According to World Health Organization (2018) the proportion of population over 60 years will double from 12% to 22% between 2015 and 2050, and by 2050, 80% of the ageing population will be from low and middle income countries (LMICs). In Pakistan, the elderly population is projected to increase to 43.3 million by 2050. At present, the geriatric population constitutes approximately 14 million of the total population. Youth development has remained a major focus for many economic initiatives but without consideration to the overall demographic changing patterns in the Pakistani society, policies related to economic growth will remain narrow and simplistic.
The geriatric population occupies a unique position in the Pakistani society due to its collectivistic nature. The elderly have been safely anchored within a typical Pakistani household. Traditionally, they have occupied a revered position in the society due to social and religious norms governing respect of the elderly. The elderly, once they move out of the formal labour force, have tended to remain the central figure in households, with younger generations relying on them for advice, particularly in rural areas. In urban areas, the elders in the household tend to be an informal source of economic labour. As an example, they assist in taking care of their grandchildren, running the households and errands particularly as more middle class households have women joining the formal labour force.
These demographic and societal shifts play an important role in planning for the future development of the country. The reality is that the population of the elderly will continue to grow, with the geriatric population continuing to age due to the marvels of modern healthcare, with an increased life expectancy. At the same time, they will also have rising healthcare needs due to the increase in non-communicable diseases such as diabetes and hypertension and associated chronic conditions such as cardiovascular diseases. Ageing is also associated with frailty which requires management, the source of which often comes from within the household. As they age, individuals will require support not only in Instrumental Activities of Daily Living (IADLs) such as managing finances and transportation but also essential Activities of Daily Living (ADLs) such as walking, feeding, grooming, bathing and transferring.
Typically, such activities have been performed by ‘informal’ groups such as those within the family who will not be financially remunerated for the work they perform. Much of this support comes from the women within the household which could include daughters, daughtersin-law, sisters and wives. Between 2018 and 2019, I conducted a study with women including daughters and daughters-in-law who were taking care of the elderly within their households such as parents and parents-inlaw. I explored lived experiences of women belonging to upper socioeconomic strata using in-depth interviews with these women. The study was motivated partly since there are no qualitative explorations on this topic from within Pakistan and those using quantitative measures use the lens of ‘caregiver’s burden’ to determine experiences of informal caregivers.
In Pakistan, the use of the word, ‘burden’ to describe the experience of caring of a family member can be considered pejorative which is why ten women I interviewed did not use the Urdu equivalent, ‘bojh.’ While limited in its scope due to the socioeconomic strata of the study participants, the study shed light onto some important areas that require meaningful thought as we plan ahead. Women generally form the pool of caregivers but in certain socioeconomic strata, there is hired help to do the basic tasks. However, this formal help comes at a high cost. The cost tends to be shouldered by the men in the households but the emotional labour and managing the help remains strictly the domain of women. This occurs even when women work outside the home, but with significant strains on their career development as well as their mental health. This phenomenon of course can be attributed to the gender stereotypes which associate care work with women since they are considered to be more ‘nurturing,’ a common belief that my study participants also shared. When asked about provision of formal old age homes, study participants believed that the elderly are supposed to stay in the household since they are considered a ‘blessing.’ In general, old age homes are looked down upon and stigmatised by the Pakistani society, at least within a certain socioeconomic strata.
However, an important aspect that came to surface is that this is likely to change in the future. As more women join the workforce motivated in particular due to the rising living costs, the caregiver pool will continue to become restricted. For families with modest means, financial access to formal help will also not be possible. Another issue that is likely to crop up, as evidence from India, with similar sociocultural norms shows, is that increasing rates of emigration within the younger age group mean that the elderly may just be left behind.
Another growing area of concern is the incidences of elderly abuse that have been reported. Literature from within the Pakistani context shows that elderly abuse is on the rise although no nation-wide studies have been taken that can validate this claim. However anecdotal evidence suggests that this occurs translating into poor quality of life for adults.
At the same time, limited safety net exists for the elderly in the form of governmental support. Global Age Watch Index (GAWI), an international organization analyses international data on socioeconomic well-being of older population looking at income security, health status, employment and education and enabling environments. Pakistan’s overall rank was 92 out of 96 in 2015, which is quite low. As there are hardly any systems in place for government pensions, income security will continue to pose a major challenge for a large part of the elderly population. Moreover, the healthcare system is hardly equipped to do its task for managing the unique physical and mental health needs of the elderly. Over the age of 70 years old, dementia, a mental health disorder, rapidly increases but number of mental healthcare professionals including psychiatrists and therapists remain low in the country. This creates a significant void in attending to the healthcare needs of the elderly.
And for those elderly who get left behind as the collectivistic nature of the Pakistan society gradually breaks down, as more young couples choose to live in nuclear households as opposed to joint family especially in urban areas, or those who move abroad for economic prosperity, little or no safety net exists. There are very few old age homes, and their quality remains abysmally poor with inadequate service provision and overcrowding considered to be major issues. As family systems evolve, and economic patterns change, the government cannot rely on the existing system for elderly care provision; rather it needs to take a more proactive role in shaping the safety net for the elderly populations of the future.
The writer is Assistant Professor at CBEC, SIUT Karachi
