Aging in Nepal

Abstract

Like many countries, the increase in the population of older adults in Nepal has led to national policies and programs to address their needs. It would, however, also be fair to say that not enough is yet known about older adults and hence it is unclear if government programs truly address those needs. Nepal is a very poor country that is still largely rural and characterized by extremes of inequality based on caste/ethnicity, gender, region, and income/wealth. In this paper, we describe the demographic and social conditions of older adults in Nepal, inequality, sources, and limitations of the data about older adults, and public policy and programs for older adults. We believe that studies of older adults in Nepal would benefit from adopting social determinants of health, healthy aging, and life-course perspectives to both identify needs and formulate policy for older adults in Nepal.

Nepal is a small, poor country ranking 138th of 157 countries on the Human Development Index (HDI; Oxfam & Humanitarian Accountability Monitoring Initiative [HAMI], 2019). It has a population of about 30 million people. It is sandwiched between China and India and the home of Mount Everest. Nepal has three distinctive ecological zones that differ by climate, economics, culture, and development; the mountains, the hills, and the plains (Tarai). Ninety-two languages are spoken in Nepal and there are at least 125 different ethnic groups. Per capita income is 870 USD, and the principal occupation of Nepalis is agriculture—66%. Seventeen percent of the population is urban. Ninety percent of the population has access to electricity but only 27% have access to safely managed water. Nepal has a literacy rate of 68% (men, 75% and women, 57%).

Like many societies undergoing a demographic transition (declining fertility and mortality), Nepal has experienced a notable increase in the size of its population aged 60 and older. Almost 9% of the population is now 60 or older.

Nepal is a society of extreme and crosscutting inequalities based on gender, caste, ethnicity, regional identity, and income/wealth (Pradhan & Shrestha, 2005). The inequalities that characterize Nepali society are deeply embedded in its culture and social arrangements. Nepal has one of the highest income (49.4) and one of the highest wealth (74) GINI coefficients in the world (Oxfam & HAMI, 2019). The richest 10% of the population has 26 times the wealth of the poorest 40% of the population (Central Bureau of Statistics, 2012; Pradhan & Shrestha, 2005).

Disadvantaged caste-based, ethnicity-based, and gender-based discrimination affects poverty rates, income, food insecurity, occupation, employment, education, health, HDI, and political access (Indian Institute of Dalit Studies, 2008). Social exclusion and discrimination are entrenched in Nepal’s political, economic, and social fabric and are a defining feature of its historical and cultural development (Asian Development Bank, 2010). Life is harder for poor people, people of lower caste and less privileged ethnicity, rural residents, and women. Hence, “most Nepalese enter old age after a lifetime of poverty and deprivation, poor access to health care and a diet that is usually inadequate in quality and quantity” (Geriatric Center Nepal, 2010, p. 2). Many developing and developed countries including Brazil, New Zealand, Mexico, and the United States report that aging experiences differ by social determinants such as ethnicity, race, and/or socioeconomic status (Neumann & Albert, 2018; Parr-Brownlie et al., 2020; Schoeni et al., 2005; Tobin et al., 2021; Torres et al., 2018).

Existing research on older adults in Nepal is also limited, as noted in other developing countries such as Tunisia, the Philippines, and Bulgaria (Badana & Andel, 2018; Karlin et al., 2018; Pitheckoff, 2017). There are, however, some active research programs on older adults in Nepal and on the impact that older adults have on family, local and national institutions (Chalise, 2020; Chalise & Brightman, 2006; Chalise & Paudel, 2020; Geriatric Center Nepal, 2010; Ghimire et al., 2018; Limbu, 2012). Overall, it is probably fair to say that not enough is yet known about older adults in Nepal and that government attention to the “problem” of older adults is not yet thorough or effective (Basnyat, 2009; Bhandari, 2019; Bhattarai, 2012; Harris et al., 2013; Kunkel & Subedi, 1995; National Planning Commission Nepal, 2012; Oxfam & HAMI, 2019; Poudel & Magar, 2016; The Asia Foundation, 2012; UNFPA Nepal, 2017).

Demographic and Social Condition of Older Adults in Nepal

Culturally, older adults in Nepal are respected and their knowledge and experience are revered (Subedi, 2003). Traditionally older men are considered the heads of their households. In extended households, older adults are economically sustained by their children and grandchildren while maintaining control of family assets. It is a filial obligation to take care of one’s older members. This duty is supported by religion and tradition and requires no societal structures or “policy.” These rights and obligations are, however, also officially recognized in Nepal’s Senior Citizen Acts.

Societally, Nepal is still a mostly rural and agricultural society. In 2011 (the date of the last national census), 82.9% of the total population and 85.6% of Nepalis over the age of 60 lived in rural areas (Central Bureau of Statistics, 2013, 2014). According to a study by Chalise and Rosenberg (2019), 70% of their sample of older adults were illiterate; 46% of males and 94% of women.

Seventy-eight percent of older adults reported living with family members while an additional 12% lived only with their spouse (Chalise & Rosenberg, 2019; Chaudhary, 2004). Thus, 90% of older adults were living with family. Only 6% reported living alone. This is an important result as it reflects the traditional and cultural obligation that families have for their older members and means that older adults can often obtain support and care from other family members. Sixty-four percent of men and 38% of women were married, while 32% of men were widowed, and 58% of women were widowed (there is a cultural bias that prevents widows from remarrying—with many negative consequences). Both older men and women reported working (paid or unpaid) in about 71% of cases. Older adults thus remain economic contributors to their families despite stereotypical assumptions that older adults are more likely to be physically and mentally “disabled” (Poudel, 2011). Both older men and women reported high levels of physical and mental health problems (women reported higher rates than men), but these health problems do not appear to always affect the ability of older adults to contribute in some way to the family work effort. Bhattarai (2012) reports that older people, in general, are often precluded from obtaining health care and that this varies by place of residence, economic factors/poverty, and caste/ethnicity. Although women now outlive men, they appear to be in somewhat more precarious positions overall (consistent with gender bias in Nepal). Women were more likely to be poor, less likely to be married, more likely to be widowed, more likely to be illiterate, and more likely to report physical and mental health problems than men.

Although there is very little information on the social participation of older adults, one study indicates that 66% of older adults reported often being visited by friends, relatives, or family members (Bhatta, 2009). About 82% of these older adults, however, reported no involvement in any organizations or social groups but we do not know if this rate of participation should be considered high or low (Bhatta, 2009). Chalise and Paudel (2020) report a high prevalence of older person abuse of 50.3%. Most of this abuse is in the form of disrespect (42.5%), neglect (41.2%), and verbal abuse (29.3%). Emotional abuse (8.1%), physical abuse (6.5%), and sexual abuse (0.9%) are less frequent.

Inequality in Nepal

The above data understate dramatic differences in the status and needs of older adults based on the social determinants of caste/ethnicity, gender, income, wealth, and region. The exact measure of these inequalities among older adults is not always available from current data but the inequality evident at the general population level applies to older adults.

Caste/ethnicity affects access to occupations, education, and income. Patel (2012) reports substantial differences in poverty level by caste/ethnicity crosscut by region across all ages. Among the many caste and ethnic groups, hill Brahmins reported a poverty rate of 10.3%, Dalits (untouchables) reported poverty rates between 38.2% and 48.9%, and indigenous peoples reported a rate of 24.6% (Subba et al., 2014). Poverty is higher in rural areas at 27% compared to urban areas at 12%. Hill Brahmins reported the highest literacy rate of 79% and the lowest proportion who have never attended school (22.7%) while Tarai Dalits reported the lowest literacy rate at 31% and the highest proportion who have never attended school (53%).

Gender alone and gender crosscut by caste/ethnicity and rural/urban residence also reveal inequalities. Men are more likely to be employed and to earn income than women (74% vs 26%). Men are more likely to be literate than women (75% vs 57%). Gender inequality is greater in rural areas (the gender development index is 0.4 in rural areas and 0.6 in urban areas). For hill Dalit women it is 15% compared to only 4% for Tarai Dalit women (Pradhan & Shrestha, 2005).

Sources and Limitations of Data About Older Adults in Nepal

There are three sources of information about the situation of older adults in Nepal; data collected by the Central Bureau of Statistics and other government ministries, including the decennial Nepal Population and Housing Census, the Nepal Living Standards Survey, the Nepal Demographic and Health Survey, and commissioned reports; data collected and analyzed by nongovernmental organizations such as the United Nations, World Bank, Asian Development Bank, United Nations Educational, Scientific and Cultural Organization, Norwegian Institute of International Affairs, Indian Institute of Dalit Studies, Oxfam, and The Asia Foundation; and small-scale surveys obtained by academic researchers through grant mechanisms.

The quality of the samples, data, and analysis vary considerably. Samples can be too small or nonrepresentative. Analyses are almost all tabulations or cross-tabulations without multivariate analysis. Some of the analytic weaknesses are a function of the absence of theoretical orientations that affect the kind of data collected or the way it is analyzed. For example, most studies do not report findings for older adults by wealth, or caste/ethnicity nor even include data on older adults (gender is often included). Much of the data collected are limited by their intended use by the Government of Nepal and the needs of other potential users (i.e., researchers) have not been taken into consideration (Bikas Udhyami, 2018). The reliability of national data in Nepal has also been rightly questioned (Simkhada et al., 2009).

Generally, the data collected and analyzed by nongovernmental organizations are more reliable and better analyzed than Nepal government data. But these data and analyses are often aimed at specific organizational purposes, use measures that are not comparable with other data collections, and are not repeated to obtain long-term information. The best information we have on gender discrimination, poverty, and caste/ethnicity comes from these studies, but it is difficult or impossible to concatenate these data to, for example, see how gender, poverty, and caste/ethnicity combine to affect health or the living conditions of older adults.

There are active research programs on older adults in Nepal that are conducted by academic and other authors using private and governmental funding (Acharya et al., 2019; Bhatta, 2009; Chalise, 2020; Chalise & Brightman 2006; Chalise & Paudel, 2020; Chalise & Rosenberg, 2019; Geriatric Center Nepal, 2010; Ghimire et al., 2018; Limbu 2012; Parker et al., 2014; Poudel, 2011; Pun et al., 2009). These studies are often sophisticated in design and well-thought-out. Small samples are generally used and many of these are samples of convenience. The academic research infrastructure in Nepal is underdeveloped and poorly funded. Nevertheless, much of what we think we know about the status and needs of older adults in Nepal can be reasonably inferred from these studies. The studies tend to be tabular and cross-tabular and not intended to test hypotheses.

What Are the Key Public Policy Issues Regarding Aging in Nepal?

Nepal, as a political entity, has adopted assumptions about the status and needs of older adults that are derived from Western, developed countries and the recommendations of institutions like the United Nations, World Health Organization, International Monetary Fund, and the World Bank and including the 2002 Political Declaration and Madrid International Plan of Action on Ageing (United Nations, 2002) rather than those based on national data. This adoption has affected how “Nepal” thinks about, studies, and interprets the status and needs of its older adults. Older adults are assumed to suffer biological decline and disability, to be increasingly dependent on others for care, and to be economically dependent.

Nepal has instituted several policies and programs that are intended to recognize and benefit older adults. These programs focus on the recognition of the rights of older adults, their economic support, and their health needs.

A Local Self-governance Act was passed in 1999 in a broad attempt to decentralize decision making, funding, and policy implementation within the country by empowering local village development committees. The Act included provisions for the protection and development of orphan children, women, older people, and the disabled (Bhandari, 2019; Ministry of Health and Population, 2020). However, assessment of the implementation of this Act suggests that the attempt to decentralize decision making has not been successful. The implementation of the Act has been criticized for its slow process of formulating policy, confusion, lack of comprehension and clarity around roles and responsibilities, the dominance of personal and party interests, the poor capability of local governments to plan, budget, manage and monitor health programs, fragmented and incoherent prioritization, corruption, and a shortage of human resources (Bhandari et al., 2020).

The Senior Citizen Policy Act was created in 1998. It envisioned incorporating economic benefit, social security, health service facilities, and participation to support older adults. A National Plan of Action was enacted in 2005 to assure older adults economic security, health and nutrition, participation and involvement, education and entertainment, and legal rights. The Senior Citizen Act of 2006 was developed to again ensure the economic and human rights of older adults, the establishment of a “Senior Citizen” welfare fund, district Senior Citizen Welfare Committees, care centers, and day service centers, and a provision to provide financial allowances to some older adults. A Senior Citizen Regulation was enacted in 2008 that provided guidelines for the implementation of the Senior Citizen Act. It also guided the establishment and running of geriatric homes, “old-age” homes, and daycare centers (Bhandari, 2019; Ministry of Health and Population, 2020).

Finally, Nepal has created a social security system for the benefit of retired government workers and older adults. This system consists of an “Old Age Allowance” that now provides adults over 70 with a modest stipend (about $10 per month). The program also provides support for single women, orphans, children, disabled persons, and “endangered” races (National Planning Commission Nepal, 2012).

Older adults are not receiving the priority, attention, health, and other services nor the financial assistance “assured” by these legislative efforts. Social security policies are said to be hampered by lack of state accountability, lack of administrative personnel, resistance to the programs at the local level, and interbody coordination and program monitoring is weak (National Planning Commission Nepal, 2012). According to Chalise (2006), old age allowances reach only 20% of those eligible, and government service pensions reach fewer than 7% of eligible recipients.

Nepal’s health policy focuses on maternal and child health, and government intent notwithstanding is much less available to older adults. Bhattarai (2012) notes that National Health Policy and Long-Term Health Plans do not include older people in the list of priority groups. Moreover, older people are excluded from receiving health services as a function of macrolevel structural factors such as low income/wealth, rural residence, and caste/ethnicity (Bhattarai, 2012). Acharya et al. (2019) observed that a notable proportion of older adults do not utilize health services despite having health problems. The Government of Nepal offers free health care for older adults at government hospitals and health centers, but awareness is minimal. The government does not have a rigorous policy to ensure the availability of specialized geriatric care and access to services was observed to be a function of ethnicity, income, and literacy (Acharya et al., 2019). Overall, it is fair to say that Nepal has endeavored to create an institutional structure and policies that recognize and support older adults and address their needs but that it has largely failed to operationalize the support required (Basnyat, 2009; Bhandari, 2019; Bhandari et al., 2020; Kunkel & Subedi, 1995; National Planning Commission Nepal, 2012; Oxfam & HAMI, 2019).

The Social Determinants of Aging in Nepal

We suggest that to better and more appropriately anticipate the condition of older adults in Nepal, we need to explore how the social inequalities of Nepali society as a whole determine the living conditions of older adults. Inequalities based on gender, caste/ethnicity, region, and wealth result in different and unequal life experiences for individuals and groups based on their positions in these hierarchies and localities. These differences also interact with social changes such as urbanization and internal and external migration. Writers and researchers can (and have) documented many of these experiences in previous descriptions of Nepal in general but this approach has not been applied to the identification of the status and needs of older adults in Nepal (Acharya, 2014; Asian Development Bank, 2010; Bhatta & Sharma 2006; Indian Institute of Dalit Studies, 2008; Patel 2012; Subba et al., 2014).

Consistent with the Social Determinants of Health argument, The Healthy Aging argument, and an Institutional Life Course perspective, we believe that the deep, persistent, and resistant patterns of inequality and discrimination in Nepal can be well-explained and most usefully applied for studying aging in Nepal (Moen, 2013; Sadana et al., 2016; Solar & Irwin, 2010; Stites et al., 2021). Such perspectives also suggest how programs and policies that affect older adults can be designed and implemented.

Conclusion

Like many other counties, the number and proportion of older adults in Nepal have and continue to grow. In response, the Government of Nepal has adopted many measures that recognize and specify the rights of older adults and Nepal’s obligations to the support and well-being of these older citizens. But the extreme and persistent inequality and discrimination that exists in Nepal and the generally ineffective implementation of national and local policies and programs, coupled with poor data resources, reduce the likelihood that the lives of older adults in Nepal will be improved soon. In suggesting that researchers, government agencies, and political actors adopt a common perspective based on the social determinants of well-being we hope to stimulate an approach to serving older adults that has the potential to improve their lives. As we observe similar conditions in other developing and even developed countries, we see this approach as one that has general application across societies and social systems.

Funding

None declared.

Conflict of Interest

None declared.

References