Evaluating the National Programme for Health Care of the Elderly in Kerala's Rapidly Ageing Context Uncovering the Geriatric Care Paradox

Evaluating the National Programme for Health Care of the Elderly in Kerala's Rapidly Ageing Context Uncovering the Geriatric Care Paradox | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the National Programme for Health Care of the Elderly in Kerala's Rapidly Ageing Context Uncovering the Geriatric Care Paradox B Aravind Chandru, Devika Rajeesh, Zehra Sabuji, P M Gopika, S S Harsha, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8494873/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Introduction Globally, the proportion of older persons is steadily increasing. In India, 8% of the population is above 60 years of age, rising to 12.6% in Kerala, the highest among all states. To address the growing health needs of this demographic, the Ministry of Health and Family Welfare launched the National Programme for Health Care of the Elderly (NPHCE) in 2010–2011. This study evaluates the implementation and impact of NPHCE across five districts in Kerala—Kozhikode, Thrissur, Pathanamthitta, Alappuzha, and Idukki—and examines its key achievements and challenges. Methods A cross-sectional, concurrent mixed-method design was used. Quantitative data were collected through structured questionnaires and observation checklists, while qualitative insights were obtained from Key Informant and In-Depth Interviews. Results The quantitative findings show that NPHCE has expanded from five pilot districts to all fourteen, establishing geriatric wards, outpatient clinics, and elderly-friendly infrastructure. However, implementation remains uneven, with disparities in staffing, infrastructure quality, and service utilisation across districts, indicating inconsistencies in accessibility and care delivery. Qualitative findings reveal that while accessibility and comfort for older adults have improved, persistent challenges remain due to workforce shortages, limited funding, and inadequate transport facilities. Beneficiaries also reported social isolation, economic vulnerability, and barriers to essential healthcare. Strengthening human resources, interdepartmental coordination, and community participation were emphasised to enhance programme effectiveness. Conclusion Kerala’s decentralised healthcare model provides a strong foundation for elderly care. However, addressing political, financial, and operational challenges remains critical to improving the quality of life for the state’s ageing population. Ageing population Geriatric health services Health policy Long-term care National health programme Figures Figure 1 Figure 2 INTRODUCTION Globally, the proportion of older persons is on the rise. As per the Census 2011, 8% of the total population in India is above 60 years of age. Asia is home to more than half of the world's elderly population. Kerala has a higher percentage of elderly residents than the rest of India, at 10.1% on a national average and 16.5% in the state of Kerala ( 1 ). In light of the profound impact that the ageing of the population in India can potentially have on the social, political and economic spheres alike, research on the health and well-being of the elderly population is the need of the hour to ensure and facilitate the process of healthy ageing. India has been experiencing a gradual increase in both the size and share of the older population over the past few decades ( 2 ). The ongoing epidemiological transition in India has led to an increase in Non-Communicable Disease (NCD) deaths in addition to health issues related to old age ( 3 ). Ageing is a global phenomenon. India is in Stage 3 of the demographic transition, suggesting a fall in birth rate, with the death rate staying low, and the population will continue to grow steadily ( 4 ). As a result, the number of elderly people in India is increasing, and measures that address their health issues are essential. It is necessary to have a comprehensive and integrated approach to elderly healthcare instead of the traditional fragmented approach that addresses the health needs of older adults through separate disease-specific programmes for non-communicable diseases, cancer, and mental health ( 5 ). The demographic landscape of Kerala, a state in India, is undergoing a significant transformation, characterised by a rapidly ageing population ( 6 ) ( 7 ). This makes the state an important case study, given that the country's entire elderly population is projected to double by 2050 ( 8 ). This shift is occurring at a pace that surpasses the national average, presenting unique challenges for public health and healthcare infrastructure. According to the Kerala Ageing Survey (KAS) 2013 report, the state is home to 4.2 million individuals aged 60 and above, marking an annual growth rate of 2.3%, compared to the general population's growth rate of 0.5%. Notably, within this elderly demographic, 11% are categorised as old-old (above 80 years), underscoring the complex healthcare needs and vulnerabilities specific to this age group ( 9 ) ( 10 ) ( 11 ). This demographic trend is not isolated but reflects a global increase in the proportion of older persons. Kerala's population is ageing more quickly than the national average. The state already has the highest percentage of older adults in the nation, at 16.5 percent in 2021, rising to an estimated 22.8 percent in 2022, and expected to surpass one-fifth of all citizens by 2036 ( 12 ). In Kerala, there has been a steady rise in chronic conditions such as diabetes, hypertension, and coronary heart disease, accompanied by an increasing prevalence of risk factors including obesity, sedentary lifestyles, elevated serum lipid levels, and smoking ( 13 ). The Ministry of Health & Family Welfare launched the “National Programme for the Health Care of Elderly” (NPHCE) during 2010-11 to address various health-related problems of elderly people and promote healthy ageing ( 6 ). This initiative aims to provide accessible, affordable, and high-quality long-term care services to the ageing population, supporting their functional ability and overall well-being. Aligned with international and national commitments under the United Nations Convention on the Rights of Persons with Disabilities, the NPHCE integrates provisions from the National Policy on Older Persons (1999) and Section 20 of “The Maintenance and Welfare of Parents and Senior Citizens Act, 2007” ( 14 ) ( 15 ). The programme's planning, monitoring, and implementation are overseen by the NCD cell at national and state levels, established under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases (CVD), and Stroke ( 16 ). By establishing geriatric clinics, dedicated hospital wards, rehabilitation units, and community-based care, the programme strives to enhance the healthcare infrastructure and services specifically tailored for the elderly ( 9 ). A comprehensive initiative like the NPHCE is essential to ensure long-term and dedicated services that promote active and healthy ageing. Initially, five districts in Kerala, such as Pathanamthitta, Kozhikode, Alappuzha, Idukki, and Thrissur, were selected for the first phase of the NPHCE, which was later expanded to cover all districts by 2016-17 ( 17 ). In this study, the infrastructural changes, the process of implementation, and the program's output, along with understanding the perception of policymakers, implementers, and the beneficiaries regarding the NPHCE, were explored. METHODOLOGY Design This study employed a cross-sectional, concurrent mixed-methods design to evaluate the NPHCE at the secondary-level health facilities in Kerala. The design integrated both quantitative and qualitative components for a comprehensive assessment of the infrastructure, implementation process, and stakeholder perceptions. Data collection for both components was carried out simultaneously between July 2023 and September 2023, after obtaining ethical clearance from the Institutional Ethics Committee (IEC) of the Department of Health Services, General Hospital, Thiruvananthapuram, Kerala (33/03/02/21-GHEC). All methods were carried out in accordance with relevant guidelines and regulations, including the Declaration of Helsinki and the ethical standards of the Institutional Ethics Committee of the State Health Systems Resource Centre Kerala. Study setting and participants The study was conducted in ten secondary care health facilities (General hospitals, District hospitals and Taluk Headquarters Hospital (THQH)) across five districts in Kerala, India: Kozhikode, Thrissur, Pathanamthitta, Alappuzha, and Idukki. These districts were purposely selected, as they represented the initial pilot sites for NPHCE in the state. In consultation with the State Nodal Officer (SNO) for NPHCE, two facilities were selected from each district, comprising a mix of the original five initial pilot sites and five subsequently incorporated centres that received NPHCE programme funds from the state. The study engaged a multi-tiered group of participants. For the qualitative component, purposive sampling was used to recruit key stakeholders. This included Key Informant Interviews (KIIs) with five policymakers and senior implementers, including SNO and the NPHCE District Nodal Officers from the five selected districts. In-Depth Interviews (IDIs) were conducted with 9 healthcare providers (medical superintendents, NPHCE medical officers, staff nurses of geriatric wards, NPHCE physiotherapists, and NPHCE dieticians) and elderly beneficiaries aged 60 and above from both the Out-Patient Department (OPD) and the In-Patient Department (IPD) and their primary caregivers who have utilised NPHCE services at the selected location within the preceding six months. Additionally, beneficiary selection was based on availability and feasibility. For the quantitative component, all ten selected healthcare facilities were included as the unit of analysis. Data collection techniques Data collection involved distinct qualitative and quantitative instruments. Qualitative data were gathered using semi-structured interview guides tailored to each stakeholder group, developed in Malayalam (regional language), translated into English, and back-translated to ensure conceptual accuracy. KIIs explored strategic themes such as programme rollout, human resources, monitoring and evaluation systems, interdepartmental convergence (example: NCD and palliative care) and funding, while IDIs with providers focused on daily operational experiences, adequacy of infrastructure and equipment, patient load, clinical workflows, training received and challenges in delivering geriatric-specific care. The IDI guide for beneficiaries explored their pathways to accessing care, experiences with the physical accessibility of facilities, interactions with staff, affordability of services, and satisfaction with the care received. All interviews were conducted in Malayalam and audio recorded with written informed consent by the Principal Investigator (RMR) and Co-Investigator (BAC) and trained data collectors of the research team (Research Assistants and Public Health Interns of the State Health Systems Resource Centre). Informed consent was obtained from all participants, and confidentiality was maintained through anonymised data handling. Detailed field notes were maintained to capture contextual observations. Quantitative data were collected using two structured tools developed from NPHCE operational guidelines: a facility survey questionnaire that documented staffing patterns and service utilisation metrics, and a geriatric-friendly infrastructure audit checklist that was used to conduct a physical verification of geriatric-friendly features, comprising 17 specific criteria, assessed the environment for safety and accessibility, documenting the presence or absence of elements such as ramp railings, anti-skid flooring, designated waiting areas, etc. Both qualitative and quantitative tools were refined after a pilot test at one non-study site to ensure clarity and relevance. Data analysis: Quantitative data were analysed using Microsoft Excel, focusing on cleaning, descriptive analysis, and data visualisation to summarise findings relevant to healthcare infrastructure and programme efficacy. Qualitative data underwent a hybrid coding strategy, starting with inductive open coding for initial interviews to identify patterns, which were then compared with existing literature. Subsequent interviews were coded deductively, allowing for the thematic analysis of comprehensive stakeholder perspectives. The study used the “Framework for Programme Evaluation in Public Health” developed by the Centres for Disease Control and Prevention (CDC) as the basic reference for evaluating the NPHCE ( 18 ). This framework provides a systematic and participatory approach to evaluating public health programmes through six interconnected steps: engaging stakeholders, describing the programme, focusing the evaluation design, gathering credible evidence, justifying conclusions, and ensuring use and sharing lessons learned. The framework emphasises utility, feasibility, propriety, and accuracy, thereby facilitating a comprehensive assessment of programme implementation, effectiveness, and contextual factors. In this study, the framework guided the structured examination of the NPHCE, enabling the integration of quantitative and qualitative findings to assess programme processes, outputs, and outcomes in a systematic manner. Based on the results obtained, this framework was adapted to effectively represent and organise the study findings. RESULTS This evaluation examined the implementation, service delivery, and utilisation of the NPHCE in Kerala using a mixed-methods approach, guided by the CDC Framework for Programme Evaluation in Public Health. Quantitative facility-level data were used to assess infrastructure, human resources, funding, and service utilisation, while qualitative findings from KIIs and IDIs provided contextual insights into operational processes, beneficiary experiences, and implementation challenges. 1. Rapid ageing population and emerging need for comprehensive geriatric care Kerala is undergoing a profound demographic transition, marked by a rapid increase in the elderly population and a changing population structure. This shift has far-reaching implications for the health system, social support mechanisms, and economic security of older adults. This demographic change is not just a numerical increase but also brings structural shifts in the population pyramid. Kerala is witnessing a shrinking base and widening top of the pyramid, which represents an ageing population with a declining younger population. “Based on our 2011 census data, we had 12 percent of the 60-plus elderly population. If we can check now our rate of growth, this might have reached around 20%... after 2040, we are thinking that a quarter of our population will be elderly... When the elderly population size increases, our demographic pyramid gets disturbed… the upper portion of the pyramid is getting bigger, and also the decrease in the number of under-five children is causing the lower portion to get reduced.” -(State Nodal Officer, NPHCE) This demographic transition is reflected in the lived experiences of older adults, who describe progressive physical weakness and declining functional capacity as part of everyday life. “I feel my hands and feet are becoming numb and I experience weakness.” - (Beneficiary- GH Kozhikode, 72 years, female) Demographic patterns lead to increasing demands on the health system and call for specialized services for elderly care. Alongside this transition, the health profile of older adults is changing, with a notable rise in chronic diseases and comorbidities. Unlike previous generations, today’s elderly are living longer but often with multiple health conditions that require regular care and support. These health challenges are compounded by economic insecurities faced by older adults. A large proportion of the elderly, particularly those outside the formal employment sector, lack stable income sources or pension benefits. This creates a significant barrier to accessing timely and adequate healthcare. “If we look at the KAS (Kerala Ageing Survey) study, which was done previously, and also our disease profile and morbidity status, our 60 plus population is having one or more comorbid conditions. They are entering with lifestyle diseases. So, that is why we are not having healthy ageing.” - (Medical Superintendent, THQH, Idukki) “My wife requires a lot of money for medication… especially as she is hypertensive, she would require two medications… which cost us around Rs 1000 a month.” (Beneficiary, DH Vadakara, 72 years, Male) In the case of economic concerns, changing family structures and migration patterns have deepened the psychosocial challenges faced by the elderly in Kerala. With more families shifting to nuclear systems and many younger members migrating abroad or to urban centres, increasing numbers of older adults are left to live alone, often without adequate support. Such social isolation and emotional distress can further aggravate health problems, reduce quality of life, and increase the need for accessible and supportive care environments. “Since we are moving towards nuclear families, the number of elderly persons being thrown out to elderly care homes is increasing in our area.” (District Nodal Officer NPHCE, Idukki) “I get 1600 as pension… I have been taking medications for the last five years. I am unable to meet the expenses.” -(Beneficiary, DH Kozhencherry, 72 years, female) “There is no one to take care of me… I don’t get any help for cooking or washing.”- (Beneficiary, DH Mavelikkara, 62 years, Female) All these interconnected factors, such as rapid demographic transition, rising morbidity, economic vulnerability, and social isolation, point toward an urgent need for a structured, comprehensive, and integrated health programme for the elderly. Therefore, programmes like NPHCE are essential to build an age-friendly and inclusive health system in Kerala. 2. Organisation and Operational Framework of NPHCE 2.1 Programme Scope and Implementation Process The NPHCE was established to address the healthcare needs of Kerala’s ageing population through a structured network of geriatric clinics, specialised wards, and rehabilitation services. The programme aims to ensure affordable, accessible, and quality healthcare for older adults across the state. At the District Hospital level, the NPHCE has developed a comprehensive geriatric healthcare infrastructure, which includes a dedicated Geriatric Clinic offering specialised outpatient services, a 10-bed Geriatric Ward with respite care facilities, and referral services for secondary healthcare. Existing specialists in geriatrics are deployed to manage these units, thereby optimising available expertise to meet the unique health needs of the elderly. In addition, additional staff have been sanctioned to support the efficient functioning of these clinics and wards. “During the initial phase, the programme was implemented in 100 selected districts all over India; five districts were from Kerala, namely Kozhikode, Pathanamthitta, Alappuzha, Idukki, and Thrissur… The first geriatric ward was set up in Pathanamthitta district hospital with four staff nurses, one physiotherapist, one care coordinator, and a medical officer… Currently, in the district hospital, there will be one care coordinator, 2 staff nurses, 1 doctor, and a physiotherapist. In a general hospital, one care coordinator, a staff nurse, a doctor, and a physiotherapist” - (State Nodal Officer, NPHCE) The NPHCE implementation in Thrissur evolved gradually, beginning with outpatient-based elderly care services before the establishment of dedicated inpatient facilities. Early implementation was constrained by limited financial resources, which delayed the development of geriatric wards despite regular service provision at the outpatient level. “Before I came here, I was in Chalakudy… we used to normally conduct an elderly care clinic once a week… Since there were no funds available, we did not begin a ward.” - (NPHCE District Nodal Officer, Thrissur) The journey of the NPHCE programme in Kerala started small, with just five districts. But as its success became evident, the state government expanded it to all 14 districts, showing a strong commitment to making sure elderly care reaches as many people as possible. The programme didn’t just grow in size; it also integrated elderly care into existing health structures, especially at the Community Health Centre (CHC) level, with staff dedicated to elderly and palliative care. This thoughtful expansion demonstrates a methodical approach to making sure elderly care becomes a permanent part of healthcare in Kerala. 2.2 Human resource allocation of the programme In analysing the distribution of healthcare professionals across districts for the NPHCE and NCD clinics in Kerala, significant variations emerge in staffing levels. Alappuzha, Kozhikode and Idukki exhibit moderate staffing, with emphasis on NCD clinics and minimal presence in NPHCE. Pathanamthitta shows a balanced approach with a specific focus on physiotherapy and dietetics alongside basic healthcare provisions. Thrissur stands out with robust staffing, particularly in nursing roles (Table 1 ). These findings point to the need for more standardised and equitable distribution of healthcare resources to optimise elderly care services across all districts. Table 1 The district-wise staffing numbers in NCD and NPHCE clinics. District Total HR Doctors Nurses Physiotherapist Dietician NCD NPHCE NCD NPHCE NCD NPHCE NCD NPHCE NCD NPHCE Sum Sum Sum Sum Sum Sum Sum Sum Sum Sum Alappuzha 9 0 2 0 3 0 2 0 2 0 Idukki 8 0 1 0 3 0 2 0 2 0 Kozhikode 9 0 1 0 3 0 3 0 2 0 Pathanamthitta 3 4 0 1 1 1 1 1 1 1 Thrissur 3 10 1 1 1 5 0 2 1 2 Thrissur district was identified as one of the relatively well-performing centres in terms of geriatric service readiness. The availability of designated medical personnel and supporting staff has strengthened geriatric service delivery at the district hospital. “GH Thrissur is functioning very well… They have a designated doctor for geriatric care here, and also all the necessary staff.” (NPHCE District Nodal Officer, Thrissur) It is also considered a key challenge facing the NPHCE that the shortage of dedicated staff at the CHC level. Without a separate nursing staff for NPHCE, it’s harder to provide the specialised care that elderly patients need. Moreover, in the geriatric wards, where only MBBS doctors are available, the absence of specialists means that the complex health issues of elderly patients might not always receive the comprehensive attention they require. “We have arranged an eight-bedded geriatric ward (four plus four, male and female ward), but we did not get any separate human resources, especially for this program; we got supporting staff from the NCD wing, one doctor, two staff nurses, and a physiotherapist.” (Medical Superintendent, THQH, Idukki) “At the CHC level, we don’t have separate nursing staff for NPHCE… The main problem is in the geriatric ward; only an MBBS doctor is available; no specialist is available." (NPHCE- District Nodal Officer, Idukki) The elderly are also addressing the need for improved healthcare resources and staffing to better serve the growing and diverse needs of patients. “Increase the number of doctors and medications so that more people can benefit from them.” (Beneficiary, NPHCE-DH Mavelikkara, 67 years, Male) 2.3 Stakeholder engagement The NPHCE in Kerala operates through a well-defined administrative hierarchy that integrates health services at the state and district levels. The implementation structure involves multiple layers of leadership and coordination across administrative and clinical domains. This reflects a dual administrative framework, where the State Mission Director (SMD) oversees programme administration and financial management, while the Directorate of Health Services (DHS) manages technical and medical aspects. Below these levels, state and district nodal officers ensure operational execution and monitoring. “The highest level is the minister, then the principal secretary; side by side are SMD and DHS. Doctor-related activities are done through DHS, and administration-related activities are done by SMD… Below that is the State Nodal Officer, and in every district, there would be a District Nodal Officer. SMD has district programme officers of NHM, who will administer this in the district.” (State Nodal Officer, NPHCE) At the primary and community health care level, the NPHCE in Kerala operates with limited dedicated staff for elderly care. While elderly clinics are conducted weekly at PHCs and CHCs, there are no uniformly appointed geriatric staff across all centres. In some CHCs, staff appointed under the palliative care or chronic disease programmes also provide elderly care services, including physiotherapy and NCD management, reflecting an integrated but resource-limited approach “Before in CHCs, people were appointed, but now we have changed everyone and no one is there in CHCs. In the remaining areas, the physician will be in charge of the elderly care programme. We don’t have separate staff in PHCs and CHCs, but elderly clinics are conducted weekly once… In CHCs, there is a staff member known as a chronic disease nurse. They are appointed as part of the palliative care programme. There will be one staff nurse and a physiotherapist exclusively for elderly care, palliative care, and NCD care. They only have these works.” - (Superintendent, DH Vadakara) The key elements of the programme encompass infrastructural development, systematic implementation processes, comprehensive service delivery, adequate human resource allocation, sustainable funding mechanisms, interdepartmental convergence, and robust monitoring and reporting systems. Collectively, these components reflect the NPHCE’s comprehensive and integrated approach to strengthening geriatric care and improving health outcomes for the elderly population in Kerala. 2.4 Program-Driven Infrastructural Transformation Kerala has made remarkable progress in strengthening healthcare infrastructure to better serve its ageing population, with the NPHCE playing a pivotal role in driving these changes. The state’s healthcare facilities, particularly newly established Family Health Centres (FHCs) and District Hospitals, have integrated elderly-friendly design features such as handrails, ramps, and accessible toilets, significantly improving the comfort, safety, and mobility of older adults. In addition to new constructions, retrofitting of existing facilities with such features is also underway, reflecting a statewide commitment to inclusivity and accessibility in healthcare delivery. “Infrastructure in all places has become elderly friendly. In all the newly built FHCs, hospitals, and everywhere with elderly-friendly rails, ramps, and toilets, these concepts have come.” (District Nodal Officer NPHCE, Idukki) “So even before the programme, they were getting care. And after the programme came, they were getting added care. Because we had an elderly-friendly hospital initiative under this programme, wherein some of the wards were made elderly-friendly.” (State Nodal Officer, NPHCE) The programme strategically manages and reallocates funds to ensure that elderly-friendly improvements are implemented across all health centres. Even when resources are limited, funds are combined with other projects to achieve the intended upgrades, demonstrating flexibility and commitment to accessible care. “The programme focuses on providing geriatric-friendly ramps instead of steps, doors, toilets, etc., in all centres like CHCs. Attempts are made to bring these facilities according to the availability of funds. Our concept is to convert all the centres to geriatric-friendly ones; if the funds are insufficient, we are trying to mingle with other projects and get it done.” (State Nodal Officer, NPHCE) Beyond large architectural changes like ramps and rails, the programme has introduced smaller, yet highly impactful, operational changes that directly improve the patient experience, even if patients do not realise the source of the improvement. “We have eliminated line systems, provided seating for the elderly, and ensured drinking water in all of the facilities. We can see that the changes have occurred, even though patients are unaware that the new chair they use when they visit was made possible by the programme.” (District Nodal Officer NPHCE, Idukki) Even though the programme has made major efforts to improve all facilities, there are also some infrastructural challenges that are faced by the elderly at health institutions, which cause a significant barrier to accessing essential healthcare services. The physical layout of the building, like the steep slope, makes it difficult for them to access the services provided there. This shows that while inside hospital facilities have become more elderly-friendly, outside access issues can still reduce the overall benefit of these improvements. “There is a building where we used to come and check for blood, BP, sugar, etc. But because of the difficulty of reaching there, I avoid... It’s a steep slope. I have breathing difficulty while climbing the slope.” -(Beneficiary, NPHCE-GH Alappuzha, 70 years, Female) 2.5 Services Provided under NPHCE The NPHCE programme in Kerala has focused on improving geriatric infrastructure and service delivery across different levels of the healthcare system. One of the program’s major objectives was to strengthen district hospitals by establishing dedicated 10-bed geriatric wards equipped with elderly-friendly features such as anti-skid floor tiles, ramps, rails, and customised furniture. These facilities were designed to create safe and accessible environments for older adults. “The primary objectives of the programme were to strengthen the district hospitals for geriatric care, and the main target was to have a 10-bedded geriatric ward at every district hospital. We have a hospital with anti-slip floor tiles, ramp facilities, rails, geriatric-friendly toilets, and furniture using the funds allocated.” (District Nodal Officer NPHCE, Idukki) “We have a 10-bedded geriatric ward… The ward is comfortable, well-ventilated, and patient-friendly.” (NPHCE Medical Officer, GH Thrissur) In addition to inpatient wards, several outpatient-based initiatives were implemented to improve accessibility and comfort for elderly patients. Separate queues, drinking water facilities, and department assistance were available in select hospitals, with GH Thrissur and DH Mavelikara emerging as the most geriatric-supportive centres overall. Only a few facilities, such as GH Thrissur and DH Mavelikara, had separate, well-maintained toilets, while features like mobility aids, ramp railings, and anti-skid flooring were inconsistently available. The main physical and emotional challenge faced by elderly patients is the particular difficulty with prolonged waiting times. Special provisions, including separate queues and pharmacy counters for NCD patients, were identified as important facilitators. “The elderly people struggle with waiting in queues…but now we have separate queues at the OP counters and a dedicated NCD pharmacy counter.” - (Staff Nurse, DH Wadakkancherry) “Now they have a separate queue for senior citizens; usually they don’t have... but today they do.” - (Beneficiary, GH Kozhikode, 73 years, female) Although basic accessibility features such as ramps and proximity of services were reported, significant limitations were noted with respect to space and privacy. Such limitations particularly affected counselling services, which require confidential discussions around diet, mental health, and socio-economic issues. Also, infrastructural limitations within the hospital, including lack of lifts and ramps in older buildings, restricted elderly participation in health promotion activities. “It is very congested… it is hard to provide counselling because the patients can’t hear or understand us properly and also there is no proper waiting area, and it gets very hot.” - (Dietitian, DH Kozhencherry) “There is no privacy… counselling takes time and requires digging into a patient’s social and financial background and we have conducted yoga and camps, often at Anganwadis. However, holding programmes on the upper floors of the hospital is difficult because there are no ramps or lifts to the higher levels in the old building.” - (Staff Nurse, DH Wadakkanchery) The state has made substantial progress in establishing geriatric-friendly services; variability in infrastructure and accessibility remains across districts, indicating the need for continued investment and monitoring. Only four facilities (DH Mavelikara, DH Vadakara, GH Alappuzha, and GH Thrissur) provided clear signage, while geriatric-friendly waiting areas were found in just three (DH Mavelikara, GH Alappuzha, and GH Thrissur). Although all ten facilities had department assistance, only three (DH Mavelikara, GH Alappuzha, and GH Thrissur) offered dedicated queues, and geriatric token stations were available at GH Mavelikara, GH Kozhikode, and GH Thrissur. Anti-skid flooring was limited to DH Thodupuzha and GH Thrissur. Four facilities (DH Mavelikara, DH Vadakara, DH Wadakkanchery, and GH Thrissur) provided mobility aids, with beds featuring railings in eight facilities (excluding DH Wadakkanchery and THQH Peerumedu). Ramp railings were absent in three facilities, while seating facilities were adequate at GH Alappuzha, GH Kozhikode, and GH Thrissur, with only GH Thrissur offering additional seat support. Separate and well-maintained toilets were accessible only at GH Thrissur and DH Mavelikara. Pharmacy queues and elderly-friendly activities were more widely present, but only GH Thrissur offered all 17 geriatric-friendly features. GH Thrissur and DH Mavelikara emerged as the most geriatric-supportive centres overall. 2.6 Fund Allocation of the Program Funding for the NPHCE programme in Kerala is routed through the National Health Mission (NHM) via an annual Programme Implementation Plan (PIP). Each year, the state submits a proposal to the Government of India, which is reviewed during NPCE meetings. Once approved, a Record of Proceedings (ROP) is issued, specifying the allocated funds. Allocated funds are utilised across multiple components, including infrastructure strengthening, capacity building, information, education and communication (IEC) activities, and outreach programmes. “We are getting funds from NHM. Each year we send a proposal, it is reviewed by the Government of India, and finally, after this, we will get ROP...record of proceedings with which we could know about the things granted for us.…from 2010-11 onwards, every year we had a substantial increment in the elderly programme.”- (District Nodal Officer NPHCE, Idukki) “We have been given funds from NHM for elderly care… for purchasing furniture, capacity building, IEC material, and also for conducting camps.” -(District Nodal Officer, Thrissur) Funding is always a challenge, but Kerala’s approach to the NPHCE programme shows how creative and committed the state is to elderly care. By adjusting available funds, they’ve managed to set up geriatric wards in multiple districts. However, while some districts have been able to establish more than one geriatric ward, the uneven distribution of resources means that providing consistent, high-quality care across the board is still a challenge. “The fund that we are receiving is from the NCD nodal officer. Last week, we received a fund of 50000 rupees for IEC, which can be used for NCD OP, geriatric OP, and palliative OP. During the COVID-19 pandemic, we received funding for setting up a geriatric ICU, so the geriatric ward that we had was upgraded to the geriatric ICU with a centralised oxygen supply." - (Medical Superintendent, THQH, Idukki) “We were using the funds to procure equipment like pulse oximeters, which benefited the latter in developing COVID First Line Treatment Centres (CFLTCs). So before, only we had all those facilities with the help of this programme. Even in the case of post-COVID patients who require physiotherapy care, they can also avail of the services through NPHCE.” - (Medical Superintendent, THQH, Idukki) “Utilisation of such funds also was going well; the only problem with respect to the district was a shortage of funds.” - (District Nodal Officer NPHCE, Idukki) “In some districts, more than one hospital has started a geriatric ward by adjusting the funds available.”- (State Nodal Officer, NPHCE) 2.7 Monitoring and Reporting of the Program Keeping track of progress is essential, and the NPHCE programme does this through detailed annual reporting, following guidelines from the Government of India (GOI). This structured approach helps ensure that the program’s impact is measured accurately and that there’s room for improvement based on real data. Recently, the merging of monitoring efforts for the elderly and palliative care programmes has made the process even more efficient, ensuring both elderly and palliative patients receive the quality care they need. “A yearly reporting is done based on the format sent by GOI, which normally, sometimes biannually, includes the number of beneficiaries visiting the OP, IP, availing of physiotherapy, and the number of patients cured and who died in IP.” - (State Nodal Officer, NPHCE) "Recently, monitoring of NPHCE and palliative care programme has been combined under one coordinator so that the monitoring process is going well.” - (Medical Superintendent, THQH, Idukki) Regular monitoring mechanisms are in place to review fund utilisation and programme progress. Monthly reviews and scheduled meetings at the district level enable oversight and accountability in programme implementation. “We review the utilisation of these funds every month… There is a meeting happening this Saturday.” (NPHCE- District Nodal Officer, Thrissur) A separate register is maintained for geriatric OP. But in many facilities, NPHCE data is combined with NCD reports, primarily because the reporting agency is the deputy DMO for both programmes. While this approach may simplify administrative processes, it can obscure the specific reach and effectiveness of NPHCE services, making it difficult to track elderly-specific outcomes and identify programme gaps. Maintaining distinct datasets for NPHCE would enhance clarity, improve monitoring, and support evidence-based decision-making for targeted geriatric care. "NPHCE data is combined with the NCD report because the reporting agency is the same, we are reporting to the deputy DMO. But the geriatric OP register is maintained separately."- (Medical Superintendent, THQH, Idukki) 2.8 Interdepartmental Convergence Working together is often the best way to get things done, and that’s exactly what’s happening with the NPHCE programme. By coordinating with the palliative care programme, the geriatric care initiative has been able to deliver better services and achieve more effective outcomes. “We are mingling with other programmes like palliative care so that we are able to perform well. We are more concentrated on Peerumedu Hospital for ward-related services. We are providing some services, like physiotherapy, and some equipment under the programme. There are so many activities taking place under the palliative care programme.” (NPHCE- District Nodal Officer, Idukki) “We work here as a team and are not alone… if patients are bedridden, we refer them to the palliative care unit, and doctors visit them at home.” -(NPHCE Medical Officer, GH Thrissur) The clinic operates through a shared-care model in which medical consultations are integrated within routine general outpatient services, while the NCD team primarily undertakes screening, monitoring, follow-up, and patient education. This pragmatic arrangement allows continuity of services in the absence of programme-specific medical officers; however, it limits the clinic’s ability to function as an autonomous unit providing comprehensive NCD care. “We have a physician under NCD, posted in a geriatric clinic." -(Medical Superintendent, THQH, Idukki) “There is no specific MO under NHM for the NCD clinic here… The General OP doctors consult the patients, and we handle the monitoring.” -(Staff Nurse, NCD Clinic, GH Kozhikode) 3. Service Utilisation and Programme Resources 3.1 Service utilisation and disparities The daily utilisation of non-communicable disease (NCD) services across various healthcare facilities in Kerala reveals distinct patterns in both general outpatient (OP) visits and physiotherapy OP visits. Facilities like DH Vadakara and GH Alappuzha show high daily OP utilisation, which shows a significant demand for NCD services in these locations. Physiotherapy utilisation also varies, with GH Thrissur, GH Alappuzha, and GH Kozhikode recording relatively high daily visits (50, 50, and 40, respectively), indicating a need for physiotherapy services at these centres. Conversely, certain district hospitals, such as DH Wadakkancherry and DH Mavellikara, report no daily physiotherapy visits, suggesting either limited access or lower demand for these services. This variability underscores potential areas for improvement, where adjusting resource allocation or expanding services could help ensure more consistent access to NCD and physiotherapy care throughout the region. (Table 2 ) Table 2 Daily utilisation of NCD services Facility Average Daily OP (All Services) Average Daily OP (Physiotherapy) GH Kozhikode 120 40 DH Vadakara 150 15 GH Thrissur 120 50 DH Wadakkancherry 30 0 DH Thodupuzha 60 12 TQHQ Peerumedu 30 5 GH Alappuzha 150 50 DH Mavellikara 56 0 GH Pathanamthitta 56 28 DH Kozhencherry 35 15 The high number of primary cases reported at THQH Peerumedu underscores a significant reliance on secondary care facilities for routine geriatric services. This trend reflects potential gaps in the accessibility and utilisation of primary healthcare centres in the taluk, suggesting that many older adults may bypass or lack adequate support at PHCs and CHCs. Addressing these gaps through strengthened primary care infrastructure, better referral linkages, and community outreach could reduce the patient load at the taluk hospital while ensuring timely and accessible care for older adults. Moreover, understanding the patterns of service utilisation can inform targeted interventions to improve health system efficiency and optimise the distribution of geriatric services. “Most cases reported at THQH Peerumedu are primary, with some secondary cases as well. The hospital serves as the taluk headquarters, and due to the absence of other nearby hospitals, it also handles a higher number of primary geriatric patients. This underlines the need to assess PHC and CHC functioning in Peerumedu taluk to understand primary care management.”- (Medical Superintendent, THQH, Idukki) 3.2 Facilitators and Barriers for the Beneficiary Beneficiaries of elderly services experience both improvements and challenges in accessing healthcare, reflecting the ongoing efforts of programmes to enhance elderly care while highlighting persistent gaps. The introduction of operational measures, such as separate queues for senior citizens, has improved convenience and accessibility for older adults, helping them navigate healthcare facilities with greater ease. “Usually they don’t have separate queue... but today they have a separate queue for senior citizens.”- (Beneficiary, GH Thrissur, 72 years, female) Beneficiaries continue to face a lack of basic support services, such as wheelchairs, emphasising the need for universal accessibility in healthcare settings. These infrastructural gaps indicate that while certain improvements have been implemented, fundamental support services remain limited. Long queues, extended waiting times, and high transportation costs are additional barriers that limit timely access to healthcare for older adults. These operational challenges often require the assistance of family members to navigate “They should do all these things for everyone... If someone falls down, they need a wheelchair, right? They should do such things.” - (Beneficiary, GH Pathanamthitta, 64 years, male) “Long queues and waiting times are some of the biggest challenges I have faced, apart from the cost of transportation to these facilities, which is more expensive than the treatment itself. Even in the OP or for seeing a doctor, I feel weak standing in the queue, and I want to sit down soon… There is no queue for the elderly.” - (Beneficiary, GH Kozhikode, 60 years, Male) “Long queues and waiting times are some of the challenges I have faced, apart from the cost of transportation to these facilities, which is more expensive than the treatment itself.” - (Beneficiary, GH Pathanamthitta, 64 years, male) Access to expensive medications is another critical barrier. While public facilities provide low-cost drugs, patients often need to travel to private pharmacies to obtain essential medicines, incurring additional costs. There are also infrastructural gaps in basic amenities, such as water availability, which further affect the overall healthcare experience of elderly patients “They only have cheap medicines… we need to go to other hospitals to get them, but we’ll have to spend a lot on an autorickshaw… so I go to a nearby private shop.” - (Beneficiary, DH Thodupuzha, 64 years, female) Limited proximity of healthcare facilities also restricts access for elderly patients, particularly for those who are weak or live alone, making travel difficult and sometimes unsafe. While primary-level facilities like PHCs and CHCs are generally more accessible, the NPHCE programme is not yet implemented at this level, highlighting the importance of expanding elderly-focused services to primary care centres to improve coverage and reduce travel burden: “It is always better to have more services. We would be happier to have the nearest health centre. Irrespective of the number of elderly citizens in the locality, it is disappointing that we do not have a health centre nearby.” - (Beneficiary, GH Kozhikode, 73 years, female) “I go to this Kozhencherry hospital as well. I can’t travel far, as there is no one to take me along.” - (Beneficiary, DH Kozhencherry, 60 years, female) “I am happy and satisfied with the service I get in these centres. The main concern for me is the cost of transportation and meeting the doctors, which makes me think twice before going to such facilities.” - (Beneficiary, GH Thrissur, 68 years, Male) “Water shortage… we have to pay money despite them not bringing water.” - (Beneficiary, GH Alappuzha, 70 years, female) 3.3 Barriers and Disparities in the Programme Implementation Despite the programme achieving success in a few centres, substantial barriers persist across many others, limiting consistent implementation and equitable access to geriatric care. One major issue is the lack of dedicated human resources, which makes it difficult to provide the specialised care for elderly patients. Additionally, the programme faces challenges in gaining the political support that is necessary to expand and improve further. Overcoming these obstacles will be crucial for the NPHCE programme to fully realise its potential in caring for Kerala’s elderly population (Table 3 ). “We have arranged an eight-bedded geriatric ward (four plus four male and female wards), but we did not get any separate human resources, especially for this program; we got supporting staff from the NCD wing, one doctor, two staff nurses, and a physiotherapist.” - (Superintendent, DH Vadakara) In most centres, there are no dedicated staff assigned specifically for the NPHCE; they rely on staff from the NCD wing. While funds are being utilised for equipment and service delivery, the absence of dedicated personnel limits the program’s capacity to provide continuous and specialised geriatric care. Training activities, including essential certifications such as the morphine license, have been disrupted due to the COVID-19 pandemic, leading to gaps in staff readiness. This highlights the need for dedicated human resources and systematic, timely training to ensure effective programme implementation and continuity of specialised services. “Training activities used to take place on a regular basis, but for the last year, due to COVID, training activities have been suspended. Staff of the NCD wing are Responsible for implementation, and physiotherapy is a part of NPHCE.” - (Superintendent, DH Vadakara) “We did not get training and I did not get the certificate. The doctor who was working here before me had the certificate…due to the COVID pandemic, training sessions are not happening.” - (Medical Superintendent, THQH, Idukki) Despite managing complex geriatric and post-surgical cases, the physiotherapist reported limited exposure to NPHCE-specific training. Existing training opportunities were largely online and perceived as inadequate for skill-intensive rehabilitation services, underscoring the need for hands-on, programme-oriented capacity building. “Not since I came here i didn’t get any training related to NPHCE… I participated in one online training for the 'SWAAS' Clinic, but it was difficult to be active in an online session. I feel that offline, practical training is necessary.” - (Physiotherapist, DH Vadakara) Despite staffing and infrastructure limitations, the clinic manages a high daily patient volume. However, ongoing renovation work has reduced waiting space and compromised patient comfort and clinic organisation. The lack of a consolidated service area has also increased the risk of missed registrations and incomplete follow-up. “We see 140 to 160 patients a day...In that, about 40 per cent to 50 per cent of our patients are over 60 years old.” - (Staff nurse, THQH Peerumedu) Limited workspace for staff in the NCD wing, reflecting infrastructure challenges in providing elderly-friendly services. “The dietician, the doctor, and the staff checking blood pressure all work in small, cramped rooms.” - (Physiotherapist, DH Thodupuzha) The National Programme for the Health Care of the Elderly (NPHCE) faces a barrier due to a perceived lack of political will. Despite a significant proportion of politicians being in the geriatric age group themselves, the response to addressing the needs of the elderly through the NPHCE programme is described as suboptimal. The observation implies that, despite the presence of politicians from the geriatric age group, their priorities may not be aligned with the goals of the NPHCE programme. This misalignment may be due to competing priorities or differing perceptions regarding the urgency and importance of geriatric healthcare. “The barrier is the lack of political will to take up the programme. Even though a majority of our politicians belong to the geriatric age group, if we approach them for any need, the response is not so well." - (Medical Superintendent, THQH, Idukki) The high service burden on the health system, with elderly patients forming the majority of those seeking care. A large proportion present with multiple comorbidities, which increases the complexity of care delivery. The cost of managing chronic conditions is substantial, creating economic hardship for many families and contributing to inequities in access to care. Also, geriatric health continues to receive the least priority among public health programmes. Even though the burden is substantial, resource allocation and strategic planning remain inadequate, further widening disparities in access to care. While there are efforts to establish Regional Geriatric Centres across districts, progress remains slow due to economic and structural constraints. “There is a huge volume of patients, approximately 80% of the total population. They have multiple comorbidities. Some treatments are very expensive, like for heart failure, dialysis, cancer etc… all this can be unaffordable.” - (NPHCE, State nodal officer) “When we talk about the programme as a whole, out of all the programmes, this programme is given the least priority. Trying to set up Regional Geriatric Centres in all the districts, similar to that of Trivandrum. Then there are some economic issues.” - (NPHCE- District Nodal Officer, Idukki) Access to geriatric healthcare remains a major challenge in remote and hilly regions like Idukki. Limited human resources, poor availability of speciality services, and difficult terrain restrict service reach. There is a need for stronger decentralisation and improved service delivery closer to the community. “I felt gaps with respect to the lack of HR, especially from the perspective of the Idukki district. Accessibility issues are still persisting, so more decentralisation should happen, and speciality services are very limited in the district.” - (Medical Superintendent, THQH, Idukki) Physical infrastructure limitations affected service delivery in the PMR unit, particularly for elderly patients with mobility impairments, with inadequate provisions for privacy and essential amenities within the treatment area. “It would be better if there were an attached bathroom, as it is difficult for stroke patients to walk to the outside toilets. For privacy, we currently use curtains, as the room is not spacious enough to have a separate room.” - (Physiotherapist, DH Kozhencherry) A major barrier in several centres is the insufficient allocation of funds, which limits the establishment and expansion of geriatric-friendly wards. Inadequate funding also constrains initiatives such as doorstep delivery of medicines, home-based medical checkups, and e-health services, despite the potential for ASHA workers to facilitate these services. Additionally, many facilities lack basic geriatric-friendly infrastructure, such as ramps and rails, further impeding accessibility for elderly patients. The combination of limited financial resources and inadequate infrastructure reduces the program’s capacity to deliver inclusive and comprehensive care for the ageing population. “The main issue we are facing in this district is a lack of funds, and in general, hospitals for setting up geriatric-friendly wards did not receive much focus. If we get more funds and if people gain more awareness about the needs and importance of the programme, we can really make changes.” - (NPHCE- District Nodal Officer, Idukki) “We have a concept of doorstep delivery of medicines, with the help of ASHA workers, which is possible. We can improve the services through ASHA by providing home delivery of medicines, medical checkups, and assistance for e-health, but we don’t have a separate fund for this.” - (NPHCE- District Nodal Officer, Idukki) “No ramps and rails are there, as we did not receive further funds.” (Medical Superintendent, DH, Kozhikode) Table 3 Key Implementation Barriers and Challenges of the NPHCE Key Barriers/Challenges Description Lack of professionals with Specialisation There is a lack of geriatric specialised doctors in Kerala, hindering dedicated geriatric care. Lack of State Plan Fund The Kerala government faced funding issues for implementing the programme in all 14 districts, necessitating support from the Government of India. Reality or Reason for No Geriatric OPD in PHC/CHC The majority of patients (70%–80%) in CHC or PHC are elderly, making it impractical to set up a separate geriatric OP or prioritise the elderly population exclusively. Feedback about Geriatric Wards Feedback indicates that the 10-bedded geriatric wards set up under the programme accommodate diverse patient needs such as surgery, medicine, and respiratory care, posing operational challenges. Confusion Among Doctors The establishment of separate geriatric wards led to confusion among doctors regarding appropriate ward admissions for patients with varied healthcare needs. Healthcare Service Disparity: Non- Palliative Patients Elderly patients who are not bedridden face difficulty accessing primary healthcare services due to mobility issues, contrasting with palliative care patients who are predominantly bedridden. Growing Elderly Population The increasing elderly population is accompanied by rising instances of hearing impairments, dental issues, and vision problems, necessitating targeted healthcare interventions. Low Political Will Despite a significant proportion of politicians being elderly, there is a lack of adequate response and support for addressing geriatric healthcare needs. Lack of Awareness among Policy makers Policymakers are often unaware of the distinct needs of geriatric care, assuming it can be integrated with palliative care initiatives. Low Visibility and Limited Awareness of the Programme Among the Community The programme has received limited attention, resulting in a weak implementation focus. A significant proportion of older persons and their caregivers are unaware of the programme and the services available under it, indicating gaps in outreach and communication strategies. Not prioritizing elderly care Elderly care services are often overlooked and not given the attention they deserve despite the growing elderly population. Co-implementation with National Programme for Prevention and Control of Cancer Diabetes, Cardiovascular Diseases & Stroke (NPCDCS) and Palliative care programme Co-implementation with the NPCDCS programme often results in sabotaging the importance of the programme thus resulting in inability to project programme specific outcome 4. Suggestions for Improvement of the Programme One of the key recommendations is the need for dedicated staff to assist geriatric patients. This suggestion is seen as crucial, particularly in the context of implementing e-health initiatives and vaccine drives. By appointing separate staff such as doctors, nurses, and physiotherapists under the programme, service delivery could be significantly improved. This would not only ease the implementation process but also ensure that elderly patients receive the specialised attention they need (Table 4 ). “The main issue that we are facing in this district is a lack of funds, and in general hospitals, setting up geriatric-friendly wards has not received much focus. If we get more funds and if people gain more awareness about the needs and importance of the programme, we can really make changes.” - (Superintendent, DH Vadakara) “We need to increase awareness and capacity building. Doctors and staff need training on the programme's goals. For example, clinics need physical modifications like ramps and handrails to be elderly-friendly”- (District Programme Manager, Thrissur) “In my opinion, training and converting hospitals to geriatric-friendly ones are core factors. If we can appoint a separate staff for helping geriatric people, it will be well and good, and it is highly relevant in situations like the implementation of e-health, vaccine drives." - (Superintendent, THQH Peerumedu) “Awareness should be created at the bottom level.” (State Nodal Officer, NPHCE) In most of the facilities, dedicated NPHCE outpatient services were initially provided through a separate Medical Officer; however, staff shortages resulted in the merger of NPHCE and NCD clinics following reassignment of personnel to casualty services. Staff shortages were identified as a key constraint to delivering elderly-focused services, limiting the ability to organise dedicated clinic days and preventive or promotive activities. “Initially, we had two Medical Officers, one for NCD and one for NPHCE, and ran separate outpatient clinics. Due to staff shortages, the NCD doctor was reassigned to the casualty department, and NCD and NPHCE services are now merged.” - (Medical Officer, GH Pathanamthitta) “We need more staff. If we had more hands, we could dedicate two days a week specifically for those over 60… collect their phone numbers to call them for special programmes like yoga or mental health sessions. Currently, the rush is too high to do anything extra for them.”- (Staff nurse GH Pathanamthitta) Incorporating geriatric-specific equipment into rehabilitation services is recommended to better accommodate functional limitations among elderly patients. “Providing special beds that are lower in height would help so they don't have to climb up”- (Physiotherapist, DH Kozhencherry) Despite infrastructural and staffing strengths, the institution-based services alone are insufficient to meet the growing needs of the elderly population. Greater emphasis on field-level implementation and outreach was highlighted as a critical requirement. There is a high importance in community-based engagement, particularly for addressing mental health and social isolation among older adults. “To take care of these people, we need to have field-level activity… There is no point in me sitting here and saying to do this in the district. This has to reach the people. The field staff should go for such gatherings, such as the Kudumbashree meeting, and give them classes about the mental health of the elderly.” -(NPHCE- District Nodal Officer, Thrissur) Despite a high burden of age-related and gender-specific conditions, geriatric care remains fragmented, with limited attention to mental health and social isolation among older adults, which emphasises the need of coordinated cross-referral mechanisms across NCD, palliative care, and mental health programmes. “Geriatric care needs to recognise condition-specific and gender-specific issues such as arthritis, prostate-related problems in men, and health concerns unique to elderly women. Mental health remains largely neglected, especially as many older adults live alone due to the migration of their children, leading to significant loneliness. The absence of coordinated cross-referral between NCD, palliative care, and mental health programmes limits the comprehensiveness of care.”- (District Programme Manager, Thrissur) Strengthening geriatric rehabilitation under NPHCE requires targeted investments in human resources and infrastructure. Respondents emphasised the need for permanent physiotherapists, occupational therapy services, and a dedicated rehabilitation nurse to improve counselling, triage, and continuity of care. The need for accessible infrastructure was strongly articulated. “Having a dedicated, disabled-friendly ward on the ground floor is essential because our patients find it very difficult to navigate ramps and stairs.”- (Physiatrist, GH Alappuzha) Elderly people emphasise the need for social interaction and community engagement among seniors. The elderly often face loneliness and isolation, which can have significant negative impacts on their mental and emotional well-being. “Aged people are alone at home. They are getting bored. They should gather people like us and make arrangements to talk to people like you. We feel happy.” (Beneficiary, GH Alappuzha) 65 years, Male) Table 4 Expert Recommendations for Strengthening Geriatric Care in Kerala's Health System Recommended Strategy Description Incorporating Geriatric Care in Medical Curriculum There should be a chapter for geriatric care in the curriculum. Not only about system care, it should also include emotional care and social care. Introducing Specialised Geriatric Courses for Medical Professionals There should be a parallel course on geriatric care at the medical college to train all the doctors and staff nurses. Transforming Healthcare Institutions into Geriatric-Friendly Facilities All the health care institutions should be converted into geriatric-friendly ones. Including Taluk hospitals, PHCs, and CHCs. Providing Dedicated Transportation Services for Geriatric Patients Transportation services should be provided for geriatric patients. In some of the hospitals, there is a transportation service as a part of the palliative care unit. But it should be considered as a system. Promoting multi-sectoral involvement in geriatric care Geriatric care is not only the responsibility of the health department. Local governments and NGOs should also get involved in this. LSG can make a place where elderly people can walk. Then we can get a synergistic result under geriatric health. Enhancing Accessibility and Decentralisation of Services Accessibility issues are still persisting, so more decentralisation should happen, and speciality services are very limited in the district. Since the district's population is mainly rural poor, more facilities for affordable speciality services should be made accessible to its population. Defining programme-specific guidelines for implementation and programme-specific indicators for monitoring and evaluation Since the implementation of similar programmes, such as NCD and Palliative care programmes, is being carried out by the same nodal officer, there is ambiguity regarding the programme indicators and the outcome. Improve awareness among the health care workers and the general population regarding the programme and its objectives Lack of awareness regarding the programme among the beneficiaries and the providers often result in achieving the potential outcome. DISCUSSION This assessment points to a central tension that may be termed the Kerala Geriatric Care Paradox ; while the state has achieved notable success in expanding geriatric infrastructure and establishing dedicated wards across all districts under the NPHCE, these structural gains have not consistently translated into accessible, equitable, or well-integrated elderly care at the primary level. This paradox underscores a disconnect between programme expansion and service delivery, resulting in continued reliance on secondary care and unmet preventive needs among Kerala’s ageing population. This assessment of NPHCE in Kerala assumes significance in realising that it has made extensive progress in infrastructure development in secondary level, especially in establishing geriatric wards in each district. The quantitative results reveal irregular service delivery in primary levels, a lack of manpower in healthcare, and confusion in fund allocation and accountability of programmes. The overall results using multiple methods indicate that although NPHCE has arrived in Kerala, an appropriate time and place programme, with respect to Kerala's need for handling this age factor in the population, this programme has not yet utilized its full potential in being properly integrated at primary levels and in having trained manpower. Significant progress has been made in meeting the healthcare demands of the ageing population in Kerala under the NPHCE programme. An important step towards enhancing geriatric care has been taken with the effective creation of geriatric wards in major hospitals of all 14 districts, after a trial period in five districts. The deliberate choice to spread the programme statewide in spite of financial difficulties highlights the state government's dedication to improving senior citizens' access to healthcare. Implementing the programme through the comprehensive public health care infrastructure was one of the strengths of the programme as mentioned in Verma et al. and Joshi et al. ( 19 ) ( 20 ) The introduction of NPHCE was timely given Kerala’s rapidly ageing population, the increasing burden of chronic diseases and multiple comorbidities, limited access to routine healthcare services due to physical, social, financial and mobility limitations, and gaps in the provision of elderly-friendly infrastructure and trained geriatric care personnel within existing health facilities. One of the most notable successes of the NPHCE initiative is the establishment of dedicated geriatric wards, starting with Pathanamthitta District Hospital. The expansion of geriatric wards to all districts, including Neyyatinkara in Trivandrum and Kollam District Hospitals, highlights the program's widespread impact. Nonetheless, maintaining dedicated geriatric outpatient services remains a challenge. The high proportion of elderly patients (70%-80%) in Community Health Centres (CHCs) and Primary Health Centres (PHCs) makes it impractical to establish separate outpatient departments exclusively for the elderly. The programme has shifted its focus from enhancing geriatric-friendly infrastructure, such as installing ramps, rails, and suitable furniture, to better accommodate the needs of elderly patients, similar to findings from other parts of India ( 21 ). Similar to observations in other elderly welfare initiatives in Kerala, such as “ Vathilpadi Sevanam” (Deliver essential public services directly to the homes of vulnerable citizens, including the elderly (60+), persons with disabilities, bedridden patients, and those in extreme poverty) and “ Vayomithram” (Provides health care and support to elderly above the age of 65 years residing at Corporation/Municipal Areas in the state), the NPHCE programme has demonstrated positive impacts in improving healthcare access and promoting dignity among older adults. Consistent with prior evidence, challenges remain in ensuring equitable reach, adequate staffing, and accessibility, particularly at primary care levels. These findings highlight the continued need for innovative strategies, community engagement, and strengthened integration of services to provide comprehensive, age-friendly care for Kerala’s rapidly ageing population ( 8 ). The nonavailability of trained geriatric doctors has resulted in MBBS graduates being appointed for the management of older patients. This is a pragmatic solution but highlights the need for further training and specialisation in geriatric care. Studies by Vaishnav et al. emphasise that specialised geriatric care is essential, especially for those older adults with complex health needs ( 21 ). Similar shortages have been observed in other parts of India, where healthcare providers are often reassigned from geriatric wards to other services like palliative care and non-communicable disease (NCD) clinics ( 16 ). Similarly, reassignment of nurses recruited for elderly care to other departments, such as NCD and palliative care clinics, remains a challenge to the provision of care for older person. This reflects a broader issue of inefficient resource utilization, as described by Dumka et al., who note that human resource allocation in India's healthcare system often results in fragmented care ( 22 ). The decentralised nature of Kerala's healthcare delivery model, while intended to optimise resource use, has resulted in a dilution of focus. Nurses are often required to cover multiple programmes, leaving elderly patients without dedicated care. This issue is compounded by a lack of systematic training for healthcare providers, an issue also raised in global studies on geriatric care. Studies from other regions, such as Jones et al., have similarly highlighted that the shortage of specialised healthcare providers undermines the efficacy of elderly care programmes ( 23 ). This highlights the need for sustained, integrated, and adaptive approaches beyond initial programme roll-out to comprehensively address the health and care needs of Kerala’s ageing population. The reliance on general practitioners rather than specialised geriatricians to manage geriatric wards complicates care, especially for elderly patients with specific needs. The reassignment of geriatric staff to general duties is another area of concern, as this further reduces the focus on specialised elderly care. Racz's research echoes this sentiment, emphasising the need for a greater focus on specialised geriatric medicine to improve healthcare outcomes for the elderly ( 23 ) ( 24 ). There is a clear need for increased training programmes that equip medical professionals with the skills necessary to address the unique challenges faced by the elderly population. Similar to the Punjab study, which identified only moderate readiness for geriatric services and highlighted the urgent need to strengthen leadership, governance, financial allocation, and training programmes at peripheral healthcare levels, it strongly corroborates the findings of this study. Both studies point to a systemic weakness: insufficient staffing and low prioritisation of elderly care at the grassroots level. Consequently, advancing the NPHCE requires directly addressing these gaps by establishing dedicated geriatric leadership, ensuring sustainable and non-mingled financial support, and implementing integrated care models. Such measures must go beyond infrastructure enhancement to guarantee comprehensive, accessible, and high-quality preventive, curative, and rehabilitative services for older adults across all tiers of healthcare ( 25 ). A secondary analysis of the 5th Indonesian Family Life Survey showed that older adults in rural areas and with lower education primarily use community health centres, highlighting how socioeconomic and accessibility factors shape care-seeking ( 26 ). Similarly, a qualitative study from rural Pakistan found that inadequate staff, medicines, and infrastructure at primary care facilities forced people to seek secondary-level services ( 27 ). These findings align with our Kerala study, where elderly individuals prefer primary care but NPHCE services were largely unavailable at PHCs and CHCs, emphasising the need to expand geriatric programmes to primary care for better access to preventive and supportive services. Overall, the health care delivery was inconsistent and inadequate, as the elderly population did not receive comprehensive care, including vital health care services like mental health counselling and chronic disease management. Flexible fund utilisation under the National Programme for Health Care of the Elderly (NPHCE) has facilitated the establishment of geriatric wards and the upgrading of facilities in several districts. However, limitations arise due to uneven or insufficient funding, leading to disparities in service availability and infrastructure. A study highlighted that funding constraints, infrastructure gaps, and a shortage of trained personnel in geriatric care hamper quality service delivery, especially in rural and coastal areas ( 8 ). This highlights the need for equitable and sustained financial support to ensure comprehensive and accessible geriatric services across all regions. The utilisation of funds across NPHCE, Palliative Care, and NPCDCS in a shared manner has led to considerable ambiguity in programme-wise fund receipt, allocation, and utilisation. The presence of a single nodal officer overseeing multiple programmes, along with the absence of clearly defined financial and operational guidelines, has limited programme-specific accountability and oversight. In addition, outcomes are often reported in an aggregated manner, making it challenging to attribute results to individual programmes. The overlap in beneficiary populations further contributes to this complexity, thereby constraining a clear assessment of programme-wise performance, efficiency, and impact. Although the programme envisages comprehensive care for older persons across the continuum of care, its implementation has largely been confined to infrastructural strengthening, with limited emphasis on primary care–based geriatric services. Community-level and preventive components remain insufficiently developed, similar to findings in Joshi et al. In contrast to programmes such as RCH, IHIP and NPCDCS, NPHCE has had relatively low programmatic visibility and integration within routine health system processes, suggesting that the system may not have been fully prepared to internalise and operationalise the programme at scale. NPHCE was introduced at an appropriate time, particularly in view of Kerala’s advanced demographic transition and the increasing health needs of older persons. At the time of its rollout, Kerala already had a well-established palliative care system that had evolved since the 1990s and was deeply embedded within the public health system and community structures, playing a substantial role in addressing the care needs of older persons. In this context, several health and supportive care needs of older persons were perceived to be addressed through existing palliative care services. This has, at times, led to an implicit assumption that palliative care constitutes comprehensive care for the elderly, which does not fully align with the broader spectrum of geriatric health needs. Consequently, NPHCE was often implemented in close alignment with palliative care activities, which, while enabling service convergence, may have reduced the programme’s distinct visibility and prioritisation at the implementation level. This underscores the need for clearer articulation of complementary roles and programme-specific focus to optimise elderly care services in the state. Moreover, Tthehealth system is still in the process of clearly articulating and responding to the distinct and evolving needs of an ageing population. A more deliberate strategy to integrate NPHCE with existing programmes such as NPCDCS, Palliative care, “ Vayomitram” , “ Vathilppadi Sevanam” , while explicitly addressing gaps specific to older persons, could have enabled a more efficient, coordinated, and impactful approach to elderly care in the state. The decentralised care model in Kerala, which includes programmes such as elderly recreation parks and yoga sessions, offers a promising avenue for improving the quality of life for the elderly. Similar approaches have been highlighted in studies on healthy ageing in Asia ( 28 ) ( 29 ). The challenges, such as a lack of political will and misconceptions regarding the integration of geriatric and palliative care services, must be addressed, as Aldridge et al. have pointed out in their review of global palliative care integration ( 30 ). Raising awareness about the distinct needs of geriatric patients and incorporating geriatric topics into the medical curriculum, as suggested by Kotsani et al., will be crucial in overcoming these challenges ( 27 ). The findings of Dev et al. on resource utilisation for healthy ageing in Kerala resonate with our study results, particularly regarding awareness and uptake of elderly care services. Both studies highlight barriers such as accessibility constraints, socioeconomic factors, and reluctance to adopt supportive resources. These observations show the importance of a structured, community-sensitive, and well-coordinated approach to enhance both awareness and use of healthy ageing resources across the state ( 31 ). With the best decentralised model, several local initiatives in Kerala have demonstrated how local self-governments can enhance accessibility, inclusiveness, and monitoring of elderly care services in a holistic way, incorporating physical, mental, social and spiritual elements Leveraging Kerala’s strong decentralised governance framework, several local initiatives have demonstrated the potential of local self-governments to enhance the accessibility, inclusiveness, and monitoring of elderly care services through holistic approaches that address physical, mental, social, and spiritual well-being. Manickal Grama Panchayat’s initiative to establish Age-Friendly Forums and create inclusive spaces for older persons represents a pioneering model of local governance in the state. By actively engaging schools, Parent-Teacher Associations, and wider community stakeholders, the initiative promotes intergenerational bonding and works to reduce ageism. The Panchayat’s phased strategy to transform public institutions into Old-Age-Friendly Institutions , with coordinated support from multiple government departments, underscores the potential of decentralised and community-driven approaches to elderly care. Its emphasis on multi-sectoral collaboration, systematic ward-level data collection, and targeted service delivery highlights how local governance can respond more effectively to the diverse needs of older persons ( 32 ) ( 33 ). Embedding community engagement and age-friendly infrastructure within local systems complements facility-based services and helps address gaps in the reach and effectiveness of NPHCE. If successfully scaled, the Manickal model could serve as a replicable framework for other local bodies to develop sustainable, age-friendly ecosystems that strengthen both preventive and curative geriatric care. CONCLUSION The evaluation of the National Programme for Health Care of the Elderly (NPHCE) in Kerala highlights both the progress achieved and the challenges that remain in addressing the health needs of a rapidly ageing population. The study findings demonstrate how integrating geriatric services into existing healthcare structures can strengthen access to care, improve infrastructure, and promote age-friendly environments. The establishment of geriatric wards across districts, the introduction of elderly-friendly design features, and the incorporation of physiotherapy and rehabilitation services represent major milestones toward comprehensive geriatric care. Even with Kerala being the Indian state with the highest proportion of older adults and having a well-established, decentralised public health system, the evaluation reveals a critical gap in geriatric specialised service delivery at the primary level. There exists a significant absence of specifically designed initiatives and geriatric-friendly facilities for the aged in the primary health facilities, with geriatric services being predominantly a concern for the secondary-level health facilities. There are implementation barriers, including inadequate human resources, inconsistent funding, lack of specialised training, and uneven service delivery, particularly at primary and community health centre levels. The merging of geriatric and palliative care services, while operationally efficient, often diffuses focus from preventive and rehabilitative care for older adults. To ensure sustainability and equity, the programme needs capacity building, dedicated staffing, financial support, integration with other programmes and intersectoral collaboration involving local governments and communities. Strengthening monitoring mechanisms, expanding geriatric care to the primary level, and incorporating geriatric health into medical education are also essential. Declarations ACKNOWLEDGEMENTS We extend our sincere gratitude to the Directorate of Health Services (DHS), Kerala for granting permission and providing necessary support for this study. We acknowledge Dr. Sreeshma K. S., former intern at SHSRC-K, for her diligent assistance with conduct of KIIs and transcription during the initial stages of this study. We also thank the research assistant of the State Health Systems Resource Centre, Kerala (SHSRC-K), Dr. Thusharamol N. S., for meticulous proofreading of the manuscript. Special thanks are also due to Mr. Mahesh R, current intern at SHSRC-K and MPH student at Azim Premji University, Bhopal, for contributing an academic perspective that enriched the analytical scope of this paper. This work would not have been possible without the collaborative efforts and institutional support of all the individuals and entities. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest: The researchers claim no conflicts of interest. Author’s contribution: RMR and BAC provided overall leadership for the study. RMR was responsible for conceptualisation and supervision. BAC contributed to the methodology, project administration, data collection, and data analysis. HSS and SC conducted the centre survey and interviews and performed initial thematic analysis. Data analysis was supported by all co-authors. The original draft of the manuscript was prepared by BAC, RMR, DR, and ZS. PMG was responsible for review and editing of the manuscript. RMR provided critical expert feedback and final approval. DR, ZS, and PMG contributed equally to this work. Data availability: The datasets generated and analysed during the current study are not publicly available to protect the confidentiality of the participants, in accordance with the conditions of the ethical approval granted for this research. This restriction is due to the qualitative nature of the data, which includes in-depth interviews and key informant responses that contain detailed contextual and professional information; public release could compromise participant privacy or lead to indirect identification, particularly for key personnel in specific roles. Excerpts supporting the findings are included within the manuscript. Anonymised portions of the data may be made available from the corresponding author upon reasonable request and subject to approval from the Institutional Ethics Committee and relevant health authorities. Critical trial number: Not applicable Ethical consideration: The study received ethical clearance from the Institutional Ethics Committee of the General Hospital, Thiruvananthapuram (Sl.No 32/03/02/21-GHEC). All necessary permission was obtained from authorities before the conduct of the study, and consent was taken from each participant before interviews. Care was taken to ensure no harm was done to the participants of the study and that the smooth operation of NPHCE was not hampered. Consent to participate : Written informed consent was obtained from all participants prior to data collection. For key informants (policymakers, state and district nodal officers, and healthcare providers), consent included agreement to be identified by their professional roles in published findings, given the programme evaluation context where positional transparency is essential for accountability and analysis. For elderly beneficiaries and primary caregivers, confidentiality and anonymity were assured, and they were informed that only aggregated or anonymised data would be used in reporting. All participants were informed of the voluntary nature of the study and their right to withdraw at any stage without consequence. Consent to publication: All authors have read and approved the final version of the manuscript. They consent to its submission for publication in Discover Public Health and affirm that the work is original, has not been published previously, and is not under consideration for publication elsewhere. References Situation Analysis Of The Elderly in India [Internet]. [cited 2025 Dec 23]. Available from: https://www.mospi.gov.in/sites/default/files/publication_reports/elderly_in_india.pdf Banerjee S. Determinants of rural-urban differential in healthcare utilization among the elderly population in India. BMC Public Health. 2021 May 17;21(1):939. Rashmi R, Srivastava S, Muhammad T, Kumar M, Paul R. Indigenous population and major depressive disorder in later life: a study based on the data from Longitudinal Ageing Study in India. BMC Public Health. 2022 Dec 3;22:2258. Sarkar S. Providing Services for Elderly in Rural India – Is Anganwadi Centres a feasible option? International Journal of Medicine and Public Health. 2016 July 1;6:57–8. Malik C, Khanna S, Jain Y, Jain R. Geriatric population in India: Demography, vulnerabilities, and healthcare challenges. J Family Med Prim Care. 2021 Jan;10(1):72–6. National Programme for healthcare of Elderly(NPHCE) :: National Health Mission [Internet]. [cited 2025 Dec 23]. Available from: https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=1046&lid=605 Mini GK. Socioeconomic and demographic diversity in the health status of elderly people in a transitional society, Kerala, India. J Biosoc Sci. 2009 July;41(4):457–67. K S, Sathyamurthi DK. Growing Old in Kerala: A Comprehensive Review of Elderly Welfare Initiatives. Int J Res Rev. 2025 Aug 9;12(8):35–41. National Programme for Health Care of the Elderly(NPHCE) | Ministry of Health and Family Welfare | GOI [Internet]. [cited 2025 Dec 23]. Available from: https://www.mohfw.gov.in/?q=en/major-programmes/Non-Communicable-Diseases/Non-Communicable-Diseases-1 Ratcliffe J. Social justice and the demographic transition: lessons from India’s Kerala State. Int J Health Serv. 1978;8(1):123–44. Caldwell JC, Zachariah KC, Rajan SI. Kerala’s Demographic Transition: Determinants and Consequences. Pacific Affairs. 1999;72(3):458. Pritam B, Soumya C, Deepankar S, Prashant S. Technology Framework for India’s Road Freight Transport: Compliance and Enforcement Architecture Reform [Internet]. Asian Development Bank; 2021 Aug [cited 2025 Dec 23]. Available from: https://www.adb.org/publications/technology-india-road-freight-transport Study on the Health Situation of Urban Elderly in Kerala (1). National Policy for Older Persons Year 1999.pdf [Internet]. [cited 2025 Dec 23]. Available from: https://socialjustice.gov.in/writereaddata/UploadFile/National%20Policy%20for%20Older%20Persons%20Year%201999.pdf Vaishnav LM, Joshi SH, Joshi AU, Mehendale AM. The National Programme for Health Care of the Elderly: A Review of its Achievements and Challenges in India. Ann Geriatr Med Res. 2022 Sept;26(3):183–95. Mundada PS, Sharma S, Gupta B, Padhi MM, Dey AB, Dhiman KS. Review of health-care services for older population in India and possibility of incorporating AYUSH in public health system for geriatric care. Ayu. 2020;41(1):3–11. Mohan D, Iype T, Varghese S, Usha A, Mohan M. A cross-sectional study to assess prevalence and factors associated with mild cognitive impairment among older adults in an urban area of Kerala, South India. BMJ Open. 2019 Mar 20;9(3):e025473. Kidder DP, Fierro LA, Luna E, Salvaggio H, McWhorter A, Bowen SA, et al. CDC Program Evaluation Framework, 2024. MMWR Recomm Rep. 2024 Sept 26;73(6):1–37. Verma R, Khanna P. National program of health-care for the elderly in India: a hope for healthy ageing. Int J Prev Med. 2013 Oct;4(10):1103–7. Ovid [Internet]. [cited 2025 Dec 23]. Strengths, Weaknesses, Opportunities, and Threats... : Journal of the Indian Academy of Geriatrics. Available from: https://www.ovid.com/journals/jiag/fulltext/10.4103/jiag.jiag_9_23~strengths-weaknesses-opportunities-and-threats-analysis-of Vaishnav LM, Joshi SH, Joshi AU, Mehendale AM. The National Programme for Health Care of the Elderly: A Review of its Achievements and Challenges in India. Ann Geriatr Med Res. 2022 Sept;26(3):183–95. Dumka N, Mangat S, Ahmed T, Hannah E, Kotwal A. Adding health to years: A review of the National Programme for Health Care of the Elderly (NPHCE) in India. J Family Med Prim Care. 2022 Nov;11(11):6654–9. Jones CH, Dolsten M. Healthcare on the brink: navigating the challenges of an aging society in the United States. NPJ Aging. 2024 Apr 6;10(1):22. Besdine R, Boult C, Brangman S, Coleman EA, Fried LP, Gerety M, et al. Caring for older Americans: the future of geriatric medicine. J Am Geriatr Soc. 2005 June;53(6 Suppl):S245-256. Kumar S, Verma M, Aggarwal R, Chauhan S, Mishra S, Gill SS, et al. Assessment of the public health system preparedness to provide geriatric-friendly healthcare services in Punjab, India: A cross-sectional study. J Family Med Prim Care. 2025 Sept;14(9):4001–8. (PDF) EXPLORING THE REASONS FOR UNDERUTILIZATION OF PRIMARY HEALTH CARE SERVICES IN PAKISTAN: A QUALITATIVE ANALYSIS. ResearchGate [Internet]. 2025 Aug 9 [cited 2025 Dec 23]; Available from: https://www.researchgate.net/publication/348603834_EXPLORING_THE_REASONS_FOR_UNDERUTILIZATION_OF_PRIMARY_HEALTH_CARE_SERVICES_IN_PAKISTAN_A_QUALITATIVE_ANALYSIS Primary healthcare utilization by the elderly: a secondary analysis of the 5th Indonesian Family Life Survey. ResearchGate [Internet]. 2025 Aug 6 [cited 2025 Dec 23]; Available from: https://www.researchgate.net/publication/340501525_Primary_healthcare_utilization_by_the_elderly_a_secondary_analysis_of_the_5th_Indonesian_Family_Life_Survey Kotsani M, Kravvariti E, Avgerinou C, Panagiotakis S, Bograkou Tzanetakou K, Antoniadou E, et al. The Relevance and Added Value of Geriatric Medicine (GM): Introducing GM to Non-Geriatricians. J Clin Med. 2021 July 7;10(14):3018. Routledge & CRC Press [Internet]. [cited 2025 Dec 23]. Healthy Ageing in Asia: Culture, Prevention and Wellness. Available from: https://www.routledge.com/Healthy-Ageing-in-Asia-Culture-Prevention-and-Wellness/Soon-Bodeker-Kariippanon/p/book/9780367473884 Aldridge MD, Hasselaar J, Garralda E, van der Eerden M, Stevenson D, McKendrick K, et al. Education, implementation, and policy barriers to greater integration of palliative care: A literature review. Palliat Med. 2016 Mar;30(3):224–39. Dev G, Thrivikraman SK. Resource Utilization for Healthy Aging in Kerala: A Mixed Methods Approach. Journal of the Indian Academy of Geriatrics. 2023 Dec;19(4):249. A Case Study of Manickal Grama Panchayat in Thiruvananthapuram District [Internet]. [cited 2025 Dec 23]. Available from: https://spb.kerala.gov.in/sites/default/files/inline-files/28.pdf Kumar DV. The New Indian Express. 2015 [cited 2025 Dec 23]. Manickal Gearing up to be First Old-age-friendly Panchayat in State. Available from: https://www.newindianexpress.com/states/kerala/2015/Aug/01/manickal-gearing-up-to-be-first-old-age-friendly-panchayat-in-state-792902.html Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Mar, 2026 Reviews received at journal 17 Feb, 2026 Reviews received at journal 07 Feb, 2026 Reviewers agreed at journal 07 Feb, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 09 Jan, 2026 Submission checks completed at journal 08 Jan, 2026 First submitted to journal 08 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8494873","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582325999,"identity":"45a9c32c-04f6-4550-b617-38ccd5b6139d","order_by":0,"name":"B Aravind Chandru","email":"","orcid":"","institution":"State Health Systems Resource Centre- Kerala","correspondingAuthor":false,"prefix":"","firstName":"B","middleName":"Aravind","lastName":"Chandru","suffix":""},{"id":582326000,"identity":"86401d8d-e684-4cb3-a354-bcb257defd99","order_by":1,"name":"Devika Rajeesh","email":"","orcid":"","institution":"State Health Systems Resource Centre- Kerala","correspondingAuthor":false,"prefix":"","firstName":"Devika","middleName":"","lastName":"Rajeesh","suffix":""},{"id":582326001,"identity":"080744c2-0465-44cb-858a-bab816be2466","order_by":2,"name":"Zehra Sabuji","email":"","orcid":"","institution":"State Health Systems Resource Centre- Kerala","correspondingAuthor":false,"prefix":"","firstName":"Zehra","middleName":"","lastName":"Sabuji","suffix":""},{"id":582326002,"identity":"7720c97c-d7df-45b6-9d34-96cf1003b9b7","order_by":3,"name":"P M Gopika","email":"","orcid":"","institution":"State Health Systems Resource Centre- Kerala","correspondingAuthor":false,"prefix":"","firstName":"P","middleName":"M","lastName":"Gopika","suffix":""},{"id":582326003,"identity":"fc639675-224b-4bba-b014-5dd8d3472996","order_by":4,"name":"S S Harsha","email":"","orcid":"","institution":"Tata Institute of Social Sciences","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"S","lastName":"Harsha","suffix":""},{"id":582326004,"identity":"49a73cfd-805e-4a1c-a1f4-30d0a4b0b8af","order_by":5,"name":"Samuel Prasad Cherian","email":"","orcid":"","institution":"Tata Institute of Social Sciences","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"Prasad","lastName":"Cherian","suffix":""},{"id":582326005,"identity":"ff2409ad-de56-4308-bda4-b900f5e54902","order_by":6,"name":"Rekha M Ravindran","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYDCCA1Caj70BSBpYkKCFjQfEMpAgRYtEAogiQgvf8R7jz7w7bOTYJJ9f3fCjQIKBv707Aa8WyTNnzKR5z6QZs0nnlN3sATpM4szZDXi1GNxIS2PmbTuc2Cadk3aDB6jFQCKXgJb7z5I/87b9r2+TPJN28w9RWm4wH5DmbTuQwCbBfuw2UbZInkk+Jjm3LdmwjSeH7baMgQQPQb/wHT/Y/OFtm508P/vxZzff/LGR42/vxa8FCfAYgElilYMA+wNSVI+CUTAKRsEIAgA2nkVFtuRG8gAAAABJRU5ErkJggg==","orcid":"","institution":"Directorate of Health Services, Kerala","correspondingAuthor":true,"prefix":"","firstName":"Rekha","middleName":"M","lastName":"Ravindran","suffix":""}],"badges":[],"createdAt":"2026-01-01 11:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8494873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8494873/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101523030,"identity":"cfb691df-8762-4ebe-9bd3-ffbb4024d7e7","added_by":"auto","created_at":"2026-01-30 17:40:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92214,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2. Facility-Specific Implementation of Geriatric-Friendly Features\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8494873/v1/80d6fd7b5462d68d164fb9ff.png"},{"id":101522949,"identity":"5e6a8546-47e0-44a9-badc-b8e015fa3e23","added_by":"auto","created_at":"2026-01-30 17:40:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":214503,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig 1: The Geriatric Care Paradox—Structural Enablers, Implementation Gaps, and resulting Inequities in NPHCE Service Delivery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8494873/v1/6214eec5d617f6268114eed6.png"},{"id":101523076,"identity":"9dd5bd98-3565-4cd2-884d-d1e5d8a38c02","added_by":"auto","created_at":"2026-01-30 17:40:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1514713,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8494873/v1/ed66e2e7-3fc6-4f98-b75c-c9c9fce8670d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the National Programme for Health Care of the Elderly in Kerala's Rapidly Ageing Context Uncovering the Geriatric Care Paradox","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGlobally, the proportion of older persons is on the rise. As per the Census 2011, 8% of the total population in India is above 60 years of age. Asia is home to more than half of the world's elderly population. Kerala has a higher percentage of elderly residents than the rest of India, at 10.1% on a national average and 16.5% in the state of Kerala (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In light of the profound impact that the ageing of the population in India can potentially have on the social, political and economic spheres alike, research on the health and well-being of the elderly population is the need of the hour to ensure and facilitate the process of healthy ageing. India has been experiencing a gradual increase in both the size and share of the older population over the past few decades (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The ongoing epidemiological transition in India has led to an increase in Non-Communicable Disease (NCD) deaths in addition to health issues related to old age (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Ageing is a global phenomenon. India is in Stage 3 of the demographic transition, suggesting a fall in birth rate, with the death rate staying low, and the population will continue to grow steadily (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As a result, the number of elderly people in India is increasing, and measures that address their health issues are essential. It is necessary to have a comprehensive and integrated approach to elderly healthcare instead of the traditional fragmented approach that addresses the health needs of older adults through separate disease-specific programmes for non-communicable diseases, cancer, and mental health (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe demographic landscape of Kerala, a state in India, is undergoing a significant transformation, characterised by a rapidly ageing population (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This makes the state an important case study, given that the country's entire elderly population is projected to double by 2050 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This shift is occurring at a pace that surpasses the national average, presenting unique challenges for public health and healthcare infrastructure. According to the Kerala Ageing Survey (KAS) 2013 report, the state is home to 4.2\u0026nbsp;million individuals aged 60 and above, marking an annual growth rate of 2.3%, compared to the general population's growth rate of 0.5%. Notably, within this elderly demographic, 11% are categorised as old-old (above 80 years), underscoring the complex healthcare needs and vulnerabilities specific to this age group (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This demographic trend is not isolated but reflects a global increase in the proportion of older persons. Kerala's population is ageing more quickly than the national average. The state already has the highest percentage of older adults in the nation, at 16.5 percent in 2021, rising to an estimated 22.8 percent in 2022, and expected to surpass one-fifth of all citizens by 2036 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In Kerala, there has been a steady rise in chronic conditions such as diabetes, hypertension, and coronary heart disease, accompanied by an increasing prevalence of risk factors including obesity, sedentary lifestyles, elevated serum lipid levels, and smoking (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Ministry of Health \u0026amp; Family Welfare launched the \u0026ldquo;National Programme for the Health Care of Elderly\u0026rdquo; (NPHCE) during 2010-11 to address various health-related problems of elderly people and promote healthy ageing (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This initiative aims to provide accessible, affordable, and high-quality long-term care services to the ageing population, supporting their functional ability and overall well-being. Aligned with international and national commitments under the United Nations Convention on the Rights of Persons with Disabilities, the NPHCE integrates provisions from the National Policy on Older Persons (1999) and Section 20 of \u0026ldquo;The Maintenance and Welfare of Parents and Senior Citizens Act, 2007\u0026rdquo; (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The programme's planning, monitoring, and implementation are overseen by the NCD cell at national and state levels, established under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases (CVD), and Stroke (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). By establishing geriatric clinics, dedicated hospital wards, rehabilitation units, and community-based care, the programme strives to enhance the healthcare infrastructure and services specifically tailored for the elderly (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA comprehensive initiative like the NPHCE is essential to ensure long-term and dedicated services that promote active and healthy ageing. Initially, five districts in Kerala, such as Pathanamthitta, Kozhikode, Alappuzha, Idukki, and Thrissur, were selected for the first phase of the NPHCE, which was later expanded to cover all districts by 2016-17 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In this study, the infrastructural changes, the process of implementation, and the program's output, along with understanding the perception of policymakers, implementers, and the beneficiaries regarding the NPHCE, were explored.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003e \u003cb\u003eDesign\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study employed a cross-sectional, concurrent mixed-methods design to evaluate the NPHCE at the secondary-level health facilities in Kerala. The design integrated both quantitative and qualitative components for a comprehensive assessment of the infrastructure, implementation process, and stakeholder perceptions. Data collection for both components was carried out simultaneously between July 2023 and September 2023, after obtaining ethical clearance from the Institutional Ethics Committee (IEC) of the Department of Health Services, General Hospital, Thiruvananthapuram, Kerala (33/03/02/21-GHEC). All methods were carried out in accordance with relevant guidelines and regulations, including the Declaration of Helsinki and the ethical standards of the Institutional Ethics Committee of the State Health Systems Resource Centre Kerala.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy setting and participants\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study was conducted in ten secondary care health facilities (General hospitals, District hospitals and Taluk Headquarters Hospital (THQH)) across five districts in Kerala, India: Kozhikode, Thrissur, Pathanamthitta, Alappuzha, and Idukki. These districts were purposely selected, as they represented the initial pilot sites for NPHCE in the state. In consultation with the State Nodal Officer (SNO) for NPHCE, two facilities were selected from each district, comprising a mix of the original five initial pilot sites and five subsequently incorporated centres that received NPHCE programme funds from the state.\u003c/p\u003e \u003cp\u003eThe study engaged a multi-tiered group of participants. For the qualitative component, purposive sampling was used to recruit key stakeholders. This included Key Informant Interviews (KIIs) with five policymakers and senior implementers, including SNO and the NPHCE District Nodal Officers from the five selected districts. In-Depth Interviews (IDIs) were conducted with 9 healthcare providers (medical superintendents, NPHCE medical officers, staff nurses of geriatric wards, NPHCE physiotherapists, and NPHCE dieticians) and elderly beneficiaries aged 60 and above from both the Out-Patient Department (OPD) and the In-Patient Department (IPD) and their primary caregivers who have utilised NPHCE services at the selected location within the preceding six months. Additionally, beneficiary selection was based on availability and feasibility. For the quantitative component, all ten selected healthcare facilities were included as the unit of analysis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection techniques\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData collection involved distinct qualitative and quantitative instruments. Qualitative data were gathered using semi-structured interview guides tailored to each stakeholder group, developed in Malayalam (regional language), translated into English, and back-translated to ensure conceptual accuracy. KIIs explored strategic themes such as programme rollout, human resources, monitoring and evaluation systems, interdepartmental convergence (example: NCD and palliative care) and funding, while IDIs with providers focused on daily operational experiences, adequacy of infrastructure and equipment, patient load, clinical workflows, training received and challenges in delivering geriatric-specific care. The IDI guide for beneficiaries explored their pathways to accessing care, experiences with the physical accessibility of facilities, interactions with staff, affordability of services, and satisfaction with the care received. All interviews were conducted in Malayalam and audio recorded with written informed consent by the Principal Investigator (RMR) and Co-Investigator (BAC) and trained data collectors of the research team (Research Assistants and Public Health Interns of the State Health Systems Resource Centre). Informed consent was obtained from all participants, and confidentiality was maintained through anonymised data handling. Detailed field notes were maintained to capture contextual observations.\u003c/p\u003e \u003cp\u003eQuantitative data were collected using two structured tools developed from NPHCE operational guidelines: a facility survey questionnaire that documented staffing patterns and service utilisation metrics, and a geriatric-friendly infrastructure audit checklist that was used to conduct a physical verification of geriatric-friendly features, comprising 17 specific criteria, assessed the environment for safety and accessibility, documenting the presence or absence of elements such as ramp railings, anti-skid flooring, designated waiting areas, etc. Both qualitative and quantitative tools were refined after a pilot test at one non-study site to ensure clarity and relevance.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003eQuantitative data were analysed using Microsoft Excel, focusing on cleaning, descriptive analysis, and data visualisation to summarise findings relevant to healthcare infrastructure and programme efficacy. Qualitative data underwent a hybrid coding strategy, starting with inductive open coding for initial interviews to identify patterns, which were then compared with existing literature. Subsequent interviews were coded deductively, allowing for the thematic analysis of comprehensive stakeholder perspectives.\u003c/p\u003e \u003cp\u003eThe study used the \u0026ldquo;Framework for Programme Evaluation in Public Health\u0026rdquo; developed by the Centres for Disease Control and Prevention (CDC) as the basic reference for evaluating the NPHCE (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This framework provides a systematic and participatory approach to evaluating public health programmes through six interconnected steps: engaging stakeholders, describing the programme, focusing the evaluation design, gathering credible evidence, justifying conclusions, and ensuring use and sharing lessons learned. The framework emphasises utility, feasibility, propriety, and accuracy, thereby facilitating a comprehensive assessment of programme implementation, effectiveness, and contextual factors. In this study, the framework guided the structured examination of the NPHCE, enabling the integration of quantitative and qualitative findings to assess programme processes, outputs, and outcomes in a systematic manner. Based on the results obtained, this framework was adapted to effectively represent and organise the study findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis evaluation examined the implementation, service delivery, and utilisation of the NPHCE in Kerala using a mixed-methods approach, guided by the CDC Framework for Programme Evaluation in Public Health. Quantitative facility-level data were used to assess infrastructure, human resources, funding, and service utilisation, while qualitative findings from KIIs and IDIs provided contextual insights into operational processes, beneficiary experiences, and implementation challenges.\u003c/p\u003e\n\u003ch3\u003e1. Rapid ageing population and emerging need for comprehensive geriatric care\u003c/h3\u003e\n\u003cp\u003eKerala is undergoing a profound demographic transition, marked by a rapid increase in the elderly population and a changing population structure. This shift has far-reaching implications for the health system, social support mechanisms, and economic security of older adults. This demographic change is not just a numerical increase but also brings structural shifts in the population pyramid. Kerala is witnessing a shrinking base and widening top of the pyramid, which represents an ageing population with a declining younger population.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Based on our 2011 census data, we had 12 percent of the 60-plus elderly population. If we can check now our rate of growth, this might have reached around 20%... after 2040, we are thinking that a quarter of our population will be elderly... When the elderly population size increases, our demographic pyramid gets disturbed\u0026hellip; the upper portion of the pyramid is getting bigger, and also the decrease in the number of under-five children is causing the lower portion to get reduced.\u0026rdquo; -(State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis demographic transition is reflected in the lived experiences of older adults, who describe progressive physical weakness and declining functional capacity as part of everyday life.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I feel my hands and feet are becoming numb and I experience weakness.\u0026rdquo; - (Beneficiary- GH Kozhikode, 72 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDemographic patterns lead to increasing demands on the health system and call for specialized services for elderly care. Alongside this transition, the health profile of older adults is changing, with a notable rise in chronic diseases and comorbidities. Unlike previous generations, today\u0026rsquo;s elderly are living longer but often with multiple health conditions that require regular care and support. These health challenges are compounded by economic insecurities faced by older adults. A large proportion of the elderly, particularly those outside the formal employment sector, lack stable income sources or pension benefits. This creates a significant barrier to accessing timely and adequate healthcare.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If we look at the KAS (Kerala Ageing Survey) study, which was done previously, and also our disease profile and morbidity status, our 60 plus population is having one or more comorbid conditions. They are entering with lifestyle diseases. So, that is why we are not having healthy ageing.\u0026rdquo; - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My wife requires a lot of money for medication\u0026hellip; especially as she is hypertensive, she would require two medications\u0026hellip; which cost us around Rs 1000 a month.\u0026rdquo; (Beneficiary, DH Vadakara, 72 years, Male)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn the case of economic concerns, changing family structures and migration patterns have deepened the psychosocial challenges faced by the elderly in Kerala. With more families shifting to nuclear systems and many younger members migrating abroad or to urban centres, increasing numbers of older adults are left to live alone, often without adequate support. Such social isolation and emotional distress can further aggravate health problems, reduce quality of life, and increase the need for accessible and supportive care environments.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Since we are moving towards nuclear families, the number of elderly persons being thrown out to elderly care homes is increasing in our area.\u0026rdquo; (District Nodal Officer NPHCE, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I get 1600 as pension\u0026hellip; I have been taking medications for the last five years. I am unable to meet the expenses.\u0026rdquo; -(Beneficiary, DH Kozhencherry, 72 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is no one to take care of me\u0026hellip; I don\u0026rsquo;t get any help for cooking or washing.\u0026rdquo;- (Beneficiary, DH Mavelikkara, 62 years, Female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAll these interconnected factors, such as rapid demographic transition, rising morbidity, economic vulnerability, and social isolation, point toward an urgent need for a structured, comprehensive, and integrated health programme for the elderly. Therefore, programmes like NPHCE are essential to build an age-friendly and inclusive health system in Kerala.\u003c/p\u003e\n\u003ch3\u003e2. Organisation and Operational Framework of NPHCE\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Programme Scope and Implementation Process\u003c/h2\u003e \u003cp\u003eThe NPHCE was established to address the healthcare needs of Kerala\u0026rsquo;s ageing population through a structured network of geriatric clinics, specialised wards, and rehabilitation services. The programme aims to ensure affordable, accessible, and quality healthcare for older adults across the state. At the District Hospital level, the NPHCE has developed a comprehensive geriatric healthcare infrastructure, which includes a dedicated Geriatric Clinic offering specialised outpatient services, a 10-bed Geriatric Ward with respite care facilities, and referral services for secondary healthcare. Existing specialists in geriatrics are deployed to manage these units, thereby optimising available expertise to meet the unique health needs of the elderly. In addition, additional staff have been sanctioned to support the efficient functioning of these clinics and wards.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;During the initial phase, the programme was implemented in 100 selected districts all over India; five districts were from Kerala, namely Kozhikode, Pathanamthitta, Alappuzha, Idukki, and Thrissur\u0026hellip; The first geriatric ward was set up in Pathanamthitta district hospital with four staff nurses, one physiotherapist, one care coordinator, and a medical officer\u0026hellip; Currently, in the district hospital, there will be one care coordinator, 2 staff nurses, 1 doctor, and a physiotherapist. In a general hospital, one care coordinator, a staff nurse, a doctor, and a physiotherapist\u0026rdquo; - (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe NPHCE implementation in Thrissur evolved gradually, beginning with outpatient-based elderly care services before the establishment of dedicated inpatient facilities. Early implementation was constrained by limited financial resources, which delayed the development of geriatric wards despite regular service provision at the outpatient level.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Before I came here, I was in Chalakudy\u0026hellip; we used to normally conduct an elderly care clinic once a week\u0026hellip; Since there were no funds available, we did not begin a ward.\u0026rdquo; - (NPHCE District Nodal Officer, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe journey of the NPHCE programme in Kerala started small, with just five districts. But as its success became evident, the state government expanded it to all 14 districts, showing a strong commitment to making sure elderly care reaches as many people as possible. The programme didn\u0026rsquo;t just grow in size; it also integrated elderly care into existing health structures, especially at the Community Health Centre (CHC) level, with staff dedicated to elderly and palliative care. This thoughtful expansion demonstrates a methodical approach to making sure elderly care becomes a permanent part of healthcare in Kerala.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Human resource allocation of the programme\u003c/h2\u003e \u003cp\u003eIn analysing the distribution of healthcare professionals across districts for the NPHCE and NCD clinics in Kerala, significant variations emerge in staffing levels. Alappuzha, Kozhikode and Idukki exhibit moderate staffing, with emphasis on NCD clinics and minimal presence in NPHCE. Pathanamthitta shows a balanced approach with a specific focus on physiotherapy and dietetics alongside basic healthcare provisions. Thrissur stands out with robust staffing, particularly in nursing roles (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These findings point to the need for more standardised and equitable distribution of healthcare resources to optimise elderly care services across all districts.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe district-wise staffing numbers in NCD and NPHCE clinics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal HR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eDoctors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ePhysiotherapist\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eDietician\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNCD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNPHCE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNCD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNPHCE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNCD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNPHCE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNCD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNPHCE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNCD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNPHCE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlappuzha\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIdukki\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKozhikode\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePathanamthitta\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThrissur\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThrissur district was identified as one of the relatively well-performing centres in terms of geriatric service readiness. The availability of designated medical personnel and supporting staff has strengthened geriatric service delivery at the district hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;GH Thrissur is functioning very well\u0026hellip; They have a designated doctor for geriatric care here, and also all the necessary staff.\u0026rdquo; (NPHCE District Nodal Officer, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIt is also considered a key challenge facing the NPHCE that the shortage of dedicated staff at the CHC level. Without a separate nursing staff for NPHCE, it\u0026rsquo;s harder to provide the specialised care that elderly patients need. Moreover, in the geriatric wards, where only MBBS doctors are available, the absence of specialists means that the complex health issues of elderly patients might not always receive the comprehensive attention they require.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have arranged an eight-bedded geriatric ward (four plus four, male and female ward), but we did not get any separate human resources, especially for this program; we got supporting staff from the NCD wing, one doctor, two staff nurses, and a physiotherapist.\u0026rdquo; (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;At the CHC level, we don\u0026rsquo;t have separate nursing staff for NPHCE\u0026hellip; The main problem is in the geriatric ward; only an MBBS doctor is available; no specialist is available.\" (NPHCE- District Nodal Officer, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe elderly are also addressing the need for improved healthcare resources and staffing to better serve the growing and diverse needs of patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Increase the number of doctors and medications so that more people can benefit from them.\u0026rdquo; (Beneficiary, NPHCE-DH Mavelikkara, 67 years, Male)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Stakeholder engagement\u003c/h2\u003e \u003cp\u003eThe NPHCE in Kerala operates through a well-defined administrative hierarchy that integrates health services at the state and district levels. The implementation structure involves multiple layers of leadership and coordination across administrative and clinical domains. This reflects a dual administrative framework, where the State Mission Director (SMD) oversees programme administration and financial management, while the Directorate of Health Services (DHS) manages technical and medical aspects. Below these levels, state and district nodal officers ensure operational execution and monitoring.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The highest level is the minister, then the principal secretary; side by side are SMD and DHS. Doctor-related activities are done through DHS, and administration-related activities are done by SMD\u0026hellip; Below that is the State Nodal Officer, and in every district, there would be a District Nodal Officer. SMD has district programme officers of NHM, who will administer this in the district.\u0026rdquo; (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAt the primary and community health care level, the NPHCE in Kerala operates with limited dedicated staff for elderly care. While elderly clinics are conducted weekly at PHCs and CHCs, there are no uniformly appointed geriatric staff across all centres. In some CHCs, staff appointed under the palliative care or chronic disease programmes also provide elderly care services, including physiotherapy and NCD management, reflecting an integrated but resource-limited approach\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Before in CHCs, people were appointed, but now we have changed everyone and no one is there in CHCs. In the remaining areas, the physician will be in charge of the elderly care programme. We don\u0026rsquo;t have separate staff in PHCs and CHCs, but elderly clinics are conducted weekly once\u0026hellip; In CHCs, there is a staff member known as a chronic disease nurse. They are appointed as part of the palliative care programme. There will be one staff nurse and a physiotherapist exclusively for elderly care, palliative care, and NCD care. They only have these works.\u0026rdquo; - (Superintendent, DH Vadakara)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe key elements of the programme encompass infrastructural development, systematic implementation processes, comprehensive service delivery, adequate human resource allocation, sustainable funding mechanisms, interdepartmental convergence, and robust monitoring and reporting systems. Collectively, these components reflect the NPHCE\u0026rsquo;s comprehensive and integrated approach to strengthening geriatric care and improving health outcomes for the elderly population in Kerala.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Program-Driven Infrastructural Transformation\u003c/h2\u003e \u003cp\u003eKerala has made remarkable progress in strengthening healthcare infrastructure to better serve its ageing population, with the NPHCE playing a pivotal role in driving these changes. The state\u0026rsquo;s healthcare facilities, particularly newly established Family Health Centres (FHCs) and District Hospitals, have integrated elderly-friendly design features such as handrails, ramps, and accessible toilets, significantly improving the comfort, safety, and mobility of older adults. In addition to new constructions, retrofitting of existing facilities with such features is also underway, reflecting a statewide commitment to inclusivity and accessibility in healthcare delivery.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Infrastructure in all places has become elderly friendly. In all the newly built FHCs, hospitals, and everywhere with elderly-friendly rails, ramps, and toilets, these concepts have come.\u0026rdquo; (District Nodal Officer NPHCE, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So even before the programme, they were getting care. And after the programme came, they were getting added care. Because we had an elderly-friendly hospital initiative under this programme, wherein some of the wards were made elderly-friendly.\u0026rdquo; (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe programme strategically manages and reallocates funds to ensure that elderly-friendly improvements are implemented across all health centres. Even when resources are limited, funds are combined with other projects to achieve the intended upgrades, demonstrating flexibility and commitment to accessible care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The programme focuses on providing geriatric-friendly ramps instead of steps, doors, toilets, etc., in all centres like CHCs. Attempts are made to bring these facilities according to the availability of funds. Our concept is to convert all the centres to geriatric-friendly ones; if the funds are insufficient, we are trying to mingle with other projects and get it done.\u0026rdquo; (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBeyond large architectural changes like ramps and rails, the programme has introduced smaller, yet highly impactful, operational changes that directly improve the patient experience, even if patients do not realise the source of the improvement.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have eliminated line systems, provided seating for the elderly, and ensured drinking water in all of the facilities. We can see that the changes have occurred, even though patients are unaware that the new chair they use when they visit was made possible by the programme.\u0026rdquo; (District Nodal Officer NPHCE, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEven though the programme has made major efforts to improve all facilities, there are also some infrastructural challenges that are faced by the elderly at health institutions, which cause a significant barrier to accessing essential healthcare services. The physical layout of the building, like the steep slope, makes it difficult for them to access the services provided there. This shows that while inside hospital facilities have become more elderly-friendly, outside access issues can still reduce the overall benefit of these improvements.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is a building where we used to come and check for blood, BP, sugar, etc. But because of the difficulty of reaching there, I avoid... It\u0026rsquo;s a steep slope. I have breathing difficulty while climbing the slope.\u0026rdquo; -(Beneficiary, NPHCE-GH Alappuzha, 70 years, Female)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Services Provided under NPHCE\u003c/h2\u003e \u003cp\u003eThe NPHCE programme in Kerala has focused on improving geriatric infrastructure and service delivery across different levels of the healthcare system. One of the program\u0026rsquo;s major objectives was to strengthen district hospitals by establishing dedicated 10-bed geriatric wards equipped with elderly-friendly features such as anti-skid floor tiles, ramps, rails, and customised furniture. These facilities were designed to create safe and accessible environments for older adults.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The primary objectives of the programme were to strengthen the district hospitals for geriatric care, and the main target was to have a 10-bedded geriatric ward at every district hospital. We have a hospital with anti-slip floor tiles, ramp facilities, rails, geriatric-friendly toilets, and furniture using the funds allocated.\u0026rdquo; (District Nodal Officer NPHCE, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have a 10-bedded geriatric ward\u0026hellip; The ward is comfortable, well-ventilated, and patient-friendly.\u0026rdquo; (NPHCE Medical Officer, GH Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn addition to inpatient wards, several outpatient-based initiatives were implemented to improve accessibility and comfort for elderly patients. Separate queues, drinking water facilities, and department assistance were available in select hospitals, with GH Thrissur and DH Mavelikara emerging as the most geriatric-supportive centres overall. Only a few facilities, such as GH Thrissur and DH Mavelikara, had separate, well-maintained toilets, while features like mobility aids, ramp railings, and anti-skid flooring were inconsistently available. The main physical and emotional challenge faced by elderly patients is the particular difficulty with prolonged waiting times. Special provisions, including separate queues and pharmacy counters for NCD patients, were identified as important facilitators.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The elderly people struggle with waiting in queues\u0026hellip;but now we have separate queues at the OP counters and a dedicated NCD pharmacy counter.\u0026rdquo; - (Staff Nurse, DH Wadakkancherry)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now they have a separate queue for senior citizens; usually they don\u0026rsquo;t have... but today they do.\u0026rdquo; - (Beneficiary, GH Kozhikode, 73 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlthough basic accessibility features such as ramps and proximity of services were reported, significant limitations were noted with respect to space and privacy. Such limitations particularly affected counselling services, which require confidential discussions around diet, mental health, and socio-economic issues. Also, infrastructural limitations within the hospital, including lack of lifts and ramps in older buildings, restricted elderly participation in health promotion activities.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is very congested\u0026hellip; it is hard to provide counselling because the patients can\u0026rsquo;t hear or understand us properly and also there is no proper waiting area, and it gets very hot.\u0026rdquo; - (Dietitian, DH Kozhencherry)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is no privacy\u0026hellip; counselling takes time and requires digging into a patient\u0026rsquo;s social and financial background and we have conducted yoga and camps, often at Anganwadis. However, holding programmes on the upper floors of the hospital is difficult because there are no ramps or lifts to the higher levels in the old building.\u0026rdquo; - (Staff Nurse, DH Wadakkanchery)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe state has made substantial progress in establishing geriatric-friendly services; variability in infrastructure and accessibility remains across districts, indicating the need for continued investment and monitoring.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOnly four facilities (DH Mavelikara, DH Vadakara, GH Alappuzha, and GH Thrissur) provided clear signage, while geriatric-friendly waiting areas were found in just three (DH Mavelikara, GH Alappuzha, and GH Thrissur). Although all ten facilities had department assistance, only three (DH Mavelikara, GH Alappuzha, and GH Thrissur) offered dedicated queues, and geriatric token stations were available at GH Mavelikara, GH Kozhikode, and GH Thrissur. Anti-skid flooring was limited to DH Thodupuzha and GH Thrissur. Four facilities (DH Mavelikara, DH Vadakara, DH Wadakkanchery, and GH Thrissur) provided mobility aids, with beds featuring railings in eight facilities (excluding DH Wadakkanchery and THQH Peerumedu). Ramp railings were absent in three facilities, while seating facilities were adequate at GH Alappuzha, GH Kozhikode, and GH Thrissur, with only GH Thrissur offering additional seat support. Separate and well-maintained toilets were accessible only at GH Thrissur and DH Mavelikara. Pharmacy queues and elderly-friendly activities were more widely present, but only GH Thrissur offered all 17 geriatric-friendly features. GH Thrissur and DH Mavelikara emerged as the most geriatric-supportive centres overall.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Fund Allocation of the Program\u003c/h2\u003e \u003cp\u003eFunding for the NPHCE programme in Kerala is routed through the National Health Mission (NHM) via an annual Programme Implementation Plan (PIP). Each year, the state submits a proposal to the Government of India, which is reviewed during NPCE meetings. Once approved, a Record of Proceedings (ROP) is issued, specifying the allocated funds. Allocated funds are utilised across multiple components, including infrastructure strengthening, capacity building, information, education and communication (IEC) activities, and outreach programmes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We are getting funds from NHM. Each year we send a proposal, it is reviewed by the Government of India, and finally, after this, we will get ROP...record of proceedings with which we could know about the things granted for us.\u0026hellip;from 2010-11 onwards, every year we had a substantial increment in the elderly programme.\u0026rdquo;- (District Nodal Officer NPHCE, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have been given funds from NHM for elderly care\u0026hellip; for purchasing furniture, capacity building, IEC material, and also for conducting camps.\u0026rdquo; -(District Nodal Officer, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFunding is always a challenge, but Kerala\u0026rsquo;s approach to the NPHCE programme shows how creative and committed the state is to elderly care. By adjusting available funds, they\u0026rsquo;ve managed to set up geriatric wards in multiple districts. However, while some districts have been able to establish more than one geriatric ward, the uneven distribution of resources means that providing consistent, high-quality care across the board is still a challenge.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The fund that we are receiving is from the NCD nodal officer. Last week, we received a fund of 50000 rupees for IEC, which can be used for NCD OP, geriatric OP, and palliative OP. During the COVID-19 pandemic, we received funding for setting up a geriatric ICU, so the geriatric ward that we had was upgraded to the geriatric ICU with a centralised oxygen supply.\" - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We were using the funds to procure equipment like pulse oximeters, which benefited the latter in developing COVID First Line Treatment Centres (CFLTCs). So before, only we had all those facilities with the help of this programme. Even in the case of post-COVID patients who require physiotherapy care, they can also avail of the services through NPHCE.\u0026rdquo; - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Utilisation of such funds also was going well; the only problem with respect to the district was a shortage of funds.\u0026rdquo; - (District Nodal Officer NPHCE, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In some districts, more than one hospital has started a geriatric ward by adjusting the funds available.\u0026rdquo;- (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Monitoring and Reporting of the Program\u003c/h2\u003e \u003cp\u003eKeeping track of progress is essential, and the NPHCE programme does this through detailed annual reporting, following guidelines from the Government of India (GOI). This structured approach helps ensure that the program\u0026rsquo;s impact is measured accurately and that there\u0026rsquo;s room for improvement based on real data. Recently, the merging of monitoring efforts for the elderly and palliative care programmes has made the process even more efficient, ensuring both elderly and palliative patients receive the quality care they need.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;A yearly reporting is done based on the format sent by GOI, which normally, sometimes biannually, includes the number of beneficiaries visiting the OP, IP, availing of physiotherapy, and the number of patients cured and who died in IP.\u0026rdquo; - (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Recently, monitoring of NPHCE and palliative care programme has been combined under one coordinator so that the monitoring process is going well.\u0026rdquo; - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eRegular monitoring mechanisms are in place to review fund utilisation and programme progress. Monthly reviews and scheduled meetings at the district level enable oversight and accountability in programme implementation.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We review the utilisation of these funds every month\u0026hellip; There is a meeting happening this Saturday.\u0026rdquo; (NPHCE- District Nodal Officer, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA separate register is maintained for geriatric OP. But in many facilities, NPHCE data is combined with NCD reports, primarily because the reporting agency is the deputy DMO for both programmes. While this approach may simplify administrative processes, it can obscure the specific reach and effectiveness of NPHCE services, making it difficult to track elderly-specific outcomes and identify programme gaps. Maintaining distinct datasets for NPHCE would enhance clarity, improve monitoring, and support evidence-based decision-making for targeted geriatric care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"NPHCE data is combined with the NCD report because the reporting agency is the same, we are reporting to the deputy DMO. But the geriatric OP register is maintained separately.\"- (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Interdepartmental Convergence\u003c/h2\u003e \u003cp\u003eWorking together is often the best way to get things done, and that\u0026rsquo;s exactly what\u0026rsquo;s happening with the NPHCE programme. By coordinating with the palliative care programme, the geriatric care initiative has been able to deliver better services and achieve more effective outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We are mingling with other programmes like palliative care so that we are able to perform well. We are more concentrated on Peerumedu Hospital for ward-related services. We are providing some services, like physiotherapy, and some equipment under the programme. There are so many activities taking place under the palliative care programme.\u0026rdquo; (NPHCE- District Nodal Officer, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We work here as a team and are not alone\u0026hellip; if patients are bedridden, we refer them to the palliative care unit, and doctors visit them at home.\u0026rdquo; -(NPHCE Medical Officer, GH Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe clinic operates through a shared-care model in which medical consultations are integrated within routine general outpatient services, while the NCD team primarily undertakes screening, monitoring, follow-up, and patient education. This pragmatic arrangement allows continuity of services in the absence of programme-specific medical officers; however, it limits the clinic\u0026rsquo;s ability to function as an autonomous unit providing comprehensive NCD care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have a physician under NCD, posted in a geriatric clinic.\" -(Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is no specific MO under NHM for the NCD clinic here\u0026hellip; The General OP doctors consult the patients, and we handle the monitoring.\u0026rdquo; -(Staff Nurse, NCD Clinic, GH Kozhikode)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e3. Service Utilisation and Programme Resources\u003c/h3\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Service utilisation and disparities\u003c/h2\u003e \u003cp\u003eThe daily utilisation of non-communicable disease (NCD) services across various healthcare facilities in Kerala reveals distinct patterns in both general outpatient (OP) visits and physiotherapy OP visits. Facilities like DH Vadakara and GH Alappuzha show high daily OP utilisation, which shows a significant demand for NCD services in these locations. Physiotherapy utilisation also varies, with GH Thrissur, GH Alappuzha, and GH Kozhikode recording relatively high daily visits (50, 50, and 40, respectively), indicating a need for physiotherapy services at these centres. Conversely, certain district hospitals, such as DH Wadakkancherry and DH Mavellikara, report no daily physiotherapy visits, suggesting either limited access or lower demand for these services. This variability underscores potential areas for improvement, where adjusting resource allocation or expanding services could help ensure more consistent access to NCD and physiotherapy care throughout the region. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDaily utilisation of NCD services\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacility\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage Daily OP (All Services)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAverage Daily OP (Physiotherapy)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGH Kozhikode\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDH Vadakara\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGH Thrissur\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDH Wadakkancherry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDH Thodupuzha\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTQHQ Peerumedu\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGH Alappuzha\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDH Mavellikara\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGH Pathanamthitta\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDH Kozhencherry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe high number of primary cases reported at THQH Peerumedu underscores a significant reliance on secondary care facilities for routine geriatric services. This trend reflects potential gaps in the accessibility and utilisation of primary healthcare centres in the taluk, suggesting that many older adults may bypass or lack adequate support at PHCs and CHCs. Addressing these gaps through strengthened primary care infrastructure, better referral linkages, and community outreach could reduce the patient load at the taluk hospital while ensuring timely and accessible care for older adults. Moreover, understanding the patterns of service utilisation can inform targeted interventions to improve health system efficiency and optimise the distribution of geriatric services.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most cases reported at THQH Peerumedu are primary, with some secondary cases as well. The hospital serves as the taluk headquarters, and due to the absence of other nearby hospitals, it also handles a higher number of primary geriatric patients. This underlines the need to assess PHC and CHC functioning in Peerumedu taluk to understand primary care management.\u0026rdquo;- (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Facilitators and Barriers for the Beneficiary\u003c/h2\u003e \u003cp\u003eBeneficiaries of elderly services experience both improvements and challenges in accessing healthcare, reflecting the ongoing efforts of programmes to enhance elderly care while highlighting persistent gaps. The introduction of operational measures, such as separate queues for senior citizens, has improved convenience and accessibility for older adults, helping them navigate healthcare facilities with greater ease.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Usually they don\u0026rsquo;t have separate queue... but today they have a separate queue for senior citizens.\u0026rdquo;- (Beneficiary, GH Thrissur, 72 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBeneficiaries continue to face a lack of basic support services, such as wheelchairs, emphasising the need for universal accessibility in healthcare settings. These infrastructural gaps indicate that while certain improvements have been implemented, fundamental support services remain limited. Long queues, extended waiting times, and high transportation costs are additional barriers that limit timely access to healthcare for older adults. These operational challenges often require the assistance of family members to navigate\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They should do all these things for everyone... If someone falls down, they need a wheelchair, right? They should do such things.\u0026rdquo; - (Beneficiary, GH Pathanamthitta, 64 years, male)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Long queues and waiting times are some of the biggest challenges I have faced, apart from the cost of transportation to these facilities, which is more expensive than the treatment itself. Even in the OP or for seeing a doctor, I feel weak standing in the queue, and I want to sit down soon\u0026hellip; There is no queue for the elderly.\u0026rdquo; - (Beneficiary, GH Kozhikode, 60 years, Male)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Long queues and waiting times are some of the challenges I have faced, apart from the cost of transportation to these facilities, which is more expensive than the treatment itself.\u0026rdquo; - (Beneficiary, GH Pathanamthitta, 64 years, male)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAccess to expensive medications is another critical barrier. While public facilities provide low-cost drugs, patients often need to travel to private pharmacies to obtain essential medicines, incurring additional costs. There are also infrastructural gaps in basic amenities, such as water availability, which further affect the overall healthcare experience of elderly patients\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They only have cheap medicines\u0026hellip; we need to go to other hospitals to get them, but we\u0026rsquo;ll have to spend a lot on an autorickshaw\u0026hellip; so I go to a nearby private shop.\u0026rdquo; - (Beneficiary, DH Thodupuzha, 64 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLimited proximity of healthcare facilities also restricts access for elderly patients, particularly for those who are weak or live alone, making travel difficult and sometimes unsafe. While primary-level facilities like PHCs and CHCs are generally more accessible, the NPHCE programme is not yet implemented at this level, highlighting the importance of expanding elderly-focused services to primary care centres to improve coverage and reduce travel burden:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is always better to have more services. We would be happier to have the nearest health centre. Irrespective of the number of elderly citizens in the locality, it is disappointing that we do not have a health centre nearby.\u0026rdquo; - (Beneficiary, GH Kozhikode, 73 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I go to this Kozhencherry hospital as well. I can\u0026rsquo;t travel far, as there is no one to take me along.\u0026rdquo; - (Beneficiary, DH Kozhencherry, 60 years, female)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am happy and satisfied with the service I get in these centres. The main concern for me is the cost of transportation and meeting the doctors, which makes me think twice before going to such facilities.\u0026rdquo; - (Beneficiary, GH Thrissur, 68 years, Male)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Water shortage\u0026hellip; we have to pay money despite them not bringing water.\u0026rdquo; - (Beneficiary, GH Alappuzha, 70 years, female)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Barriers and Disparities in the Programme Implementation\u003c/h2\u003e \u003cp\u003eDespite the programme achieving success in a few centres, substantial barriers persist across many others, limiting consistent implementation and equitable access to geriatric care. One major issue is the lack of dedicated human resources, which makes it difficult to provide the specialised care for elderly patients. Additionally, the programme faces challenges in gaining the political support that is necessary to expand and improve further. Overcoming these obstacles will be crucial for the NPHCE programme to fully realise its potential in caring for Kerala\u0026rsquo;s elderly population (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have arranged an eight-bedded geriatric ward (four plus four male and female wards), but we did not get any separate human resources, especially for this program; we got supporting staff from the NCD wing, one doctor, two staff nurses, and a physiotherapist.\u0026rdquo; - (Superintendent, DH Vadakara)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn most centres, there are no dedicated staff assigned specifically for the NPHCE; they rely on staff from the NCD wing. While funds are being utilised for equipment and service delivery, the absence of dedicated personnel limits the program\u0026rsquo;s capacity to provide continuous and specialised geriatric care. Training activities, including essential certifications such as the morphine license, have been disrupted due to the COVID-19 pandemic, leading to gaps in staff readiness. This highlights the need for dedicated human resources and systematic, timely training to ensure effective programme implementation and continuity of specialised services.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Training activities used to take place on a regular basis, but for the last year, due to COVID, training activities have been suspended. Staff of the NCD wing are Responsible for implementation, and physiotherapy is a part of NPHCE.\u0026rdquo; - (Superintendent, DH Vadakara)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We did not get training and I did not get the certificate. The doctor who was working here before me had the certificate\u0026hellip;due to the COVID pandemic, training sessions are not happening.\u0026rdquo; - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite managing complex geriatric and post-surgical cases, the physiotherapist reported limited exposure to NPHCE-specific training. Existing training opportunities were largely online and perceived as inadequate for skill-intensive rehabilitation services, underscoring the need for hands-on, programme-oriented capacity building.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Not since I came here i didn\u0026rsquo;t get any training related to NPHCE\u0026hellip; I participated in one online training for the 'SWAAS' Clinic, but it was difficult to be active in an online session. I feel that offline, practical training is necessary.\u0026rdquo; - (Physiotherapist, DH Vadakara)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite staffing and infrastructure limitations, the clinic manages a high daily patient volume. However, ongoing renovation work has reduced waiting space and compromised patient comfort and clinic organisation. The lack of a consolidated service area has also increased the risk of missed registrations and incomplete follow-up.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We see 140 to 160 patients a day...In that, about 40 per cent to 50 per cent of our patients are over 60 years old.\u0026rdquo; - (Staff nurse, THQH Peerumedu)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLimited workspace for staff in the NCD wing, reflecting infrastructure challenges in providing elderly-friendly services.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The dietician, the doctor, and the staff checking blood pressure all work in small, cramped rooms.\u0026rdquo; - (Physiotherapist, DH Thodupuzha)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe National Programme for the Health Care of the Elderly (NPHCE) faces a barrier due to a perceived lack of political will. Despite a significant proportion of politicians being in the geriatric age group themselves, the response to addressing the needs of the elderly through the NPHCE programme is described as suboptimal. The observation implies that, despite the presence of politicians from the geriatric age group, their priorities may not be aligned with the goals of the NPHCE programme. This misalignment may be due to competing priorities or differing perceptions regarding the urgency and importance of geriatric healthcare.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The barrier is the lack of political will to take up the programme. Even though a majority of our politicians belong to the geriatric age group, if we approach them for any need, the response is not so well.\" - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe high service burden on the health system, with elderly patients forming the majority of those seeking care. A large proportion present with multiple comorbidities, which increases the complexity of care delivery. The cost of managing chronic conditions is substantial, creating economic hardship for many families and contributing to inequities in access to care. Also, geriatric health continues to receive the least priority among public health programmes. Even though the burden is substantial, resource allocation and strategic planning remain inadequate, further widening disparities in access to care. While there are efforts to establish Regional Geriatric Centres across districts, progress remains slow due to economic and structural constraints.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is a huge volume of patients, approximately 80% of the total population. They have multiple comorbidities. Some treatments are very expensive, like for heart failure, dialysis, cancer etc\u0026hellip; all this can be unaffordable.\u0026rdquo; - (NPHCE, State nodal officer)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When we talk about the programme as a whole, out of all the programmes, this programme is given the least priority. Trying to set up Regional Geriatric Centres in all the districts, similar to that of Trivandrum. Then there are some economic issues.\u0026rdquo; - (NPHCE- District Nodal Officer, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAccess to geriatric healthcare remains a major challenge in remote and hilly regions like Idukki. Limited human resources, poor availability of speciality services, and difficult terrain restrict service reach. There is a need for stronger decentralisation and improved service delivery closer to the community.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I felt gaps with respect to the lack of HR, especially from the perspective of the Idukki district. Accessibility issues are still persisting, so more decentralisation should happen, and speciality services are very limited in the district.\u0026rdquo; - (Medical Superintendent, THQH, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePhysical infrastructure limitations affected service delivery in the PMR unit, particularly for elderly patients with mobility impairments, with inadequate provisions for privacy and essential amenities within the treatment area.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It would be better if there were an attached bathroom, as it is difficult for stroke patients to walk to the outside toilets. For privacy, we currently use curtains, as the room is not spacious enough to have a separate room.\u0026rdquo; - (Physiotherapist, DH Kozhencherry)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA major barrier in several centres is the insufficient allocation of funds, which limits the establishment and expansion of geriatric-friendly wards. Inadequate funding also constrains initiatives such as doorstep delivery of medicines, home-based medical checkups, and e-health services, despite the potential for ASHA workers to facilitate these services. Additionally, many facilities lack basic geriatric-friendly infrastructure, such as ramps and rails, further impeding accessibility for elderly patients. The combination of limited financial resources and inadequate infrastructure reduces the program\u0026rsquo;s capacity to deliver inclusive and comprehensive care for the ageing population.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The main issue we are facing in this district is a lack of funds, and in general, hospitals for setting up geriatric-friendly wards did not receive much focus. If we get more funds and if people gain more awareness about the needs and importance of the programme, we can really make changes.\u0026rdquo; - (NPHCE- District Nodal Officer, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have a concept of doorstep delivery of medicines, with the help of ASHA workers, which is possible. We can improve the services through ASHA by providing home delivery of medicines, medical checkups, and assistance for e-health, but we don\u0026rsquo;t have a separate fund for this.\u0026rdquo; - (NPHCE- District Nodal Officer, Idukki)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;No ramps and rails are there, as we did not receive further funds.\u0026rdquo; (Medical Superintendent, DH, Kozhikode)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey Implementation Barriers and Challenges of the NPHCE\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey Barriers/Challenges\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of professionals with\u003c/p\u003e \u003cp\u003eSpecialisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere is a lack of geriatric specialised doctors in Kerala, hindering dedicated geriatric care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of State Plan Fund\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Kerala government faced funding issues for implementing the programme in all 14 districts, necessitating support from the Government of India.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReality or Reason for No Geriatric OPD in PHC/CHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe majority of patients (70%\u0026ndash;80%) in CHC or PHC are elderly, making it impractical to set up a separate geriatric OP or prioritise the elderly population exclusively.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeedback about Geriatric Wards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeedback indicates that the 10-bedded geriatric wards set up under the programme accommodate diverse patient needs such as surgery, medicine, and respiratory care,\u003c/p\u003e \u003cp\u003eposing operational challenges.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfusion Among Doctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe establishment of separate geriatric wards led to confusion among doctors regarding appropriate ward admissions for patients with varied healthcare needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare Service Disparity: Non- Palliative Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElderly patients who are not bedridden face difficulty accessing primary healthcare services due to mobility issues, contrasting with palliative care patients who are\u003c/p\u003e \u003cp\u003epredominantly bedridden.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrowing Elderly Population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe increasing elderly population is accompanied by rising instances of hearing impairments, dental issues, and vision problems, necessitating targeted healthcare\u003c/p\u003e \u003cp\u003einterventions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow Political Will\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDespite a significant proportion of politicians being elderly, there is a lack of adequate response and support for addressing geriatric healthcare needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of Awareness among Policy makers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicymakers are often unaware of the distinct needs of geriatric care, assuming it can be integrated with palliative care initiatives.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow Visibility and Limited Awareness of the Programme Among the Community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe programme has received limited attention, resulting in a weak implementation focus. A significant proportion of older persons and their caregivers are unaware of the programme and the services available under it, indicating gaps in outreach and communication strategies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot prioritizing elderly care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElderly care services are often overlooked and not given the attention they deserve despite the growing elderly population.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-implementation with National Programme for Prevention and Control of Cancer Diabetes, Cardiovascular Diseases \u0026amp; Stroke (NPCDCS) and Palliative care programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCo-implementation with the NPCDCS programme often results in sabotaging the importance of the programme thus resulting in inability to project programme specific outcome\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e4. Suggestions for Improvement of the Programme\u003c/h3\u003e\n\u003cp\u003eOne of the key recommendations is the need for dedicated staff to assist geriatric patients. This suggestion is seen as crucial, particularly in the context of implementing e-health initiatives and vaccine drives. By appointing separate staff such as doctors, nurses, and physiotherapists under the programme, service delivery could be significantly improved. This would not only ease the implementation process but also ensure that elderly patients receive the specialised attention they need (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The main issue that we are facing in this district is a lack of funds, and in general hospitals, setting up geriatric-friendly wards has not received much focus. If we get more funds and if people gain more awareness about the needs and importance of the programme, we can really make changes.\u0026rdquo; - (Superintendent, DH Vadakara)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We need to increase awareness and capacity building. Doctors and staff need training on the programme's goals. For example, clinics need physical modifications like ramps and handrails to be elderly-friendly\u0026rdquo;- (District Programme Manager, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In my opinion, training and converting hospitals to geriatric-friendly ones are core factors. If we can appoint a separate staff for helping geriatric people, it will be well and good, and it is highly relevant in situations like the implementation of e-health, vaccine drives.\" - (Superintendent, THQH Peerumedu)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Awareness should be created at the bottom level.\u0026rdquo; (State Nodal Officer, NPHCE)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn most of the facilities, dedicated NPHCE outpatient services were initially provided through a separate Medical Officer; however, staff shortages resulted in the merger of NPHCE and NCD clinics following reassignment of personnel to casualty services. Staff shortages were identified as a key constraint to delivering elderly-focused services, limiting the ability to organise dedicated clinic days and preventive or promotive activities.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Initially, we had two Medical Officers, one for NCD and one for NPHCE, and ran separate outpatient clinics. Due to staff shortages, the NCD doctor was reassigned to the casualty department, and NCD and NPHCE services are now merged.\u0026rdquo; - (Medical Officer, GH Pathanamthitta)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We need more staff. If we had more hands, we could dedicate two days a week specifically for those over 60\u0026hellip; collect their phone numbers to call them for special programmes like yoga or mental health sessions. Currently, the rush is too high to do anything extra for them.\u0026rdquo;- (Staff nurse GH Pathanamthitta)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIncorporating geriatric-specific equipment into rehabilitation services is recommended to better accommodate functional limitations among elderly patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Providing special beds that are lower in height would help so they don't have to climb up\u0026rdquo;- (Physiotherapist, DH Kozhencherry)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite infrastructural and staffing strengths, the institution-based services alone are insufficient to meet the growing needs of the elderly population. Greater emphasis on field-level implementation and outreach was highlighted as a critical requirement. There is a high importance in community-based engagement, particularly for addressing mental health and social isolation among older adults.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;To take care of these people, we need to have field-level activity\u0026hellip; There is no point in me sitting here and saying to do this in the district. This has to reach the people. The field staff should go for such gatherings, such as the Kudumbashree meeting, and give them classes about the mental health of the elderly.\u0026rdquo; -(NPHCE- District Nodal Officer, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite a high burden of age-related and gender-specific conditions, geriatric care remains fragmented, with limited attention to mental health and social isolation among older adults, which emphasises the need of coordinated cross-referral mechanisms across NCD, palliative care, and mental health programmes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Geriatric care needs to recognise condition-specific and gender-specific issues such as arthritis, prostate-related problems in men, and health concerns unique to elderly women. Mental health remains largely neglected, especially as many older adults live alone due to the migration of their children, leading to significant loneliness. The absence of coordinated cross-referral between NCD, palliative care, and mental health programmes limits the comprehensiveness of care.\u0026rdquo;- (District Programme Manager, Thrissur)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStrengthening geriatric rehabilitation under NPHCE requires targeted investments in human resources and infrastructure. Respondents emphasised the need for permanent physiotherapists, occupational therapy services, and a dedicated rehabilitation nurse to improve counselling, triage, and continuity of care. The need for accessible infrastructure was strongly articulated.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Having a dedicated, disabled-friendly ward on the ground floor is essential because our patients find it very difficult to navigate ramps and stairs.\u0026rdquo;- (Physiatrist, GH Alappuzha)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eElderly people emphasise the need for social interaction and community engagement among seniors. The elderly often face loneliness and isolation, which can have significant negative impacts on their mental and emotional well-being.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Aged people are alone at home. They are getting bored. They should gather people like us and make arrangements to talk to people like you. We feel happy.\u0026rdquo; (Beneficiary, GH Alappuzha) 65 years, Male)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExpert Recommendations for Strengthening Geriatric Care in Kerala's Health System\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecommended Strategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncorporating Geriatric Care in Medical Curriculum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere should be a chapter for geriatric care in the curriculum. Not only about system care, it should also include emotional care and social care.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntroducing Specialised Geriatric Courses for Medical Professionals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere should be a parallel course on geriatric care at the medical college to train all the doctors and staff nurses.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransforming Healthcare Institutions into Geriatric-Friendly Facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll the health care institutions should be converted into geriatric-friendly ones. Including Taluk hospitals, PHCs, and CHCs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProviding Dedicated Transportation Services for Geriatric Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransportation services should be provided for geriatric patients. In some of the hospitals, there is a transportation service as a part of the palliative care unit. But it should be considered as a system.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePromoting multi-sectoral involvement in geriatric care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeriatric care is not only the responsibility of the health department. Local governments and NGOs should also get involved in this. LSG can make a place where elderly people can walk. Then we can get a synergistic result under geriatric health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnhancing Accessibility and Decentralisation of Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccessibility issues are still persisting, so more decentralisation should happen, and speciality services are very limited in the district. Since the district's population is mainly rural poor, more facilities for affordable speciality services should be made accessible to its population.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefining programme-specific guidelines for implementation and programme-specific indicators for monitoring and evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSince the implementation of similar programmes, such as NCD and Palliative care programmes, is being carried out by the same nodal officer, there is ambiguity regarding the programme indicators and the outcome.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprove awareness among the health care workers and the general population regarding the programme and its objectives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of awareness regarding the programme among the beneficiaries and the providers often result in achieving the potential outcome.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis assessment points to a central tension that may be termed the \u003cem\u003eKerala Geriatric Care Paradox\u003c/em\u003e; while the state has achieved notable success in expanding geriatric infrastructure and establishing dedicated wards across all districts under the NPHCE, these structural gains have not consistently translated into accessible, equitable, or well-integrated elderly care at the primary level. This paradox underscores a disconnect between programme expansion and service delivery, resulting in continued reliance on secondary care and unmet preventive needs among Kerala\u0026rsquo;s ageing population.\u003c/p\u003e \u003cp\u003eThis assessment of NPHCE in Kerala assumes significance in realising that it has made extensive progress in infrastructure development in secondary level, especially in establishing geriatric wards in each district. The quantitative results reveal irregular service delivery in primary levels, a lack of manpower in healthcare, and confusion in fund allocation and accountability of programmes. The overall results using multiple methods indicate that although NPHCE has arrived in Kerala, an appropriate time and place programme, with respect to Kerala's need for handling this age factor in the population, this programme has not yet utilized its full potential in being properly integrated at primary levels and in having trained manpower.\u003c/p\u003e \u003cp\u003eSignificant progress has been made in meeting the healthcare demands of the ageing population in Kerala under the NPHCE programme. An important step towards enhancing geriatric care has been taken with the effective creation of geriatric wards in major hospitals of all 14 districts, after a trial period in five districts. The deliberate choice to spread the programme statewide in spite of financial difficulties highlights the state government's dedication to improving senior citizens' access to healthcare.\u003c/p\u003e \u003cp\u003eImplementing the programme through the comprehensive public health care infrastructure was one of the strengths of the programme as mentioned in Verma et al. and Joshi et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) The introduction of NPHCE was timely given Kerala\u0026rsquo;s rapidly ageing population, the increasing burden of chronic diseases and multiple comorbidities, limited access to routine healthcare services due to physical, social, financial and mobility limitations, and gaps in the provision of elderly-friendly infrastructure and trained geriatric care personnel within existing health facilities.\u003c/p\u003e \u003cp\u003eOne of the most notable successes of the NPHCE initiative is the establishment of dedicated geriatric wards, starting with Pathanamthitta District Hospital. The expansion of geriatric wards to all districts, including Neyyatinkara in Trivandrum and Kollam District Hospitals, highlights the program's widespread impact. Nonetheless, maintaining dedicated geriatric outpatient services remains a challenge. The high proportion of elderly patients (70%-80%) in Community Health Centres (CHCs) and Primary Health Centres (PHCs) makes it impractical to establish separate outpatient departments exclusively for the elderly. The programme has shifted its focus from enhancing geriatric-friendly infrastructure, such as installing ramps, rails, and suitable furniture, to better accommodate the needs of elderly patients, similar to findings from other parts of India (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Similar to observations in other elderly welfare initiatives in Kerala, such as \u0026ldquo;\u003cem\u003eVathilpadi Sevanam\u0026rdquo;\u003c/em\u003e(Deliver essential public services directly to the homes of vulnerable citizens, including the elderly (60+), persons with disabilities, bedridden patients, and those in extreme poverty) and \u0026ldquo;\u003cem\u003eVayomithram\u0026rdquo;\u003c/em\u003e(Provides health care and support to elderly above the age of 65 years residing at Corporation/Municipal Areas in the state), the NPHCE programme has demonstrated positive impacts in improving healthcare access and promoting dignity among older adults. Consistent with prior evidence, challenges remain in ensuring equitable reach, adequate staffing, and accessibility, particularly at primary care levels. These findings highlight the continued need for innovative strategies, community engagement, and strengthened integration of services to provide comprehensive, age-friendly care for Kerala\u0026rsquo;s rapidly ageing population (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe nonavailability of trained geriatric doctors has resulted in MBBS graduates being appointed for the management of older patients. This is a pragmatic solution but highlights the need for further training and specialisation in geriatric care. Studies by Vaishnav et al. emphasise that specialised geriatric care is essential, especially for those older adults with complex health needs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Similar shortages have been observed in other parts of India, where healthcare providers are often reassigned from geriatric wards to other services like palliative care and non-communicable disease (NCD) clinics (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimilarly, reassignment of nurses recruited for elderly care to other departments, such as NCD and palliative care clinics, remains a challenge to the provision of care for older person. This reflects a broader issue of inefficient resource utilization, as described by Dumka et al., who note that human resource allocation in India's healthcare system often results in fragmented care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The decentralised nature of Kerala's healthcare delivery model, while intended to optimise resource use, has resulted in a dilution of focus. Nurses are often required to cover multiple programmes, leaving elderly patients without dedicated care. This issue is compounded by a lack of systematic training for healthcare providers, an issue also raised in global studies on geriatric care. Studies from other regions, such as Jones et al., have similarly highlighted that the shortage of specialised healthcare providers undermines the efficacy of elderly care programmes (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This highlights the need for sustained, integrated, and adaptive approaches beyond initial programme roll-out to comprehensively address the health and care needs of Kerala\u0026rsquo;s ageing population.\u003c/p\u003e \u003cp\u003eThe reliance on general practitioners rather than specialised geriatricians to manage geriatric wards complicates care, especially for elderly patients with specific needs. The reassignment of geriatric staff to general duties is another area of concern, as this further reduces the focus on specialised elderly care. Racz's research echoes this sentiment, emphasising the need for a greater focus on specialised geriatric medicine to improve healthcare outcomes for the elderly (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). There is a clear need for increased training programmes that equip medical professionals with the skills necessary to address the unique challenges faced by the elderly population.\u003c/p\u003e \u003cp\u003eSimilar to the Punjab study, which identified only moderate readiness for geriatric services and highlighted the urgent need to strengthen leadership, governance, financial allocation, and training programmes at peripheral healthcare levels, it strongly corroborates the findings of this study. Both studies point to a systemic weakness: insufficient staffing and low prioritisation of elderly care at the grassroots level. Consequently, advancing the NPHCE requires directly addressing these gaps by establishing dedicated geriatric leadership, ensuring sustainable and non-mingled financial support, and implementing integrated care models. Such measures must go beyond infrastructure enhancement to guarantee comprehensive, accessible, and high-quality preventive, curative, and rehabilitative services for older adults across all tiers of healthcare (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA secondary analysis of the 5th Indonesian Family Life Survey showed that older adults in rural areas and with lower education primarily use community health centres, highlighting how socioeconomic and accessibility factors shape care-seeking (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similarly, a qualitative study from rural Pakistan found that inadequate staff, medicines, and infrastructure at primary care facilities forced people to seek secondary-level services (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). These findings align with our Kerala study, where elderly individuals prefer primary care but NPHCE services were largely unavailable at PHCs and CHCs, emphasising the need to expand geriatric programmes to primary care for better access to preventive and supportive services. Overall, the health care delivery was inconsistent and inadequate, as the elderly population did not receive comprehensive care, including vital health care services like mental health counselling and chronic disease management.\u003c/p\u003e \u003cp\u003eFlexible fund utilisation under the National Programme for Health Care of the Elderly (NPHCE) has facilitated the establishment of geriatric wards and the upgrading of facilities in several districts. However, limitations arise due to uneven or insufficient funding, leading to disparities in service availability and infrastructure. A study highlighted that funding constraints, infrastructure gaps, and a shortage of trained personnel in geriatric care hamper quality service delivery, especially in rural and coastal areas (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This highlights the need for equitable and sustained financial support to ensure comprehensive and accessible geriatric services across all regions. The utilisation of funds across NPHCE, Palliative Care, and NPCDCS in a shared manner has led to considerable ambiguity in programme-wise fund receipt, allocation, and utilisation. The presence of a single nodal officer overseeing multiple programmes, along with the absence of clearly defined financial and operational guidelines, has limited programme-specific accountability and oversight. In addition, outcomes are often reported in an aggregated manner, making it challenging to attribute results to individual programmes. The overlap in beneficiary populations further contributes to this complexity, thereby constraining a clear assessment of programme-wise performance, efficiency, and impact.\u003c/p\u003e \u003cp\u003eAlthough the programme envisages comprehensive care for older persons across the continuum of care, its implementation has largely been confined to infrastructural strengthening, with limited emphasis on primary care\u0026ndash;based geriatric services. Community-level and preventive components remain insufficiently developed, similar to findings in Joshi et al. In contrast to programmes such as RCH, IHIP and NPCDCS, NPHCE has had relatively low programmatic visibility and integration within routine health system processes, suggesting that the system may not have been fully prepared to internalise and operationalise the programme at scale.\u003c/p\u003e \u003cp\u003eNPHCE was introduced at an appropriate time, particularly in view of Kerala\u0026rsquo;s advanced demographic transition and the increasing health needs of older persons. At the time of its rollout, Kerala already had a well-established palliative care system that had evolved since the 1990s and was deeply embedded within the public health system and community structures, playing a substantial role in addressing the care needs of older persons. In this context, several health and supportive care needs of older persons were perceived to be addressed through existing palliative care services. This has, at times, led to an implicit assumption that palliative care constitutes comprehensive care for the elderly, which does not fully align with the broader spectrum of geriatric health needs. Consequently, NPHCE was often implemented in close alignment with palliative care activities, which, while enabling service convergence, may have reduced the programme\u0026rsquo;s distinct visibility and prioritisation at the implementation level. This underscores the need for clearer articulation of complementary roles and programme-specific focus to optimise elderly care services in the state. Moreover, Tthehealth system is still in the process of clearly articulating and responding to the distinct and evolving needs of an ageing population. A more deliberate strategy to integrate NPHCE with existing programmes such as NPCDCS, Palliative care, \u0026ldquo;\u003cem\u003eVayomitram\u0026rdquo;\u003c/em\u003e, \u0026ldquo;\u003cem\u003eVathilppadi Sevanam\u0026rdquo;\u003c/em\u003e, while explicitly addressing gaps specific to older persons, could have enabled a more efficient, coordinated, and impactful approach to elderly care in the state. The decentralised care model in Kerala, which includes programmes such as elderly recreation parks and yoga sessions, offers a promising avenue for improving the quality of life for the elderly. Similar approaches have been highlighted in studies on healthy ageing in Asia (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The challenges, such as a lack of political will and misconceptions regarding the integration of geriatric and palliative care services, must be addressed, as Aldridge et al. have pointed out in their review of global palliative care integration (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Raising awareness about the distinct needs of geriatric patients and incorporating geriatric topics into the medical curriculum, as suggested by Kotsani et al., will be crucial in overcoming these challenges (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The findings of Dev et al. on resource utilisation for healthy ageing in Kerala resonate with our study results, particularly regarding awareness and uptake of elderly care services. Both studies highlight barriers such as accessibility constraints, socioeconomic factors, and reluctance to adopt supportive resources. These observations show the importance of a structured, community-sensitive, and well-coordinated approach to enhance both awareness and use of healthy ageing resources across the state (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith the best decentralised model, several local initiatives in Kerala have demonstrated how local self-governments can enhance accessibility, inclusiveness, and monitoring of elderly care services in a holistic way, incorporating physical, mental, social and spiritual elements\u003c/p\u003e \u003cp\u003eLeveraging Kerala\u0026rsquo;s strong decentralised governance framework, several local initiatives have demonstrated the potential of local self-governments to enhance the accessibility, inclusiveness, and monitoring of elderly care services through holistic approaches that address physical, mental, social, and spiritual well-being. Manickal Grama Panchayat\u0026rsquo;s initiative to establish \u003cem\u003eAge-Friendly Forums\u003c/em\u003e and create inclusive spaces for older persons represents a pioneering model of local governance in the state. By actively engaging schools, Parent-Teacher Associations, and wider community stakeholders, the initiative promotes intergenerational bonding and works to reduce ageism. The Panchayat\u0026rsquo;s phased strategy to transform public institutions into \u003cem\u003eOld-Age-Friendly Institutions\u003c/em\u003e, with coordinated support from multiple government departments, underscores the potential of decentralised and community-driven approaches to elderly care. Its emphasis on multi-sectoral collaboration, systematic ward-level data collection, and targeted service delivery highlights how local governance can respond more effectively to the diverse needs of older persons (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Embedding community engagement and age-friendly infrastructure within local systems complements facility-based services and helps address gaps in the reach and effectiveness of NPHCE. If successfully scaled, the Manickal model could serve as a replicable framework for other local bodies to develop sustainable, age-friendly ecosystems that strengthen both preventive and curative geriatric care.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe evaluation of the National Programme for Health Care of the Elderly (NPHCE) in Kerala highlights both the progress achieved and the challenges that remain in addressing the health needs of a rapidly ageing population. The study findings demonstrate how integrating geriatric services into existing healthcare structures can strengthen access to care, improve infrastructure, and promote age-friendly environments. The establishment of geriatric wards across districts, the introduction of elderly-friendly design features, and the incorporation of physiotherapy and rehabilitation services represent major milestones toward comprehensive geriatric care.\u003c/p\u003e \u003cp\u003eEven with Kerala being the Indian state with the highest proportion of older adults and having a well-established, decentralised public health system, the evaluation reveals a critical gap in geriatric specialised service delivery at the primary level. There exists a significant absence of specifically designed initiatives and geriatric-friendly facilities for the aged in the primary health facilities, with geriatric services being predominantly a concern for the secondary-level health facilities.\u003c/p\u003e \u003cp\u003eThere are implementation barriers, including inadequate human resources, inconsistent funding, lack of specialised training, and uneven service delivery, particularly at primary and community health centre levels. The merging of geriatric and palliative care services, while operationally efficient, often diffuses focus from preventive and rehabilitative care for older adults.\u003c/p\u003e \u003cp\u003eTo ensure sustainability and equity, the programme needs capacity building, dedicated staffing, financial support, integration with other programmes and intersectoral collaboration involving local governments and communities. Strengthening monitoring mechanisms, expanding geriatric care to the primary level, and incorporating geriatric health into medical education are also essential.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the Directorate of Health Services (DHS), Kerala for \u0026nbsp;granting permission and providing necessary support for this study. We acknowledge Dr. Sreeshma K. S., former intern at SHSRC-K, for her diligent assistance with conduct of KIIs and transcription during the initial stages of this study. We also thank the research assistant of the State Health Systems Resource Centre, Kerala (SHSRC-K), Dr. Thusharamol N. S., for meticulous proofreading of the manuscript. Special thanks are also due to Mr. Mahesh R, current intern at SHSRC-K and MPH student at Azim Premji University, Bhopal, for contributing an academic perspective that enriched the analytical scope of this paper. This work would not have been possible without the collaborative efforts and institutional support of all the individuals and entities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe researchers claim no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution:\u003c/strong\u003e RMR and BAC provided overall leadership for the study. RMR was responsible for conceptualisation and supervision. BAC contributed to the methodology, project administration, data collection, and data analysis. HSS and SC conducted the centre survey and interviews and performed initial thematic analysis. Data analysis was supported by all co-authors. The original draft of the manuscript was prepared by BAC, RMR, DR, and ZS. PMG was responsible for review and editing of the manuscript. RMR provided critical expert feedback and final approval. DR, ZS, and PMG contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe datasets generated and analysed during the current study are not publicly available to protect the confidentiality of the participants, in accordance with the conditions of the ethical approval granted for this research. This restriction is due to the qualitative nature of the data, which includes in-depth interviews and key informant responses that contain detailed contextual and professional information; public release could compromise participant privacy or lead to indirect identification, particularly for key personnel in specific roles. Excerpts supporting the findings are included within the manuscript. Anonymised portions of the data may be made available from the corresponding author upon reasonable request and subject to approval from the Institutional Ethics Committee and relevant health authorities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical consideration:\u0026nbsp;\u003c/strong\u003eThe study received ethical clearance from the Institutional Ethics Committee of the General Hospital, Thiruvananthapuram (Sl.No 32/03/02/21-GHEC). All necessary permission was obtained from authorities before the conduct of the study, and consent was taken from each participant before interviews. Care was taken to ensure no harm was done to the participants of the study and that the smooth operation of NPHCE was not hampered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e: Written informed consent was obtained from all participants prior to data collection. For key informants (policymakers, state and district nodal officers, and healthcare providers), consent included agreement to be identified by their professional roles in published findings, given the programme evaluation context where positional transparency is essential for accountability and analysis. For elderly beneficiaries and primary caregivers, confidentiality and anonymity were assured, and they were informed that only aggregated or anonymised data would be used in reporting. All participants were informed of the voluntary nature of the study and their right to withdraw at any stage without consequence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript. They consent to its submission for publication in \u003cem\u003eDiscover Public Health\u003c/em\u003e and affirm that the work is original, has not been published previously, and is not under consideration for publication elsewhere.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSituation Analysis Of The Elderly in India [Internet]. [cited 2025 Dec 23]. Available from: https://www.mospi.gov.in/sites/default/files/publication_reports/elderly_in_india.pdf \u003c/li\u003e\n\u003cli\u003eBanerjee S. Determinants of rural-urban differential in healthcare utilization among the elderly population in India. BMC Public Health. 2021 May 17;21(1):939. \u003c/li\u003e\n\u003cli\u003eRashmi R, Srivastava S, Muhammad T, Kumar M, Paul R. Indigenous population and major depressive disorder in later life: a study based on the data from Longitudinal Ageing Study in India. BMC Public Health. 2022 Dec 3;22:2258. \u003c/li\u003e\n\u003cli\u003eSarkar S. Providing Services for Elderly in Rural India \u0026ndash; Is Anganwadi Centres a feasible option? International Journal of Medicine and Public Health. 2016 July 1;6:57\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMalik C, Khanna S, Jain Y, Jain R. Geriatric population in India: Demography, vulnerabilities, and healthcare challenges. J Family Med Prim Care. 2021 Jan;10(1):72\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eNational Programme for healthcare of Elderly(NPHCE) :: National Health Mission [Internet]. [cited 2025 Dec 23]. Available from: https://nhm.gov.in/index1.php?lang=1\u0026amp;level=2\u0026amp;sublinkid=1046\u0026amp;lid=605 \u003c/li\u003e\n\u003cli\u003eMini GK. Socioeconomic and demographic diversity in the health status of elderly people in a transitional society, Kerala, India. J Biosoc Sci. 2009 July;41(4):457\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eK S, Sathyamurthi DK. Growing Old in Kerala: A Comprehensive Review of Elderly Welfare Initiatives. Int J Res Rev. 2025 Aug 9;12(8):35\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eNational Programme for Health Care of the Elderly(NPHCE) | Ministry of Health and Family Welfare | GOI [Internet]. [cited 2025 Dec 23]. Available from: https://www.mohfw.gov.in/?q=en/major-programmes/Non-Communicable-Diseases/Non-Communicable-Diseases-1 \u003c/li\u003e\n\u003cli\u003eRatcliffe J. Social justice and the demographic transition: lessons from India\u0026rsquo;s Kerala State. Int J Health Serv. 1978;8(1):123\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eCaldwell JC, Zachariah KC, Rajan SI. Kerala\u0026rsquo;s Demographic Transition: Determinants and Consequences. Pacific Affairs. 1999;72(3):458. \u003c/li\u003e\n\u003cli\u003ePritam B, Soumya C, Deepankar S, Prashant S. Technology Framework for India\u0026rsquo;s Road Freight Transport: Compliance and Enforcement Architecture Reform [Internet]. Asian Development Bank; 2021 Aug [cited 2025 Dec 23]. Available from: https://www.adb.org/publications/technology-india-road-freight-transport \u003c/li\u003e\n\u003cli\u003eStudy on the Health Situation of Urban Elderly in Kerala (1). \u003c/li\u003e\n\u003cli\u003eNational Policy for Older Persons Year 1999.pdf [Internet]. [cited 2025 Dec 23]. Available from: https://socialjustice.gov.in/writereaddata/UploadFile/National%20Policy%20for%20Older%20Persons%20Year%201999.pdf \u003c/li\u003e\n\u003cli\u003eVaishnav LM, Joshi SH, Joshi AU, Mehendale AM. The National Programme for Health Care of the Elderly: A Review of its Achievements and Challenges in India. Ann Geriatr Med Res. 2022 Sept;26(3):183\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eMundada PS, Sharma S, Gupta B, Padhi MM, Dey AB, Dhiman KS. Review of health-care services for older population in India and possibility of incorporating AYUSH in public health system for geriatric care. Ayu. 2020;41(1):3\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eMohan D, Iype T, Varghese S, Usha A, Mohan M. A cross-sectional study to assess prevalence and factors associated with mild cognitive impairment among older adults in an urban area of Kerala, South India. BMJ Open. 2019 Mar 20;9(3):e025473. \u003c/li\u003e\n\u003cli\u003eKidder DP, Fierro LA, Luna E, Salvaggio H, McWhorter A, Bowen SA, et al. CDC Program Evaluation Framework, 2024. MMWR Recomm Rep. 2024 Sept 26;73(6):1\u0026ndash;37. \u003c/li\u003e\n\u003cli\u003eVerma R, Khanna P. National program of health-care for the elderly in India: a hope for healthy ageing. Int J Prev Med. 2013 Oct;4(10):1103\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eOvid [Internet]. [cited 2025 Dec 23]. Strengths, Weaknesses, Opportunities, and Threats... : Journal of the Indian Academy of Geriatrics. Available from: https://www.ovid.com/journals/jiag/fulltext/10.4103/jiag.jiag_9_23~strengths-weaknesses-opportunities-and-threats-analysis-of \u003c/li\u003e\n\u003cli\u003eVaishnav LM, Joshi SH, Joshi AU, Mehendale AM. The National Programme for Health Care of the Elderly: A Review of its Achievements and Challenges in India. Ann Geriatr Med Res. 2022 Sept;26(3):183\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eDumka N, Mangat S, Ahmed T, Hannah E, Kotwal A. Adding health to years: A review of the National Programme for Health Care of the Elderly (NPHCE) in India. J Family Med Prim Care. 2022 Nov;11(11):6654\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eJones CH, Dolsten M. Healthcare on the brink: navigating the challenges of an aging society in the United States. NPJ Aging. 2024 Apr 6;10(1):22. \u003c/li\u003e\n\u003cli\u003eBesdine R, Boult C, Brangman S, Coleman EA, Fried LP, Gerety M, et al. Caring for older Americans: the future of geriatric medicine. J Am Geriatr Soc. 2005 June;53(6 Suppl):S245-256. \u003c/li\u003e\n\u003cli\u003eKumar S, Verma M, Aggarwal R, Chauhan S, Mishra S, Gill SS, et al. Assessment of the public health system preparedness to provide geriatric-friendly healthcare services in Punjab, India: A cross-sectional study. J Family Med Prim Care. 2025 Sept;14(9):4001\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003e(PDF) EXPLORING THE REASONS FOR UNDERUTILIZATION OF PRIMARY HEALTH CARE SERVICES IN PAKISTAN: A QUALITATIVE ANALYSIS. ResearchGate [Internet]. 2025 Aug 9 [cited 2025 Dec 23]; Available from: https://www.researchgate.net/publication/348603834_EXPLORING_THE_REASONS_FOR_UNDERUTILIZATION_OF_PRIMARY_HEALTH_CARE_SERVICES_IN_PAKISTAN_A_QUALITATIVE_ANALYSIS \u003c/li\u003e\n\u003cli\u003ePrimary healthcare utilization by the elderly: a secondary analysis of the 5th Indonesian Family Life Survey. ResearchGate [Internet]. 2025 Aug 6 [cited 2025 Dec 23]; Available from: https://www.researchgate.net/publication/340501525_Primary_healthcare_utilization_by_the_elderly_a_secondary_analysis_of_the_5th_Indonesian_Family_Life_Survey \u003c/li\u003e\n\u003cli\u003eKotsani M, Kravvariti E, Avgerinou C, Panagiotakis S, Bograkou Tzanetakou K, Antoniadou E, et al. The Relevance and Added Value of Geriatric Medicine (GM): Introducing GM to Non-Geriatricians. J Clin Med. 2021 July 7;10(14):3018. \u003c/li\u003e\n\u003cli\u003eRoutledge \u0026amp; CRC Press [Internet]. [cited 2025 Dec 23]. Healthy Ageing in Asia: Culture, Prevention and Wellness. Available from: https://www.routledge.com/Healthy-Ageing-in-Asia-Culture-Prevention-and-Wellness/Soon-Bodeker-Kariippanon/p/book/9780367473884 \u003c/li\u003e\n\u003cli\u003eAldridge MD, Hasselaar J, Garralda E, van der Eerden M, Stevenson D, McKendrick K, et al. Education, implementation, and policy barriers to greater integration of palliative care: A literature review. Palliat Med. 2016 Mar;30(3):224\u0026ndash;39. \u003c/li\u003e\n\u003cli\u003eDev G, Thrivikraman SK. Resource Utilization for Healthy Aging in Kerala: A Mixed Methods Approach. Journal of the Indian Academy of Geriatrics. 2023 Dec;19(4):249. \u003c/li\u003e\n\u003cli\u003eA Case Study of Manickal Grama Panchayat in Thiruvananthapuram District [Internet]. [cited 2025 Dec 23]. Available from: https://spb.kerala.gov.in/sites/default/files/inline-files/28.pdf \u003c/li\u003e\n\u003cli\u003eKumar DV. The New Indian Express. 2015 [cited 2025 Dec 23]. Manickal Gearing up to be First Old-age-friendly Panchayat in State. Available from: https://www.newindianexpress.com/states/kerala/2015/Aug/01/manickal-gearing-up-to-be-first-old-age-friendly-panchayat-in-state-792902.html \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ageing population, Geriatric health services, Health policy, Long-term care, National health programme","lastPublishedDoi":"10.21203/rs.3.rs-8494873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8494873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e \u003cp\u003eGlobally, the proportion of older persons is steadily increasing. In India, 8% of the population is above 60 years of age, rising to 12.6% in Kerala, the highest among all states. To address the growing health needs of this demographic, the Ministry of Health and Family Welfare launched the National Programme for Health Care of the Elderly (NPHCE) in 2010\u0026ndash;2011. This study evaluates the implementation and impact of NPHCE across five districts in Kerala\u0026mdash;Kozhikode, Thrissur, Pathanamthitta, Alappuzha, and Idukki\u0026mdash;and examines its key achievements and challenges.\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e \u003cp\u003eA cross-sectional, concurrent mixed-method design was used. Quantitative data were collected through structured questionnaires and observation checklists, while qualitative insights were obtained from Key Informant and In-Depth Interviews.\u003c/p\u003e \u003cp\u003eResults\u003c/p\u003e \u003cp\u003eThe quantitative findings show that NPHCE has expanded from five pilot districts to all fourteen, establishing geriatric wards, outpatient clinics, and elderly-friendly infrastructure. However, implementation remains uneven, with disparities in staffing, infrastructure quality, and service utilisation across districts, indicating inconsistencies in accessibility and care delivery.\u003c/p\u003e \u003cp\u003eQualitative findings reveal that while accessibility and comfort for older adults have improved, persistent challenges remain due to workforce shortages, limited funding, and inadequate transport facilities. Beneficiaries also reported social isolation, economic vulnerability, and barriers to essential healthcare. Strengthening human resources, interdepartmental coordination, and community participation were emphasised to enhance programme effectiveness.\u003c/p\u003e \u003cp\u003eConclusion\u003c/p\u003e \u003cp\u003eKerala\u0026rsquo;s decentralised healthcare model provides a strong foundation for elderly care. However, addressing political, financial, and operational challenges remains critical to improving the quality of life for the state\u0026rsquo;s ageing population.\u003c/p\u003e","manuscriptTitle":"Evaluating the National Programme for Health Care of the Elderly in Kerala's Rapidly Ageing Context Uncovering the Geriatric Care Paradox","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 17:39:25","doi":"10.21203/rs.3.rs-8494873/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T15:04:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-17T12:43:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-07T17:49:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247023144313400584122347168253689683096","date":"2026-02-07T11:03:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207901046800804741236294559327348145851","date":"2026-01-28T18:17:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86183649606408241146323534417250504754","date":"2026-01-28T16:01:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-28T15:55:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-09T06:27:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T06:48:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-01-08T06:35:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ca84d55-f5c7-44b7-825e-998c735dd545","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-01T10:15:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 17:39:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8494873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8494873","identity":"rs-8494873","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}