus, it is common for people to go into work at 9 in the morning and not leave until 10 or 12 at night.20 This is recreated in educational institutes to prep the students for long work hours. However, data has shown that long corporate work hours also lead to depression.21 Therefore, the national policy about work hours needs to include the number of hours an employee must work per day. In light of the evidence presented above, this policy needs to account for both academic and work burnout. Hence, limiting both, educational institutes and workplaces to have an 8-hour work policy. This could possibly trickle down to academic institutions which would result in workload reduction for students and would also dispel the glorification of long working days. Moreover, this policy would have other benefits like both students and employees having a better quality of life due to an increase in leisure hours. This might also, in turn, boost productivity as happier individuals would be more keen and motivated to work. 
  2. There needs to be a national policy that mandates all educational institutes to have an appropriate number of counsellors on campus. This would allow for early intervention in a mental health crisis. Moreover, it would nudge students who don’t have a supportive background at home to seek help on campus. This could create a community in universities that acts as a safe space, allowing students to be more candid and vocal about their issues. In addition to this, the provision of counsellors and mental health aid would a) raise awareness about the cause, b) normalize feeling overwhelmed and thus, reduce stigma around workload anxiety, and c) it would disrupt the negative schemas built-in students’ heads when it comes to academics.
  3. There needs to be a national policy that mandates all educational institutes to hold sensitization workshops. These workshops should be used to address the interactions between professors, students, and work: they must delineate how professors give criticism to students about their work and the language professors use. Negative schemas are often built through constant use of negative language. For example, calling a student an idiot is not a productive critique, because it is not a qualifier for the work a student does. These workshops must highlight the negative mental health effects of defamation and educate professors on how to give constructive feedback.22 The workshops can also feature psychologists who could identify and explain the early identification signs of burnout to allow early intervention for students. This would be an expensive and ambitious undertaking. To offset some of the costs, government schools could partner up with various NGOs that provide mental health counselling for a nominal fee.
  4. The state government also needs to allocate more funds in the budget towards the mental health crisis in India and create a more holistic education pedagogy. A significant step towards the betterment of mental health in educational institutes was the implementation of the ‘Happiness Curriculum’23 in Delhi’s public schools. The Happiness curriculum encourages students to peruse and explore non-academic interests and avenues. The model is founded on the philosophy of Nagraj (1999) and O’Brien (2008), and it aims to cultivate sensory, momentary and deeper happiness in students. This curriculum reverses the punitive test-score driven narrative present in education and leads to more holistic student development.

National policy is the best avenue to address student burnout. European countries have responded to the burnout crisis through the implementation of national policies aimed at reducing burnout, as established by a study at Cornell University.24 Similarly, Australia mentions burnout as a part of the Australian Health and Safety at Work Act, and in Bulgaria, the National Health Strategy 2014-2020 aims to prevent burnout at workplaces.25 Thus, there is a case to be made that national policy is the way to instill institutional change.

Student suicide rates are not just a humanitarian crisis but it also has a significant economic cost. In his book, dying for a paycheck, Jeffery Pfeffer writes that “indirect costs from things such as disengagement, being physically present but not feeling well enough to do one’s best, and being distracted by stress are typically estimated to be about five times as large as the direct medical costs”. 26 He writes in the context of employees and company work environment, however, the same argument can be applied to students. If students aren’t present and engaged with their material, they won’t perform at their “peak”- this is supported by research that says that a human brain can only focus and be productive for 6 hours in a day.27 Moreover, there is an analogical brain drain happening due to the suicide epidemic, India is losing out on well-educated professionals which is depleting India of human resources.28 Thus, the urgency for a call for action is imminent- the discussion about burnout must enter the political discourse of the country.

The current educational environment in the country is detrimental to students’ mental health, and it is imperative for policymakers to address academic burnout. Burnout, as explored above is a consequence of unhealthy academic environments that do not consider the mental health degradation of students. Policies aimed at training and raising awareness about the cause, outlining work hours and increased public spending on mental health facilities can combat the problem at hand.


References:

[1]  Maslach, Christina, Wilmar B. B. Schaufeli, and P. Leiter Micheal , Job Burnout, (2001).

[2] Papathanasiou Ioanna, “Work-related Mental Consequences: Implications of Burnout on Mental Health Status Among Health Care Providers,” ACTA Information Medica 23, 1. (2015) 22-28. 10.5455/aim.2015.23.22-28

[3]  Ankita Mukhopadhyay, When Will India Address Its Student Suicide Crisis? (2019)

[4]  Lakshmi Vijaykumar, Suicide and its prevention: The urgent need in India (April 2007)

[5]  Swagata Yadavar, Budget 2018: India’s Healthcare Crisis Is Holding back National Potential. (2018)

[6] Swagata Yadavar, Budget 2018: India’s Healthcare Crisis Is Holding back National Potential,  (2018)

[7] European Union, 2018

[8]  Birla, Neerja Birla,  Mental Health in Inida: 7.5% of the country affected; less than 4,000 experts available,  (The Econimical Times, 2019)

[9]https://mohfw.gov.in/sites/default/files/Final%20Draft%20Rules%20MHC%20Act%2C%202017%20%281%29.pdf

[10] New privately funded universities still have a conversation around mental health, and might even have counsellors.

[11]  Birla, Neerja Birla,  Mental Health in Inida: 7.5% of the country affected; less than 4,000 experts available,  (The Econimical Times, 2019)

[12]  Ramanuj Mukherjee, Indian Education System: What needs to change? (n.d)

[13] https://www.weforum.org/agenda/2018/04/5-charts-that-reveal-how-india-sees-mental-health/

[14] https://timesofindia.indiatimes.com/blogs/minorityview/indian-parents-have-very-high-expectations-about-their-childrens-education-and-careers/

[15]  Rohan Keni, Why are Indian parents obsessed with science-related degrees, (Gulf News, 2017)

[16] Schemas: https://www.verywellmind.com/what-is-a-self-schema-2795026

[17]  Julie Scelfo, Suicide on Campus and the Pressure of Perfection, (New York, 2015).

[18] These stats by Forbes shows the happiest student population across the world: https://www.forbes.com/sites/duncanmadden/2019/03/28/ranked-the-10-happiest-countries-in-the-world-in-2019/#5e7b104648a5

[19] Jodi Clarke, How the Glorification of Busyness Impacts Our Well-Being, (June, 2019).

[20] https://www.hrkatha.com/research/indian-employees-put-in-longer-working-hours/

[21] Jodi Clarke, How the Glorification of Busyness Impacts Our Well-Being, (June, 2019)

[22] Personality attacks also lead to self-fulfilling prophecy which refers to the phenomenon of someone “excepting” a behaviour based on the social label that has been given to them. People tend to assume that the social label given to them is what is “expected” out of them and thus they act in a similar manner because they start identifying with it. This is significant in educational institutes as students start behaving like the personality attacks that are expected out of them. Thus, bright students might also start to believe that they are idiots : https://www.jstor.org/stable/1175727?seq=1#page_scan_tab_contents

[23] http://edudel.nic.in/welcome_folder/happiness/HappinessCurriculumFramework_2019.pdf

[24]   Aumayr-Pintar, Christine, Catherine CErf, and Parent Agnès Thirion, Burnout in the Workplace: A Review of the Data and Policy Responses in the EU, (2018)

[25] Read the document for more policy solutions. A tangent to this idea could be the fact that India needs a meticulous cross-state study to outline and understand the different kinds of burnout faced by students. As the article mentions above, students from the happiest student population situates itself in these European countries- thus, there is a clear correlation between pro-mental health policies and a happier student population.

[26]  Jeffer  Pfeffer, Dying for a Paycheck: How Modern Management Harms Employee Health and Company Performanceand What We Can Do About It, (New York, 2018)

[27]  Travis Bradberry, Why The 8-Hour Workday Doesn’t Work, (June, 2016)

[28] Also referred to as ‘human capital flight’, brain drain is the departure of educated or professional people from one country, economic sector, or field for another usually for better pay or living conditions

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Satish Chander Gupta
Satish Chander Gupta
2 years ago

It’s a proud moment to see such an important issue taken up for study and solution thereof. I am impressed by the view point of the writer. Best Wishes for all success in helping students.

Shivani Arora
Shivani Arora
2 years ago

Congratulations Saru it is an excellent take on a pertinent topic. The alarming rates of suicide in India calls for a focussed policy.
(Social media addiction is increasing at an alarming rate, but no school or college curriculum talks about it. A policy to create Awareness about it may also be suggested to align the students towards the dangers of use . )
Again congrats on this thought provoking piece, I hope someone is listening.

Hemani Rawat
Hemani Rawat
2 years ago

The article is good. I would like to know more about the Happiness Curriculum. Thanks

Sangeeta Singh
Sangeeta Singh
2 years ago

I completely agree with the author Saru Gupta, that the priority list for policy makers should start with sensitising the support environment ,teachers, parents and society, to appreciate and encourage abilities other than the “traditionally” accepted ones. Also to encourage team work instead of promoting ” one upmanship” and a more discussion based explorative academic curriculum.
Policy changes are also needed for recruitment processes, where the emphasis is mainly based on numerically visible merits and not on out of box thinking and initiative taking abilities.

Anjul
Anjul
2 years ago

Congratulations Saru…very analytical and beautifully expressed….Today’s burning topic!! Bless u..Keep it up..

Sumit thomas
Sumit thomas
2 years ago

Well written article. Throws light on the developing critical concern.

Related Articles

India has successfully improved school enrolment in recent decades yet failed to deliver actual learning. The ASER Survey by NGO Pratham (2020) spotlights large learning deficits in students’ foundational learning. For instance, only 50% of Class V students can read texts of Class II level. More than half the students in Class VIII struggle to do simple division. The pandemic has deepened this crisis, especially because of the physical closure of 15.5 lakh schools that has affected more than 248 million students for over a year. These learning gaps are becoming critical with the emergence of the Fourth Industrial Revolution, which is emphasising digital technology, artificial intelligence and other allied technologies. Thus, it is integral to redefine education and structure it to suit the evolving technological transformation.

In response to this situation, the National Education Policy 2020 sounds like a clarion call to integrate technology at every level of education. It envisions the establishment of the National Education Technology Forum (NETF) to spearhead efforts towards the use of education technology. It recommended employing EdTech through app-based learning, online student communities, and lesson delivery beyond ‘chalk and talk’. By envisioning schools as nodal agencies, through which the underserved can access internet-powered devices, the NEP recognizes artificial intelligence (AI), virtual reality (VR), and blockchain as requisites in India’s education ecosystem. Thus, EdTech becomes a crucial link between enrolment and enhanced learning outcomes

CHALLENGES

The Indian EdTech ecosystem has a lot of potential for innovation. With over 4,500 start-ups and a current valuation of around $700 million, the market is geared for exponential growth — estimates project an astounding market size of $30 billion in the next 10 years. Eg. Byju’s, Unacademy. Despite the early implementation of technologies in the education system, India still faces teething problems.

Firstly, there are institutional obstacles. The lack of a dedicated unit to coordinate digital infrastructure, content and capacity building within the Education Ministry to look after the online learning needs of both school and higher education. Institutions need to be strengthened and made responsive to the evolving trends to ensure the dissemination of quality education.

Secondly, gender bias needs to be addressed as the gendered availability and access to technology and tools such as smartphones, laptops and internet connection is very common, especially in rural areas. Girls often face suspicion if they are demanding a phone. Education technology may not reach half of the population. A ‘Gender-Inclusion Fund’ should be set up to build the country’s capacity to provide equitable quality education to all girls and transgender students.

Thirdly, a wide digital divide. In India, the biggest obstacle to education technology integration is the prevalent digital divide and associated challenges of equity. Many view technology and associated opportunities as contradictory to equity and inclusion. Only 32% of the rural population are internet users. A national study carried out at the National Institute of Educational Planning and Administration showed the gaps in inclusive learning mediated by technology. A high level of urban-rural disparity in online classes was found. Not everyone who can afford to go to school can afford to have phones, computers, or even a quality internet connection for attending classes online. NSS data for 2017-18 showed that only 42% of urban and 15% of rural households had internet access. Thus, planning for education technology integration needs a broader lens of student diversity in contemporary campuses where a large share of students are from lower social strata (Scheduled Castes, Scheduled Tribes and Other Backward Classes and from poor households). Many are from government schools, under-developed regions, remote villages and urban margins. Bharat Net Project to connect all the 2,50,000 Gram panchayats in the country and provide 100 Mbps connectivity to all gram panchayats should be implemented. Opportunities provided by education technology can promote egalitarianism if access to technology is democratised and inclusion is institutionalised.

Fourthly, the pace of change & increasing cost makes it tough for marginalised communities to keep up with the rapidly changing technology. Even for private schools upgrading technology presents a major financial challenge, let alone government schools that are usually frequented by such groups. For harnessing full potential, the education curriculum and mode of instruction need to be aligned with technology tools. This requires increased governmental budgeting, planning, design thinking and improving teacher training.

Next, the resistance to change and low professional development hampering success. The lack of adequate professional development for teachers, who are required to integrate new technologies into their classrooms, are unprepared or unable to understand new technologies. Teachers and school leaders are comfortable with the status quo and often see technological experimentation as outside the scope of their job descriptions. School schedules often don’t have time for projects involving the use of technologies. Rigid learning and testing models are failing to challenge students to experiment and engage in informal learning. Integration of technology-based non-traditional classroom models, such as flipped classrooms and self-paced MOOC (massive open online course) are integral (suggested in NEP 2020).

Lastly, a very significant concern comes from the privacy risks associated with EdTechs. Since the pandemic hit, online education has replaced conventional classroom instruction. For learning customisation, apps collect large quantities of data from the learners (minor students). Private data collected can be misused or sold to other companies with no legal oversight or protection. It is necessary to formulate an ethics policy for EdTech companies. Issues of safety, confidentiality and anonymity of the user would be central to building a healthier learning ecosystem and ensuring the privacy of students.

WAY FORWARD

The true potential of EdTech will require collaborative efforts between the government, private sector, and NGOs. There is a need to realise that public educational institutions play an important role in social cohesion and building relations. Therefore, technology cannot substitute schools or replace teachers. Thus, it should not be “teachers versus technology” rather “teachers and technology”. 

Thorough mapping of the EdTech arena (scale, reach, and impact) is needed to bridge the digital divide at two levels – access and skills – is required to effectively use EdTech. Moreover, EdTech policy formulation and planning must align with other schemes (education, skills, digital governance, and finance). Fostering integration through public-private partnerships, factoring in voices of all stakeholders, and bolstering cooperative federalism across all levels of government is integral. The NITI Aayog’s India Knowledge Hub, Digital India Program, Government of India’s Aspirational Districts Programme on tech-enabled monitoring and implementation and the Ministry of Education’s DIKSHA and ShaGun platforms are great steps in the promotion of EdTech to transform India into a digitally empowered society and knowledge economy.

Learning from successful models as a repository of the best-in-class technology solutions, good practices and lessons from successful implementation must be curated. Some examples are:

  1. Grassroots innovation in EdTech –
    1. The Hamara Vidhyalaya in Namsai district, Arunachal Pradesh, is fostering tech-based performance assessments;
    2. Assam’s online career guidance portal is strengthening school-to-work and higher-education transition for students in grades 9 to 12;
    3. Samarth in Gujarat is facilitating the online professional development of lakhs of teachers in collaboration with IIM-Ahmedabad;
  2. International Cases –
    1. Mindspark, a computer-assisted learning software, delivers lessons through videos, games and questions on computers and tablets. The software analyses each student’s learning level, pitches content suitable for their level and adjusts the difficulty according to the student’s progress.
    2. Kenya’s literacy program Tusome, uses coaches equipped with tablets who visit classrooms, evaluate student reading skills, provide tailored advice to teachers and upload assessment data to administrators.

Author Bio:

Himanshi Bahl is a Political Science Graduate from the University of Delhi. Her research interests include emerging technologies and foreign policy.

References:

Kant, A. (2021, June 30). The future of learning in India is ed-tech. The Indian Express. https://indianexpress.com/article/opinion/columns/the-future-of-learning-in-india-is-ed-tech-pandemic-online-classes-7381782/

Malish, C. M. (2020, August 21). Technology as an enabler. The Hindu. https://www.thehindu.com/opinion/op-ed/technology-as-an-enabler/article32407777.ece

Mohammad Naciri & Atsuko Okuda. (2021, June 24). The gender technology gap has to end. The Hindu. https://www.thehindu.com/opinion/lead/the-gender-technology-gap-has-to-end/article34939814.ece

Vincent, V. (2021, May 13). EdTech needs an ethics policy. The Hindu. https://www.thehindu.com/opinion/op-ed/edtech-needs-an-ethics-policy/article34545004.ece

Introduction

​2020 has been a year of immense learning for policymakers across the globe. As Covid-19 unfolded, new social, political, healthcare, and economic challenges came to the forefront. W.r.t healthcare challenges, older adults remained disproportionately affected.1 The problems of the old have not received adequate attention in a young country like India. India is home to 134 million older people and by 2026,  this number is expected to rise to 173 million.2 The share of people above 60 years of age in India’s population stands at nearly 10% today and is rapidly growing.3 As fertility rates fall and a large proportion of the population ages, policymakers will increasingly face new challenges in terms of delivery of healthcare.

The government of India launched the National Programme for the Health Care of Elderly (NPHCE) in 2010-11.4 The NPHCE recognizes the deficiencies of the primary healthcare system and its inability to meet the long-term care needs of older people. It also recognizes the importance of the availability of care closer to the place of residence for older people given high levels of disability. Nevertheless, the policy limits healthcare provision for older people mainly to the existing healthcare settings. The proposal for home visits by trained healthcare workers is constrained by limited personnel. Besides, the regional diversity in demographics, economics, socio-politics is vast enough to call in question a universal policy solution. This clearly calls for policy debate on how to get effective solutions in place before the health of older adults turns from being a problem to a crisis. A decentralized policy option with an underlying principle of intergenerational solidarity is more likely to be efficient. A rural community-based, women-led, low-cost model, like the ones facilitated by Self-Help Groups (SHGs), can potentially be integrated with long-term healthcare services. We examine the healthcare needs of older people in India through the lens of demography and propose utilizing India’s social capital, in form of Self Help Groups (SHGs), to deliver significant components of healthcare to older adults.     

Key demographic trends in relation to healthy ageing in India

The policy challenges of the changing demographic structure of the world vary sharply between regions. For more affluent countries, where the problem of population ageing was detected earlier and social security nets were put in place, the key challenge remains allocation of resources fairly between and within generations. For the rapidly ageing developing regions though, resources are scarcer and institutions have a shorter time frame to adapt to the changing population pyramid. India is a case in point. 

“India has traditionally relied on multigenerational families to provide for the needs of older people.”5 Sathyanarayana et al draw attention to the increasing reversal of this trend. Particularly, rural and illiterate elderly women are likely to age alone, raising concerns about policy responses for their welfare.6 Also, analysis of morbidity shows an expansion of morbidity with ageing, starting as early as 45 years of age. 

Changing Living Arrangements

The Census (2011) showed that three out of four elderly people reside in rural areas. However, most of the health infrastructure is situated in urban areas.7 This creates a barrier to healthcare access for older adults. Sathyanarayana et al (2014) compared data from two National Family Health Surveys – first (1992-1993) and third (2005-2006). The proportion of single-member older adult households went from 2 percent to 5 percent and two member households with at least one older adult went up from 8 percent to 15 percent. Thus, more older persons are living alone or with a single caregiver. This increase accompanies a reduced proportion of total households with older adult members, which means that a lesser proportion of older people live with their family. The percentage of older adults living alone has gone up from 2.6 to 5 percent; with wide regional disparities. These trends indicate a disintegration of the multigenerational household, the legally obligated care-providers for older people in the country.8 A legal obligation to care falls short of addressing the capacity to care for the family. The care providers of old people are part of the 22.5 percent of the population living on less than 1.90 dollars a day.9 Financial constraints on providing long term care to older adults is significant. Moreover, India’s labour market is predominantly informal. The sector lacks comprehensive social security nets like old-age pensions and job security, which restricts time and finances for care provision. With a high prevalence of unskilled, high physical intensity, low-paying jobs, both the caregiver and the elderly workforce become disadvantaged in the present and the future. This also creates a vicious cycle of poor health and unhealthy ageing. Healthcare policies designed for rural areas, with a specific focus on the marginalized social classes, will thus be more helpful especially given the expansion of morbidity with ageing. 

Expansion of morbidity

Arokiasamy and Yadav draw attention to the exceptional rise in the non-communicable disease prevalence in older adults.10 Prina et al (2020) corroborate these findings with their assessment of Disability Free Life Expectancy.11 The lowest estimates for India were 11.5 years in men and 11.7 years in women. “With the concomitant increase in life expectancy at age 60 to 16.7 and 18.9 years for males and females respectively, older adults will thus live longer with chronic diseases”.12 The demographers also highlight early onset of morbidity, soon after 44 years of age.

While developed countries have seen a clear shift from infectious to chronic diseases, India faces a dual burden of disease.13 The pattern is reflected in the older adults’ disease patterns too, with significant morbidity associated with infectious diseases and their sequelae.  In the face of high morbidity, questions about availability, affordability, and access to long-term care services for older adults in India beg discussion. 

Availability, access, and affordability of healthcare in India 

In addition to physical barriers to healthcare access, mobility issues and distance to the healthcare system; older adults in India face significant social barriers. As Dey et al highlight in their study, gender, religion, caste, socioeconomic status, stigma impede access to healthcare for older adults.14 While availability and quality of care vary widely among regions; older people, in general, receive less care commensurate to their level of morbidity even where available. Affordability of healthcare was an additional access barrier. With only 15 percent of the population covered under insurance, resulting in 62 percent expenditure on health coming from out of pocket payments.15 Such over-reliance on out of pocket payments creates impediments for access to quality healthcare, especially for the marginalised sections of communities.  Let’s take the health of older women for instance. ‘Feminization of the older population’ is a prevalent phenomenon across the globe. This is more apparent in rural India. The rate of homebound older people is approximately 70 per 1000 persons in India, and even higher for women.16 Despite reporting worse health, older women are less likely to be hospitalized. A patriarchal society, accumulation of malnutrition, and life-long poverty compounded by high morbidity pose challenges to healthy ageing of Indian women. 

While many have to continue working in their old age, their incomes remain meagre. One in three elderly people lives below the poverty line, with another one living just above the cut-off of the poverty line.17 Social security in India is inadequate. The state pension scheme is not universal. Even among expected beneficiaries, less than 10 percent receive assistance.18 Moreover, rural to urban migration of youth leaves older parents more vulnerable. As Sinha and Batniji point out, “At times of illness, people on low-incomes in general often respond by foregoing their children’s education, selling limited assets (including those used to make a living), borrowing from informal sources at exorbitant rates, or foregoing medical treatment.”19 An average rural older adult can thus expect to live with higher morbidity and multiple chronic conditions miles away from quality healthcare, which also happens to be out of her budget. 

Trends in Policy Response to Ageing in India

India first formulated a National Policy for Older Persons in 1999.20 The NPOP aims to ensure healthcare, financial, and social well-being of older people. It also focuses on the feminization of ageing and the importance of intergenerational solidarity. It puts the onus on individuals and families to ensure “healthy” ageing with minimal state intervention. While the policy document quotes the changing demographic structure to emphasize the importance of population ageing, it fails to look beyond aggregate numbers or take into account major factors which interact with demography and shape the experience of ageing. 

The policy attributes challenges of ageing to the breakdown of families. The homogenization of ageing and its challenges forecloses a proper role for the state to take in designing welfare policies. To quote from the policy, “Welfare is intended primarily for the extremely vulnerable elderly who are disabled, infirm, and chronically sick and without any familial support” (NPOP, 1999). The national policy centres on the highly debated idea of successful ageing, putting the onus of care on individuals and extending it to families. The concept of “successful ageing” has been heavily criticized as it fails to account for differences in socioeconomic status and gender disparities, thus decontextualizing individual choices towards “healthy ageing”.21 With the breakdown of multigenerational households and a vicious cycle of poverty, neglect and poor health in old age, this approach of completely relying on families without offering extensive state support seems more and more unfeasible. 

With recommendations made in the National Policy on Older Persons (NPOP) as well as the responsibility of the Government under the Maintenance & Welfare of Parents & Senior Citizens Act, new changes were suggested. It stated that older individuals in rural areas and older women require more attention and medical technology needs to be factored into the ageing policy. The suggestions fall short of addressing challenges of the feminization of the older population, and an increasing role of the state. Besides, medical technology and assistive devices have influenced the population ageing much less than the existing gender, regional, income, and class disparities. The National Program for Health Care of the Elderly (NPHCE) is based on the objectives of the National Policy for Older People. Similar biases are thus reflected in the  NPHCE model. The NPHCE clearly outlines promoting “healthy” or “active” ageing in a “society for all ages” as its vision. Its specific objectives include easy access to health promotion, disease prevention, and curative and rehabilitative health services for older people. Its proposed strategy includes home health visits, dedicated services for elderly at all levels of the healthcare system, training of healthcare workers, and Information, Education and Communication (IEC).  However, there are some serious limitations to the stated objectives.

First, the policy fails to account for existing patterns of healthcare-seeking in rural India where most older people live. As Das et al. identify most of the healthcare in villages is provided by informal, untrained private providers.22 Second, even if the existing healthcare workforce is trained, the urban-rural ratio of health workers remains 3:1 with three doctors in urban areas for each one in a rural area.23 The policy thus fails to address the basic problem of access to healthcare, which is further complicated in the case of older adults as explained previously. Third, if the problem of access is solved, the challenge of affordability remains. The limited budget allocated to healthcare focuses more on maternal and child-care services.24 Households with older adults thus spend 3.8 times more out of their pocket to meet healthcare needs. This spending is catastrophic for poorer elderly households).25 Alternative approaches can thus be explored to deliver healthcare to older people, especially in rural areas. We suggest Self-Help Groups, already existing in rural areas, as possible delivery points of healthcare for older adults. 

We base our proposition on harnessing the principle of social capital in rural India, which has been effective in successful microfinance interventions for decades. Self-Help Groups can provide an alternative to deliver parts of the NPHCE in rural areas under the budgetary, social, and geographical constraints. The suggested policy response does not come without limitations, which are also discussed below. 

Self-Help Groups for Rural Healthcare Delivery: A Possibility

Microfinance is the provision of capital in the form of small loans, savings opportunities, insurance, and similar products designed explicitly for the poor has been a debated strategy to reduce poverty. The Ministry of Finance supports providing microfinance to self-help groups of older persons so that they can undertake income-generating activities.26 Microfinance programs in several instances have bundled health education or insurance towards better public health and increased profits. No program has tested health promotion or basic healthcare service delivery to older adults through microfinance groups. Self-Help Groups (SHGs) of younger people can be trained and supported for rural healthcare delivery tailored towards older people. Moreover, as Sinha and Batniji point out microfinance is more suited to address basic health and disability care needs; two of the most important healthcare needs of older people. 

Haldar and Stiglitz provide a theoretical basis to the debate, experiences, and a way forward for microfinance. The concepts of “social capital” and “institution” are of specific value.27 The economist duo looks at institutions as “emergent and localized reactions to collective action problems”. Designing long term care is heterogeneous and it needs local responses.  In this scenario, microfinance can be looked at as a potential  opportunity for policymakers. The confidence in the effectiveness of microfinance for successful rural ageing stems from its reliance on “social capital” to be successful. Social capital sees individual well-being “closely related to connectedness, and maintaining the affection and respect of those with whom one is closely connected, as an essential aspect of advancing an individual’s own sense of well-being”. The authors trope that non-reliance on social capital played a major role in the failure of microfinance institutions to help broadly define how microfinance can be utilized for healthy rural ageing. We emphasize on Self-Help Groups as women provide most of the caregiving needs across the world. 

Incorporating SHGs in rural ageing is in line with the social trends of a rural area. A strong sense of community, relatively strict divisions between social classes and social capital as described above can ensure effective delivery of healthcare interventions. Lorenzetti et al. state, “The leading microfinance institution Grameen Bank’s preconditions for loaning under microfinance include- all members must be “poor”, live close to one another in the village, have no blood-ties, and be from roughly similar economic conditions.28 Achievement of such homogeneity can help deliver culturally appropriate and accepted healthcare.” For instance, health promotion in older adults is a major focus of the NPHCE.29 Based on the Census (2011), the literacy rate is 39.8 percent for the oldest age cohort. This varied from 22.2 percent in Jammu and Kashmir to 76.9 percent in Kerala. As younger cohorts have higher literacy rates and are embedded in the social fabric of the community, health promotion interventions through SHGs will likely be more effective for older cohorts. Indeed, interactive sessions on HIV/AIDS, prevention of non-communicable diseases, water, and sanitation have been effective through this approach in India, Ghana, and Peru. Sessions for fall prevention, urinary incontinence, and information regarding available social schemes can be accomplished through the SHGs. Thus widening the availability of healthcare for rural older adults. 

The largest proportion of healthcare expenditure in India relates to the purchase of drugs. With the expansion of morbidity mostly driven by non-communicable diseases, long-term medical management of the condition is an essential and costly affair for progressively impoverishing rural older adults. Micro-franchise distribution of affordable, essential drugs can address some of these access to healthcare challenges. With the potential to be adapted to each setting and the decentralized nature of microfinance, it can increase the uptake of healthcare in the most marginalized of older adults. Approach to healthcare for older adults has traditionally been “holistic” and “team-based”. The same approach, supported by the principle of social capital in rural communities, can help provide appropriate healthcare to older adults. 

Critique of microfinance stems from the evaluation of interventions failing to demonstrate growth in income or gender empowerment. The microfinance crisis in the state of Andhra Pradesh in India,30 where  57 microcredit debtors committed suicide in 2010, is not lost on the writers.31 As Haldar and Stiglitz’s (2014) analysis of the failure of the model of microfinance points out, the flaws can be overcome with adherence to limited profit margins, the essentiality of social capital, and strong vertical and horizontal ties at all levels of the institution. With the Malegam committee’s proposal for a regulation of the microfinance sector, the risks of another crisis can be reduced.32 The essay does not advocate decontextualized use of microfinance; for example, the bundling of health insurance with a separate loan.33 It rather advocates a community-based approach to rural healthy ageing, delivered not by a single healthcare worker under a state-dependent structure, but developed, financed, and led by the community itself. If designed properly, microfinance backed Self-Help Groups may change the healthcare of rural older adults for the better. Especially in current times, given the restrictions to healthcare access and employment opportunities the Covid-19 pandemic has imposed, traditional financing and healthcare setups need the support of non-traditional ones, like microfinance to protect the interests of  the most disadvantaged. 

Conclusion 

Population ageing is a process and will continue to pose a challenge to income security, work and retirement, health, and social care policymaking. This is magnified in the context of ageing in India, which is heavily populated with a predominantly informal economy, near absence of social security, and wide disparities in public health and healthcare systems. With the constraints on the younger population, a more responsive rather than punitive system will likely benefit the ageing population most. With changing family structures, the country needs to expand social security for an ageing population with context-relevant, decentralized measures. Foremost, it is important to collect and analyze good quality data on demography to facilitate policy making. To reverse trends in the expansion of morbidity, the newly introduced healthcare program for older adults needs to redirect its resources where the morbidity lies – in rural, feminized, deprived populations of older adults. Provision of healthcare for healthy rural ageing through Self-Help Groups can be explored as a contextually relevant, decentralized, low-cost option for better health outcomes.

The views expressed in the post are those of the author and in no way reflect those of the ISPP Policy Review or the Indian School of Public Policy. The picture on the header for this article has been clicked by Umesh Jadhav. Other images via open source.

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Public administration is a socially embedded process of relationships, dialogue, and action. The field of public administration straddles an academic component and action component, with each one significantly influencing the other. Both components seek to promote the welfare of the people in the larger context of a welfare state. Public administration, as the action arm, is situated firmly in the context of the state and therefore, strongly influenced by its nature and priorities. This has led to various re-inventions of public administration against the backdrop of social ferment and the nature of the state. For example, the new public administration movement rose in the 1960s in the face of American societal turmoil (John F. Kennedy was assassinated in 1962, the USA lost the Vietnam war, Martin Luther King, Jr. was assassinated in 1968). Another example is that of the new public management movement in the 1980s in the face of an inefficient state and creation of global interlinkages. This gives reason for one to believe that the ongoing Covid-19 crisis, being labelled the worst economic crisis since the Great Depression of 1929, will cause major shifts in the nature of the state and by extension the nature of public administration.

Public administration as an academic discipline has traditionally responded to problems in Anglo-American societies. With the USA and Europe, being ravaged due to Covid-19, one can probably expect the following changes in the academic discipline of public administration.

Public Administration to Fix the Broken State

The financial stress being felt by most European countries, such as Italy, and the United States points to the bloated structures that are running huge deficits. The world’s largest economy, America’s budget deficit hit $3.1 trillion because of the coronavirus spending surge. The American state’s inability to rein in the crisis leading to massive costs to human lives points to a broken public administration system. The re-emergence of Neo-Taylorism in this context seems inevitable. The issue is to figure out how to ensure maximum governance with  minimum government expenditure.

Re-emergence of the State

The re-emergence of the state or dependence on the state was visible in most democracies, including India. The arrival of Covid-19 saw many private hospitals being ordered to operate and provide Covid-19 tests and treatment at affordable prices by the state. State control, however, was not limited to providing services; it also imposed strict restrictions on movement in order to curb the spread of the virus. On the other hand, the failure of the American state to control the spread of Covid-19 has exposed the hollowness of a minimal, corporate state. Ronald Reagan’s dictum, “Government is not the solution. Government is the problem,” has been challenged by Covid-19. The administration has since intervened to enforce social distancing norms and provide financial support to vulnerable citizens. Distributing Stimulus checks is one such attempt of the State. America’s Internal Revenue Service distributed stimulus checks up to $1200 to millions of Americans. This was an attempt to bring the economy back to life. The results of this experiment could very well herald the next big paradigm of the discipline. Success could lead to an intellectual consensus towards a proactive state that is reminiscent of the New Public Service of yore, with a focus on democratic governance. Failure could lead to a re-emergence of demand for a state that is more efficient and less fiscally profligate. Either way, the consensus would favour a state that has significant responsibility towards serving its citizens rather than trying to satisfy them as consumers.

Re-assertion of Sovereignty and the Associated Role of Bureaucracy

The de-globalization movement has been picking up steam since the mid-2010s. Covid-19 could be the final nail in the coffin for the globalization frenzy that began in the 1990s. This could lead to stronger national boundaries for people as well as the flow of data, Internet Protocol, etc. Global Governance Institutions like the World Trade Organization, World Health Organization, G20, etc. seem to have been rendered ineffective due to the de-globalization rhetoric and evolving geopolitical rivalries. The significance of WTO will further reduce with declining trends in global trade and the US-China trade war. The World Health Organization helped in evolving guidelines at the beginning of the pandemic, however, as time passed countries enacted their own operating procedures. The European experiment is also facing stress as member states choose to assert sovereignty rather than pooling their resources. As per European Council on Foreign Relations data, 29 percent of the respondents (grouped as “Do-It-Yourself”) believed that after the crisis, geopolitics will see greater self-dependence across nations.

This has major implications for the bureaucracy that would have to adapt to new situations. There would include – limits on bureaucratic power in negotiating with other countries; emergence of newer methods of negotiation and diplomacy at global platforms; and restructuring of processes that have so far been outsourced. The result would be a public administration which is greatly influenced by its domestic ecology and an altered politics-administration balance. It must then build capacity across institutions within this fundamentally altered ecology. How would the corridors of power change and the players inhabiting them respond? This will be an interesting development to observe during the approaching distribution of Covid-19 vaccines. The time ahead is truly interesting and one that will put the efficiency of public administration to test.

The views expressed in the post are those of the author and in no way reflect those of the ISPP Policy Review or the Indian School of Public Policy. Images via open source.