Health Conditions,Medication and Hospitalisation Preferences of Elderly in Kerala

Abstract

This article intends to study the health conditions, medication and hospitalisation preferences, and the determinants of medication preferences of the elderly population in Kerala. It is based on the primary data collected from a sample of 801 households and three old-age homes (OAHs) in three districts of the state, namely Kozhikode, Ernakulum and Trivandrum. The evidence suggests that the elderly population are vulnerable to various chronic diseases and they tend to spend more on healthcare. In the absence of public provision of effective healthcare services in Kerala, the elderly spend out-of-pocket on health expenses and choose private hospitals for effective and better treatment. However, those who prefer government hospitals mostly belong to poor and marginalised groups, including the inmates of OAHs. With regard to the type of medicines, the elderly often prefer Ayurveda and Homeopathy to Allopathy medicines. Based on these findings, we suggest that the government intervention in terms of more health care facilities and health insurance schemes for the elderly is necessary to improve their quality of life.

Keywords

Elderly health conditions medications social security Kerala

Introduction

The elderly population percentage (12.3%) is rising because of falling of both mortality and fertility rates across the countries of the world (Biswas, Kabir, Nilsson, & Zaman, 2006; Chakrabarti & Sarkar, 2011; Moe, Tha, Naing, & Htike, 2012). The number of people in the age group 60 years above is projected to grow by 56 per cent from 901 million to 1.4 billion during 2015 and 2030 and a further 2.1 billion by 2050 (United Nations Development Programme, 2015; World Health Organization, 2010). The Indian economy is also expected to become an ageing society as the number of the elderly population is likely to increase massively (Gupta & Sharma, 2018; Husain & Ghosh, 2011; Mehrotra, Parida, Sinha, & Gandhi, 2014) by 2050. Among the states of India, Kerala is likely to become the first ageing society, as it has already had the highest proportion of the elderly population (12.6%). This proportion is expected to increase to 18.3 per cent in 2026 (Singh, 2013).

A review of earlier studies shows that the countries that have turned into ageing societies also recorded the rising incidence of diseases (Alam, 2009; Angra, Murthy, Gupta, & Angra, 1997; Gulati & Rajan, 1999; Huang & Lin, 2002; Imai & Soneji, 2007; Jha et al., 2006; Kosuke, & Samir, 2004; Kumar, 2003; Kumari, 2001; Prakash, 1999; Shah & Prabhakar, 1997; Shrestha, 2000; Smith, 2004; Sugathan, Singh, & Hasni, 2014; Visaria, 2001) and hence, have experienced a surge in their private and public healthcare expenditures (Alam & Karan, 2011; Carreras, Ibern, & Inoriza, 2018; Chi & Hsin, 1999; Geue, Briggs, Lewsey, & Lorgelly, 2014; Gupta, 2009; Langford, 1964; Zweifel, Felder, & Meiers, 1999).

The rising burden of private (out-of-pocket) healthcare expenditure has implications on the incidence of poverty and financial insecurity of the elderly population as a whole (Abdulraheem, 2007; Ayyagari, 2015; Bourne 2009; Falaha, Worku, Meskele, & Facha, 2016; Ladha et al., 2009; Moe et al., 2012; Mohanty & Srivastava, 2012; Pal & Palacios, 2011; Prasad, 2007; Selden & Banthin, 2003; Shukla, Ahmad, Brajesh, Anand, & Ranjan, 2017; Smith, 1999; Waweru, Kabiru, Mbithi, & Some, 2003; Zweifel et al., 1999).

Since the state of Kerala has also recorded massive increase in the incidence of diseases, and thereby a rise in the private expenditure on healthcare (Gulati, 1993; Prasad & Beena, 2008; Rajan, 2007; Rajan & James, 2007), a study on elderly health and living conditions is important. Particularly, a context in which societal and family setups are changing due to structural transformation and globalisation, a comparative analysis of the elderly living with family members and at old-age homes (OAHs) is necessary.

This article is organised into five sections. The second section explains the data and methodology of our study. First, it explains the data collection methods, sample size, the socio-economic and demographic profile of the study area. Moreover, it provides various indicators and econometric tools used in the study. The third section provides findings based on descriptive statistics. It consists of two subsections: the first subsection explains the health conditions of elderly living in family and OAHs, while the second subsection provides their healthcare expenditure patterns. The fourth section provides econometrics results and discussions. It explores the factors determining medication and hospitalisation preferences of the elderly in Kerala. Finally, the fifth section concludes the article along with a discussion on policy measures.

Data and Methodology

The study is based on primary data. A stratified random sampling method is used for the collection of primary data. First, Kerala is divided into three major regions,¹ namely North Kerala, Central Kerala and South Kerala. One district from each of these regions, that is, Kozhikode (from North Kerala), Ernakulam (from Central Kerala) and Trivandrum (from South Kerala) has been selected. From each of these districts, one taluk is randomly selected (using the lottery method). From each of these selected taluks, one rural village and one urban ward are selected randomly. Given the total households of each selected village (and wards), the number of sample household is decided using normal distribution criteria (using 90% confidence interval criteria). The details of sample districts, taluks and villages, as well as the sample size, are given in Table 1. Out of a total of 53,144 households, only 801 households were surveyed with a pre-tested interview schedule. The information on demographic and socio-economic details along with indicators on health conditions, medication and hospitalisation preferences of the elderly are collected. A total of 1,075 elderlies from household surveys (354 from Kozhikode, 342 from Ernakulam and 379 from Trivandrum) have been interviewed in detail.

Table 1.

Sampling Details

District	Trivandrum		Ernakulam		Kozhikode
Village/Ward Name	Urban Ward	Rural Village	Urban Ward	Rural Village	Urban Ward	Rural Village	Total
Village/Ward Name	Attingal	Chirayinkeezhu	Kothamangalam	Varappetty	Vadakara	Onchiam
Census households village/ward wise	9,768	7,155	9,663	4,482	15,787	6,289
Census households of the selected villages (taluk total)	16,923		14,145		22,076		53,144
No. of households to be surveyed²	267		266		268		801
No. of households to be surveyed from each³ of the selected villages/wards	154	113	182	84	192	76	801

Source: The authors.

Moreover, this primary survey is supplemented by a survey of three OAHs in the sample districts, based on their location. One OAH from each of these sample districts has been selected purposively. The inmates (elderly) and the owner/manager of these OAHs have been interviewed with a structured interview schedule. This survey is designed to collect information on the socio-economic and demographic details, occupation, living arrangements, health status, psychological conditions, dependency status, social security and so on. A total of 78 elderlies living in the OAHs (41 from Kozhikode, 16 from Ernakulam and 21 from Trivandrum) have been interviewed personally and in detail. Moreover, in each of these OAHs, we have conducted focus group discussions (FGDs) to collect supplementary qualitative information.

Socio-economic and Demographic Profile of Selected Districts

Kozhikode

The district Kozhikode is situated in the northern part of Kerala. As per 2011 census, total population of Kozhikode is about 2 million. This district tops in the rank of most elderly populous districts in the northern region of Kerala. This district has three taluks, namely Vadakara, Quilandi and Kozhikode. The Vadakara taluk is randomly selected for our primary survey.

Ernakulam

The district Ernakulam is situated in the central region of Kerala. It possesses the highest number of elderly population among districts of central region. It is one of the most industrially advanced and flourishing districts of Kerala. It is also the highest revenue yielding and richest district in Kerala in terms of per capita District Domestic Product (income). It contributes 42 per cent of the total state revenue. It has seven taluks, namely Kunnathunad, Aluva, Paravur, Kochi, Kanayannur, Muvattupuzha and Kothamangalam. The taluk Kothamangalam has been selected randomly for the primary survey.

Thiruvananthapuram

The district Thiruvananthapuram stretches along the seashore with a distance of 78 km. It is situated in the southern region of Kerala. It has four taluks, namely Chirayinkeezhu, Nedumangad, Thiruvananthapuram and Neyyanttinkara. The taluk Chirayinkeezhu has randomly been selected for the primary survey. The detailed demographic and socio-economic profile of selected districts is given in Table 2.

Table 2.

Socio-economic Profile of Selected Districts in Kerala, 2011

Socio-economic Indicators	Kozhikode	Ernakulam	Trivandrum
Year of formulation of the district	1 January 1957	1 April 1958	1 July 1949
Geographical area (sq. km)	2,345	3,063	2,192
Population	3,086,293	3,282,388	3,301,427
District population as per cent of total population of the state	9.24	9.83	9.88
Percentage of Hindus	56.21	45.98	66.46
Percentage of Muslims	39.24	15.67	13.72
Percentage of Christians	4.26	38.20	19.10
Elderly population	235,976	450,794	429,431
Percentage of elderly population	5.63	10.75	10.24
Density of population	1,316	1,072	1,508
Literacy rate (%)	95.24	95.68	92.66
Sex ratio	1,097	1,028	1,088
Infant mortality rate	17.67	8.22	12.13
Work participation rate (%)	30.7	38.1	37.3
Life expectancy	66.62	70.1	68.33

Source: Census of India (2011).

Econometric Methods Used

Both descriptive statistics and multivariate regression models are used in this study. To explain health status—health expenditure, socio-demographic characteristics, medication and hospitalisation preferences of the elderly population; both cross-tabulations and percentage figures are used. For comparing the health expenditure by various groups, we have plotted the kernel normal density plots. Apart from these, to find out the factors determining the medication and hospitalisation preferences of the elderly population, we have run multinomial logistic regression models. The estimated regression coefficients along with their marginal effects (dy/dx) and z-statistics are given (see Table 3). In this regression model, we have controlled various socio-demographic and economic indicators as explanatory variables. These variables include level of education, marital status, status of old-age or retirement pensions, standard of livings (monthly per capita expenditures) and so on. The interpretation of the estimated results and its discussion are given in the fourth section.

Table 3.

Determinants of Medication Preferences of Elderly in Kerala (Multinomial Logit Regression Results)

Variables	Model 1						Model 2
	Ayurveda			Homeopathy			Ayurveda			Homeopathy
	Coeff.	Z-value	Marginal Effects	Coeff.	Z-value	Marginal Effects	Coeff.	Z-value	Marginal Effects	Coeff.	Z-value	Marginal Effects
Age	0.12	1.95*	0.01	1.97	1.71*	0.02	0.11	1.92*	0.01	1.57	1.87*	0.01
Age square	0.001	0.4	0.00007	0.001	1.12	0.00002	0.001	0.4	0.00006	0.001	1.04	0.00001
Log MPCE	0.33	1.74*	0.02	3.97	2.71***	0.11	–	–	–	–	–	–
Log MPCE square	–0.003	–0.14	–0.001	–3.97	–2.7***	–0.11	–	–	–	–	–	–
Log income	–	–	–	–	–	–	0.45	2.3**	0.03	0.06	0.10	0.004
SC/ST	–0.66	–1.97**	–0.06	–1.13	–1.59	–0.03	–0.68	–1.87**	–0.06	–1.83	–1.9*	–0.02
OBC	–0.41	–1.76*	–0.04	–0.38	–0.85	–0.01	–0.45	–1.73*	–0.05	–0.38	–0.75	–0.01
Female	1.63	4.84***	0.16	0.74	1.34	0.02	1.68	4.17***	0.14	0.74	1.74*	0.02
Primary	0.08	0.22	0.01	0.24	0.22	0.01	0.07	0.32	0.01	0.24	0.21	0.01
Secondary	–0.15	–0.31	–0.02	1.61	1.33	0.05	–0.18	–0.41	–0.02	1.71	1.31	0.07
Graduation and above	1.50	2.48**	0.14	2.58	1.95**	0.07	1.57	2.68**	0.15	2.88	1.75**	0.05
Married	0.70	2.45**	0.06	1.22	1.89**	0.03	0.75	2.75**	0.07	1.22	1.82*	0.02
Unmarried	0.31	0.53	0.02	2.95	3.32***	0.08	0.33	0.58	0.01	2.95	3.2***	0.07
Govt pension	0.12	0.24	0.02	–1.06	–1.49	–0.03	0.14	0.28	0.02	–1.06	–1.19	–0.02
Widow pension	–14.87	–0.01	–1.40	–15.1	–0.01	–0.38	–15.8	–0.02	–1.45	–14.1	–0.01	–0.31
Old-age pension	0.38	0.76	0.04	–1.65	–2.29**	–0.05	0.34	0.78	0.03	–1.85	–2.19**	–0.05
MPCE Quintile 2	–	–	–	–	–	–	–0.02	–0.04	–0.01	2.18	3.9***	0.04
MPCE Quintile 3	–	–	–	–	–	–	0.62	1.36	0.04	2.12	2.05**	0.07
MPCE Quintile 4	–	–	–	–	–	–	0.84	1.46	0.04	3.22	2.51**	0.08
MPCE Quintile 5	–	–	–	–	–	–	0.86	1.01	0.06	4.58	2.14**	0.11
Health insurance	–0.72	–2.9***	–0.07	0.06	0.13	0.005	–	–	–	–	–	–
Dependent on son	1.86	1.92**	0.17	4.33	3.5***	0.12	–	–	–	–	–	–
Dependent on daughter	1.40	1.36	0.11	6.19	4.1***	0.17	–	–	–	–	–	–
Dependent on relatives	1.42	1.41	0.13	3.06	1.95**	0.08	–	–	–	–	–	–
Dependent on spouse	1.60	1.51	0.14	4.50	2.99***	0.12	–	–	–	–	–	–
Dependent on institutions	–13.49	–0.01	–1.28	–12.4	–0.01	–0.30	–	–	–	–	–	–
LFP	–0.33	–1.02	–0.03	–1.84	–3.3***	–0.05	–	–	–	–	–	–
constant	3.57	0.7	–	13.04	1.26	–	4.24	0.68	–	12.07	1.47	–
Number of observations	1,038						1,038
LR chi-square	208.35						198.57
Pseudo R²	0.1875						0.1250

Source: The authors.

Note: The dependent variable medication is in three categories: Allopathy, Ayurveda and Homeopathy. Allopathy is the base category. LFP: Labour Force Participation; ENT: Ears, Nose and Throat. *, ** and *** imply statistically significance at 1%, 5% and 10% levels respectively.

Findings Based on Descriptive Statistics

Health Conditions of the Elderly in Kerala

Most of the elderly population have reported that they are suffering from ailments/illness in Kerala. Out of the total sample elderly in the household survey, about 96 per cent have reported illness during the 30 days preceding the date of the survey (see Figure 1). Only 4 per cent reported good health condition. About 44 per cent of them reported suffering from illness once in the last month, while about 35 per cent reported illness twice a month and about 18 per cent reported illness more than twice a month.

Figure 1.

Source: The authors.

In the case of the elderly living in OAHs, about 91 per cent reported illness during the last 30 days preceding the date of the survey (see Figure 1). Only 9 per cent of the elderly do not report any illness. About 58 per cent of the elderly reported that they had suffered from illness only once during the last one month, while about 25 per cent reported illness twice a month and 8 per cent more than twice during the last month. Moreover, it is noted that (from the FGD) most of elderly residing in OAHs were suffering from psychological problems to due separation from their family and children (Akbar, Tiwari, Tripathi, Kumar, & Pandey, 2014; Hegde, Kosgi, Rao, Pai, & Mudgal, 2012; Subba & Subba, 2015).

Large-scale emigration of youth (Parida & Raman, 2019), changing family structure (from joint to nuclear) and social relations due to economic advancement in Kerala were among the major factors responsible for the emergence and growth of OAHs in recent years. About 91 per cent of the sample OAHs residents have reported that they are staying in OAHs because none of their family members is available in Kerala for taking care of them (see Table 1). But about 9 per cent of the sample OAHs inmates reported that they had joined the OAH to avail better health care services. Otherwise, they would have been deprived off such services because of acute household-level income poverty.

Out of the total 78 sample inmates of the OAHs, about 77 per cent have reported that they are living in the OAHs with free of cost. However, about 18 per cent have reported that they are a paid member of the OAHs and about 5 per cent are paying the OAHs fee partially (see Table 4). It is found that most of the OAHs are philanthropic, and hence the elderly belonging to poor economic backgrounds are finding no difficulty in approaching and availing of a residency in OAHs. It is also explored that about 67 per cent of the inmates of the OAHs are not willing⁴ to go back to their family in the future, and only about 33 per cent of the elderly still miss their family (children and grandchildren) and want to go back to stay with their kids at home.

Table 4.

Responses of the Elderly Living in OAHs

Indicators		Number of Observations	Percentage
Type of old-age home (OAH)	Free home	60	76.9
	Paid home	14	18.0
	Half paid	4	5.1

Reason for joining in OAH	No one to take care	71	91.0
	Health problem	7	9.0

Reintegrate with family	Yes	26	33.3
	No	52	66.7

Source: The authors.

Healthcare Expenditure Patterns of Elderly in Kerala

We have compared the healthcare expenditure of the elderly living with family members and residing in OAHs. As expected, healthcare expenditure of the elderly living with their family and kids is higher than that of their OAHs resident counterparts (see Figure 2). The kernel density plots of annual health expenditure of the elderly living with their family placed to the right (dashed line). Since most of the elderly living in the OAHs are poor and socially marginalised, they mainly depend on the public health care system, which is either free or very negligible. On the other hand, the elderly living with their family incur greater health expenses as most of them depend on private hospitals and costlier medication patterns.

Figure 2.

Source: The authors.

It is observed that among the elderly living with family, about 34 per cent of them finance their health expenditure in Kerala (see Figure 3). These are the elderly who are either receiving retirement pension or belonging to upper economic classes. About 47 per cent of the elderly (those who live with family) have reported that their healthcare expenditure is financed by their children. About 8 per cent have reported that their spouse sponsors their healthcare expenditure. Those who have reported spouse financing healthcare expenditure are mostly women. A few of them are physically challenged elderly men, those who are fully dependent on their wives’ income. Moreover, about 6 per cent of the elderly have reported that their healthcare expenditure is financed by their close relatives including married daughter, son-in-law, grandchildren, brother-in-law and so on.

However, in the case of elderly living in OAHs, it is observed that their health expenditure is normally sponsored by their OAHs (see Figure 3) with a few exceptions. About 79 per cent of the elderly (those who live in OAHs) have reported that their healthcare expenditure is financed by their OAHs. About 16 per cent have reported that their emigrant children sponsor their healthcare expenditure. Only about 5 per cent of the elderly have reported that their healthcare expenditure is financed by their past savings.

Figure 3.

Source: The authors.

Hospitalisation and Medication Preferences of Elderly in Kerala

There are only two choices of hospitalisation (namely government/public and private hospital) available to the elder population. The medication preferences, on the other hand, has three main categories including Allopathy, Ayurveda and Homeopathy.

It is observed that elderly living with family and children mostly prefer private hospitals to government/public healthcare system. This is observed across the socio-economic groups in Kerala (see Table 5). But in the case of elderly living in OAHs, they mostly get treatment in government hospitals. This is mainly because most of the elderly residing in the OAHs are poor. Moreover, OAHs are not in a position to spend enough money to avail the healthcare services of private hospitals.

Furthermore, it is observed that elderly belonging to rural areas are more likely to choose government hospitals (about 70%). This is mainly due to cost constraints. For a few others, it is due to unavailability of private hospitals within their vicinity. Even though they have the financial capability to afford private hospital and quality health services, they could not avail it because of lack of private hospitals within their locality. Among the elderly, who are living in OAHs, very low percentage (13.5%) of them afford private hospitals and the majority go to government hospitals (about 87%).

The majority of the elderly in urban areas tend to choose private hospitals. About 63 per cent of the elderly, those who are living with their family go for private hospitals. However, this share is quite low (about 25% only) in the case of elderly living in OAHs (see Table 5). Those who prefer private hospitals, it is mainly due to the quality of healthcare services and the availability of quality medicines. Those who are depending on government hospitals are mainly because of the free availability of treatment and diagnosis, and free medicines.

It is also noted that the education level of the elderly plays an important role in their hospital preference patterns as well. With an increasing level of education, it is observed that preference towards private hospital is rising. It is true for both the elderly living with family and residing in OAHs. But we have not observed much variation in the case of social groups and by the current employment status of the elderly.

However, the types of diseases for example those who are suffering from cardiovascular diseases are preferring private hospitals. The share of the elderly population going to private hospitals for their cardiovascular treatment is about 63 per cent in the case of those who live with family. While those who live in OAHs, only about 26 per cent of the elderly population is going to private hospitals for their cardiovascular treatment.

The major reason for this hospitalisation preferences is given in Figure 4. We have classified reasons for choosing a particular hospital type into five major categories, namely convenience, service quality, availability of quality medicines and free diagnosis and treatment, and other reasons. The main reason for opting government hospitals is the availability of free diagnosis and treatment (see Figure 4: Panel A). About 72 per cent of the elderly living in OAHs have reported that they are depending on government hospitals for their treatment because it is available at free of cost. About 42 per cent of the elderly living with family have also reported that they are depending on government hospitals because of the free treatment facility.

But the main reason for opting private hospitals is because of their quality of healthcare service (see Figure 4: Panel B). About 72 per cent of the elderly those who are living with family have reported that they are preferring private hospitals because of quality services. But the elderly living in OAHs prefer to approach private hospitals because of the availability of quality medicines (34%) and for geographical convenience (30%).

Figure 4.

Source: The authors.

It is further explored that most of the elderly prefer Allopathic medicine for their treatment. This is mainly because it is readily available and very effective in the short run. The share of the elderly who prefer both Ayurveda and Homeopathic medicines are quite low (see Table 5). This is true for both the inmates of OAHs and elderly living with their family. During the FGDs in OAHs, it is explored that most of them who prefer Ayurveda medicine are highly educated and do not have financial problems, unlike many other inmates. The household-level survey has also revealed the same thing. Those elderly who are relatively better educated and well informed tend to use Ayurveda medicine instead of Allopathy, even though Ayurveda medicine is a bit costly. A few other educated elderly population prefer Homeopathic medicines to Allopathy because they believe that in the long term, Homeopathic medicines would be effective.

Table 5.

Hospitalisation and Treatment Preferences of the Elderly by Their Socio-economic Groups

Socio-economic Groups		Choice of Hospitals (in %)			Types of Treatment Preferred During Illness (in %)
		Elderly Living with Family		Elderly Living in OAH		Elderly Living with Family			Elderly Living in OAH
		Govt	Pvt	Govt	Pvt	Ayurveda	Allopathic	Homeopathic	Ayurveda	Allopathic	Homeopathic
Sex	Male	45.6	54.4	82.6	17.4	7.1	88.1	4.9	1.4	96.9	1.7
	Female	39.1	60.9	76.1	23.9	17.2	80.4	2.4	1.9	88.4	9.7
Sector	Rural	69.5	30.5	86.5	13.5	14.7	82.5	2.8	1.7	90.8	7.5
	Urban	37.6	62.5	74.6	25.4	11.9	84.3	3.8	1.6	92.7	5.7
Level of education	Illiterate	62.1	37.9	99.1	0.9	15.8	83.2	1.1	1.8	91.5	6.7
	Primary	43.5	56.5	80.5	19.5	13.2	84.4	2.4	1.7	92.8	5.5
	Secondary	33.5	66.5	70.5	29.5	7.6	86.3	6.1	1.4	94.9	3.7
	Graduation and above	19.3	80.7	66	34	24.6	64.9	10.5	2.2	71.4	26.4
Employment status	No	39.3	60.7	76.3	23.7	14.7	82.9	2.4	1.7	91.2	7.1
	Yes	47.8	52.2	84.8	15.2	8.8	85.3	5.9	1.4	93.8	4.7
Social groups	SC/ST	44.7	55.3	81.7	18.3	12.7	85.3	2.0	1.6	93.8	4.5
	OBC	43.6	56.4	80.6	19.4	11.2	85.5	3.3	1.6	94.1	4.4
	General	37.4	62.7	74.4	25.6	16.4	79.3	4.3	1.8	87.2	11.0
Diseases type	ENT	47.8	52.2	84.8	15.2	1.5	92.5	6.0	1.1	98.0	0.9
	Cardiovascular	37.1	62.9	74.1	25.9	7.1	91.2	1.8	1.4	95.0	3.6
	Respiratory	41.5	58.5	78.5	21.5	9.8	90.2	0.0	1.5	97.0	1.5
	Rheumatic	37.2	62.8	74.2	25.8	16.3	80.0	3.7	1.8	88.0	10.2
	Other diseases	48.0	52.0	85	15	16.0	84.0	0.0	1.8	92.4	5.8

Source: The authors.

About 90 per cent of the Ayurveda treatment users have reported that they use this medicine because it has hardly any side effect (see Figure 5). While about 50 per cent of Homeopathy users have reported that they use it because of no side effects. Moreover, about 34 per cent of them have reported that they use Homeopathy because of its effectiveness.

Figure 5.

Source: The authors.

The Allopathic users, on the other hand, have reported that it is because of the instant and immediate relief. About 62 per cent of the Allopathic users have reported that effectiveness is the main reason for choosing the Allopathic method of treatment. Moreover, about 16 per cent of the Allopathic users have reported that it is due to cost-effectiveness. Moreover, it is important to note that the elderly belonging to poor economic quintiles normally go for Allopathic treatment methods. They normally do not reveal any preference pattern due to their affordability reasons. The same is true in the case of most of the elderly living in OAHs.

Moreover, it is noted that Ayurveda medicine preference is high among the elderly who normally suffer from diseases such as rheumatism (joint pains, arthritis, etc.) and psychological diseases (sleeplessness, loss of memory, etc.). Whereas the elderly who suffer from either cardiovascular disease (heart, blood pressure, etc.) or cancer mainly depend on Allopathic medicines.

Determinants of the Medication Preferences of the Elderly in Kerala

We have explored the factors determining medication preferences of elderly by estimating multinomial regression models (see Table 3). But these preference equations are estimated for the elderly living with their family member only. As we have already discussed in the earlier section that elderly residing in the OAHs do not reveal any such preferences. We did not estimate their preference equation.

We begin the discussion with the coefficient of age and its square term. We have got positive estimated coefficients for both these variables. It is as expected, as with increasing age, elderly are likely to suffer from more diseases, age has an implication on their medication preferences too. It is found that with the advancement of ageing, the elderly are more likely to prefer Ayurveda and Homeopathy to Allopathy medicines. This particular result reflects the fact that the elderly who used to have Allopathy medicines for their diseases, normally shifted their preferences to either Ayurveda or Homeopathy over the years after they experienced the negative side effects of Allopathy medicines. Hence, in this case, age could be considered as a proxy for experience. Hence, it can be concluded that with the increasing experience in taking medicine, the elderly are likely to prefer either Ayurveda or Homeopathy to Allopathy medicines.

The next important factor of medication preference of the elderly is their standard of living. We have used the logarithm of monthly per capita consumption expenditure (log MPCE and its square term), logarithm of monthly income and monthly per capita consumption expenditure quintile dummies to estimate the effect of standard of living on medication preferences. We have run two separate regression models to overcome the problem of multi-collinearity and endogeneity issues. The coefficient of log MPCE shows that with the improved standard of living, the elderly are relatively more likely to prefer Ayurvedic medicines to Allopathy medicines. This result is also supplemented by the coefficients of log income and MPCE quintile dummies in the second model. This result strengthens our argument further that elderly belonging to lower economic classes do not reveal any a clear medication preference pattern in Kerala.

Moreover, the marital status of the elderly also plays an important role in the process of revealing their preference for medications. It is noted that those elderly, who had remained unmarried, are more likely to be poor and hence their marital status significantly determines their medication preferences. Those who were married and have children to take care of them revealed their preference towards Ayurvedic and Homeopathic treatment mechanisms.

The coefficients of pension status and dependency dummies also substantiate our argument that the probability of preferring Ayurvedic and Homeopathic treatment mechanisms is relatively high among those who depend on their kids. Conversely, the elderly population, who depend on institutions (like OAHs) for their treatment have no preference patterns. Hence, they mostly depend on a compulsory treatment mechanism.

Finally, the coefficient of the dummy variable measuring the elderly’s labour force participation harms the Homeopathic and Ayurveda treatment mechanism. This is mainly because elderly labour force participation is an outcome of their household-level income distress. Those elderly, who participate in the labour market normally belong to the poor and marginalised section of the society (Rajan & Kumar, 2003; Rudawska, 2010; Sanitha, Parida, & Pattayat, 2019; Van Gameren, 2008). They work either to supplement their family income or to earn a living for their family as a breadwinner. Hence, most of them prefer using Allopathy medicines because of its low cost and short-term effectiveness.

Concluding Remarks

The major findings of this study suggest that since most of the elderly population are vulnerable to chronic diseases, hence their healthcare expenditure is very high. In Kerala, the elderly population, by and large, are bearing their health expenses. There is a normal belief among the people that private hospitals are more effective and they are providing better treatment. Those who prefer government hospitals do so because of the availability of free treatment and medicines. Ayurvedic and Homeopathic medicines are a bit expensive and hence are normally preferred by relatively upper-income groups because of their low and negligible side effects.

Moreover, this study found that because of large-scale emigration, changing the social setup and the breaking of the joint family system, and so on, the responsibility of taking care of elderly members are shifting from family to the OAHs or other similar institutions. Staying with family and staying in OAHs are entirely two different things, hence, those who are staying in OAHs are having more psychological problems due to their separation from family.

Based on these findings, the study suggests that to ensure the healthcare of the elderly, geriatric departments and centres need to be set up in medical colleges and district hospitals. Comprehensive primary care and medical treatment for elderly healthcare should start from the root level. Specific schemes for social security of elderly people should also be elaborated. If some community geriatric clinics are to be set up in rural areas, it will be helpful for the needy elderly. Actions should be taken to reduce the financial dependency of the elderly to ensure social security measures and increase the role of the government in taking care of the elderly. These measures would not just help in improving the quality of life of the elderly but they will also enhance the role of the government in an improved welfare state like Kerala.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Notes

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