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Living longer in India: Better or worse?

average number of remaining years of life a person at a given age is expected to spend in various states of health. Calculating
health expectancy allows the decomposition of total remaining years of life, at a given age, into those lived in a state of
good health (healthy life expectancy) and those lived in one or more states of ill health (unhealthy life expectancy) (Saito,
Robine, and Crimmins, 2014). While the concept of health expectancy is unique, different measures have been used to
define “health.” Commonly used measures are the absence or presence (or the extent therein) of mobility limitation,
disability, activities of daily living (ADL) limitations, instrumental ADL limitations, any non-communicable disease
(NCD), or specific NCDs (Saito, Robine, and Crimmins, 2014). Health expectancy combines information about mortality
and morbidity. Thus, a comparison of changes in health expectancy over time directly addresses whether the duration of
remaining life spent with morbidity or disability is shortening or lengthening relative to changes in life expectancy.
The extant literature provides two main hypotheses for the relationship of longer life with changes in health. The first
hypothesis argues that improvements in life expectancy evolve from a delay in the onset and progression of diseases and
disability, and morbidity is generally reduced (Fries, 1980). This hypothesis is called compression of morbidity, as it
proposes that an increase in life expectancy is accompanied by a decrease in the proportion of remaining life lived with
morbidity and disability. In other words, it posits a decrease in relative unhealthy life expectancy (the ratio of unhealthy
life expectancy to life expectancy) over time. Conversely, the expansion of morbidity hypothesis states that as mortality
declines through improved medical care, an increase in life expectancy is accompanied by an increase in the proportion
of remaining life lived with morbidity and disability. That is, there is improved survival among frail individuals who have
higher expected incidence rates of disability (Gruenberg, 1977; Kramer, 1980). In other words, it suggests an increase in
relative unhealthy life expectancy over time.
Studies from several countries support the presence of both hypotheses (Doblhammer and Kytir, 2001, Graham,
Blakely, Davis et al., 2004, Crimmins and Beltrán-Sánchez, 2011, Fries, Bruce, and Chakravarty, 2011). However, to the
best of our knowledge, only one recent study, operationalizing “health” as self-reported absence (or presence) of NCDs,
assesses NCDs among older persons in India (Arokiasamy and Yadav, 2014). This 2014 study supports the expansion of
morbidity hypothesis.
While informative, the said study has its limitations. First, the use of self-reported disease status to define “health”
is sensitive to changes in awareness or literacy about diseases and to changes in health-care accessibility over time.
Thus, a change in health expectancy may simply reflect a change in awareness, or it may reflect a change in awareness
and/or access to health care. Over time, this can lead to a change in the diagnosis of diseases in otherwise undiagnosed
individuals. Alternatively, changes in health expectancy may reflect a change over time in the criteria used for diagnosing
diseases (Crimmins and Saito, 2000). Second, the list of NCDs and the referent time period varied across the rounds of
National Sample Surveys (NSS) considered for health expectancy calculations in the study. Thus, any observed change in
health expectancy, rather than real, could have been due to this variation in NCD criterion across the rounds. Third, it has
been shown in studies, though not from India, that while the prevalence of diseases among older persons has consistently
increased over the past few decades, the prevalence of functional or activity limitations consistently declined in the 1980s
and 1990s (Freedman, Crimmins, Schoeni et al., 2004) and remained stable in the 2000s (Freedman, Spillman, Andreski
et al., 2013). Thus, it is of interest to see if the expansion of morbidity observed for NCDs in India holds in the context of
functional or activity limitations.
In this paper, we use mobility limitation to define health, such that the absence of mobility limitation is considered
healthy (and its presence, unhealthy). A mobility limitation is a functional impairment which limits a person’s ability
to move her- or him-self independently and safely. Mobility limitation leads to social isolation, depression, and other
adverse mental health outcomes (Lampinen and Heikkinen, 2003), contributes to poor quality of life (Netuveli, Wiggins,
Hildon et al., 2006), and is associated with a higher risk of health service use (Penninx, Ferrucci, Leveille et al., 2000),
institutionalization (von Bonsdorff, Rantanen, Laukkanen et al., 2006), and mortality (Rolland, Lauwers-Cances, Cesari
et al., 2006). Further, mobility limitation may lead to dependency, a need for assistance, and an increased risk for disability
(Lawrence and Jette, 1996; Stuck, Walthert, Nikolaus et al., 1999). Given the pivotal role of mobility for older persons,
we thus utilize changes over time in life expectancy with and without mobility limitation among the population of older
persons in India to assess whether increases in total life expectancy at older ages are associated with better or worse states
of “health” during the years of life added. In other words, are increases in total life expectancy at older ages associated
with the compression or expansion of morbidity?
In a largely patriarchal society like India with sharp gender disparities, across age groups, in access to nutrition,
health, education, and economic resources (Agarwal, 1994; Singh, 2012; Saha, 2013; Maharana and Ladusingh, 2014),
older women become disproportionately vulnerable to disability (Sengupta and Agree, 2003, Sreerupa and Rajan, 2010),
and disease and poor health-care utilization (Sreerupa and Rajan, 2010). In a similar vein, older rural persons face a

24 International Journal of Population Studies | 2018, Volume 4, Issue 2