WITH an estimated four per cent of the population above the age of 65, and a whopping 56pc in the 0-20 age bracket, Pakistan is definitively a youthful country. Yet, UN projections indicate that by 2045 the 65-and-above population will stand at 7pc, with the number of such elderly doubling to 40 million by 2050.
With no tradition of old-age homes, and minimal attention given to geriatrics except at the largest public and private hospitals in this country’s bigger cities, the question is how will we meet the health (and other) needs of our ageing population as life expectancy continues to rise?
Currently, Pakistan predominantly relies on co-residence with family and kin for elderly care. With most of the aged that co-reside living with their sons, provision of care extends from fulfilment of financial needs to health as well as emotional needs. While most of the tangible transfers occur from the younger to the older generation, there is reciprocity — especially with regard to childcare for working couples, and at the emotive level, given the culture of respect accorded to the elderly.
Shifts in age demographics, family structures and migration patterns may see the aged population being left behind.
However, falling birth rates and rising life expectancy rates have increased the dependency ratios of the elderly. With fewer children per couple, and increased pressures of migration, elderly co-residence is exhibiting a modest decline in its trend. Similarly, urbanisation may well lead to a breakdown of traditional norms — as workers become increasingly mobile and ‘extraneous’ cultural forces lead to a greater valuation of privacy, we may well see a substantial shift towards nuclear rather than joint family systems.
In fact, a look at national level data suggests that co-residence of elderly with their sons is lower in rural as compared to urban Pakistan, suggesting that rural to urban migration may see the elderly being left behind. Here, though, wider familial and kin networks may be stepping in to fill the void left by their offspring.
At the same time, we also find that the proportion of elderly living with one son has increased with time. Hence, rather than earlier trends of multiple sons living together, we are now witnessing one son providing the major portion of care for elderly parents.
So, already, we are seeing some shifts in co-residence patterns.
And while this would certainly lead to lower emotional support provided to elderly parents, we could well see a substitution of financial for emotional support through remittances being sent in. In fact, the data does show that household level remittances are slightly higher when elderly family members do not co-reside in a household. Yet, internal and external remittances sent to parents from non co-resident offspring may begin to dry up or become insufficient relative to the needs of the elderly, who will live ever longer.
There are economic reasons to expect such transfers to become insufficient with fewer sons, and parents requiring larger lifetime transfers. In particular, as life expectancy continues to climb, people may be pushed to reallocate toward accumulating higher savings for their own retirement, as opposed to giving transfers to parents.
The economic pressures surrounding co-residence are evident when we consider how income relates to co-residence patterns. While poorer households see higher incidence of elderly living with sons, middle-income households see fewer such arrangements, perhaps because their financial need is less pronounced. Richer households — which not only have the means to support older parents but are also more likely to see their women working — are again more likely to see elderly co-reside who, in turn, provide valuable childcare support.
Similarly, higher elderly income is seen to go hand in hand with lower co-residence, while widowed elderly tend to live with their children a lot more than those who are married. Both these factors suggest that the elderly value independence to the extent that they can afford it, and look for emotional and other forms of care from their children in the absence of spousal support and financial means.
All of the above suggests that there is most definitely a role for the state to play.
As Pakistan sees greater economic development, we will likely witness more independent living and a deterioration of inter-generational ties. With a shift in cultural values as well as greater economic pressures on the younger generations, care of the elderly who see high levels of poverty will invariably suffer — unless provisions are made for by the state.
There needs to be systematic identification of the needs of the elderly. Here, social security, health insurance, quality of public services, old-age homes and geriatrics units in hospitals all matter.
For instance, geriatric diseases such as memory dysfunction, Alzheimer’s disease and orthopaedic issues require training and recruitment of specialist doctors in the public sector, with incentives also being provided for the private sector. The distribution of such services across the whole country, in both rural and urban areas, is especially important.
Similarly, community centres where trained workers provide care and counselling services also need to be established. Since loneliness tends to be a major issue among the elderly, lessons could be learned from more developed Western European nations that pair day-care facilities and elderly centres together.
Finally, the taboo against old-age homes needs to be tackled. Rather than the current practice of the elderly living alone when they can afford it, but still battling loneliness and, worse still, abandonment and subsequent residence at centres such as those established by Edhi, we should be looking to establish state-sponsored old-age homes. Here, the needs of both who wish to be in such homes, as well as those who are forced by their circumstances, must be catered for. This will become especially important as our population gradually ages, and economic pressures on younger individuals see a drying up of private funds for the elderly.
Hadia Majid is assistant professor of Economics at Lums. Sonan Memon is finishing up his BSc in economics from Lums.
Published in Dawn, February 19th, 2018