Introduction

Currently, two-thirds of older adults are located in developing countries, with this proportion set to increase to four-fifths by 2050 (Sampaio & Amrith, 2023). Although Bangladesh has until now been a demographically young nation, it is experiencing sharp growth in its older population. Several studies anticipate this rapid population ageing to result in major health and social problems and, in turn, substantial government expenditures (Barikdar et al., 2016; Hamiduzzaman et al., 2018; Rahman, 2017). Like in most developing nations, in Bangladesh, care for older adults has traditionally been offered as unpaid care by families and relatives, backed by social, cultural and religious norms and practices (Kabir et al., 2002). However, due to dynamic demographic and social changes that have transformed family structures and concepts, as well as vast migration from rural areas to cities and abroad, these traditional family care practices are no longer sustainable. As a result, older adults, especially women and widows, as well as physically disabled and economically poor individuals, have become more vulnerable and often lack adequate care and support (Rahman et al., 2004). Consequently, the concept of ageing and care, as well as the needs of older adults, particularly women and physically disabled individuals, must be identified from a developing country perspective and through the implementation of policy initiatives.

Despite growing care needs and the disintegrating family care model, practically no specific health or social care services for older adults have been provided in Bangladesh (Hamiduzzaman et al., 2018). In addition, limited household incomes and the excessive healthcare costs that individuals need to pay out of pocket multiply older people’s deprivation, especially among those in poverty. Therefore, the difficult situation of older adults and their lack of care have emerged as acute social problems in Bangladesh. However, they remain absent from governments’ or third-sector organisations’ primary development goals. This lack of policy attention has been accompanied by a lack of research attention, as few studies on ageing and care for older adults in Bangladesh have been conducted by the government, nongovernmental organisations (NGOs), academic institutes or individual researchers (Barikdar et al., 2016; Tareque et al., 2015).

This article focuses on this issue and analyses the inattention to ageing and care policy in Bangladesh. Interviews were conducted with key policy-makers to capture their understanding of the situation and how the needs of the ageing population should be met. This article introduces existing policies, especially the fairly recent Old Age Allowance (OAA) scheme, and the ongoing demographic changes occurring in Bangladesh. It also examines policy-makers’ levels of awareness of population ageing and the growing care needs of older adults as well as their ideas for policy measures to tackle these issues. First, the scant literature on population ageing in Bangladesh is reviewed, followed by a description of this study’s conceptual framework as well as its data and methods. Finally, the findings are presented and discussed.

Population Ageing and Care Needs in Bangladesh

Internationally, Bangladesh is still a very young society. In contrast, Japan, the most aged country in the world, has a population that is 28 per cent aged 65 or over, which is defined as old age in Japan. In 2020, this age group accounted for only 5 per cent in Bangladesh (World Bank, 2022). However, this will change very soon. According to Bangladesh’s National Policy on Ageing, people above 60 years are considered to be in old age (Rahman, 2017; Hamiduzzaman et al., 2018). According to the Bangladesh Bureau of Statistics (BBS), it is estimated that the share of the older population will almost triple in only 30 years, rising from 8 per cent in 2020 to 22 per cent in 2050 (BBS, 1991, 2001, 2010, 2011, 2012, 2013). The number of older persons is estimated to reach 22 million in 2030, 32 million in 2040 and 45 million in 2050 (Kabir et al., 2016; World Bank, 2021; Zaman & Sarker, 2021). This represents a dramatic demographic shift that will transform Bangladeshi society and lead to a rapid increase in care needs among the population.

Although the percentage of the older population is not yet high in Bangladesh, at over 14 million, their absolute number is already considerable (WDI, 2021). The number of people aged 60 + increased by more than 12 million between 1951 and 2020, a nearly sevenfold increase. Moreover, 22 per cent of them are aged 75+, which accounts for over 3 million people (BBS, 2020). The rapid population ageing in Bangladesh has been attributed to factors such as low birth rates, lowering mortality rates and increasing life expectancy (Hamiduzzaman et al., 2018; World Bank, 2022). Life expectancy at birth in Bangladesh is currently 72.4 years (BBS, 2023). According to the BBS, life expectancy has been increasing by 0.60 per cent every year since 2000 (BBS, 2015). Since the country became independent from Pakistan in 1971, life expectancy has increased by 26 years (World Bank, 2020).

In all societies, old age often leads to functional deterioration, degradation of physical strength and difficulty in carrying out one’s normal functioning (Barikdar et al., 2016). However, due to the diverse lifestyles and living arrangements in developing countries, the care needs, ideologies and care models are fundamentally different (Sampaio & Amrith, 2023). For example, high-commode toilets are rare, especially in rural parts of Bangladesh (BBS, 2015). As a result, going to the toilet is often very stressful for older adults, especially for those who have difficulties sitting at ground level commode and standing without support. This is relevant to several activities of daily living (ADLs), where modern technological facilities are often unavailable. These circumstances lead to higher needs for support among older adults compared to nations where such facilities are widely available. Women, in particular, tend to experience greater prevalence of poverty, loneliness and isolation (Miah & King, 2023).

Care needs, living arrangements and preferences differ according to social, cultural and economic contexts. Rana et al. (2009, 728) suggest that ‘quality of life is a subjective and complex concept which is experienced differently by individuals’. While in most of the European Union, older adults prefer and tend to live alone, in many Asian countries, especially in Southeast Asia, people of old age prefer to live with their families (Hyde & Higgs, 2017, p. 119). According to the World Population Ageing 2015 report, over three-quarters of people in less developed countries live with either a child or grandchild (UN, 2015). According to a large-scale survey report, almost all Bangladeshi older adults, regardless of gender, prefer to live with their children and relatives (BBS, 2015). This is unsurprising, as family members are to a large extent the only available source of support and care. In addition, family attachments mean that care and support are provided with emotion in a normative context (Garham, 1983).

Bangladesh is a relatively young country that has, throughout its history, struggled to combat nation-wide extreme poverty (Khoda, 2020). Due to the prevalence of poverty, both policy formulation and implementation face many constraints, such as a lack of resources, domestic interest group pressure and donor interests (Keohane & Milner, 1996). The first policy for older adults, the National Policy on Ageing (NPA), was adopted in 2007. However, there was no action taken to implement the policy except distributing a small amount of funding to some NGOs that provide limited care services to older adults (Rahman, 2017). Following this policy, the government of Bangladesh initiated the Parents Care Act (PCA) in 2013 to ensure the dignity and proper care of older adults by their children, but it had little effect due to a lack of detailed formulation and implementation plans (Pradhan et al., 2017). However, following the limitations of previous policies, in 2018, the government initiated an updated plan, the Welfare of Older Foundation Act, which monitors and executes the government’s decisions and plans for improving the well-being of older adults (Ferdousi, 2019).

The only measures that have thus far been taken to support older adults in Bangladesh are limited coverage pension schemes for government employees and the OAA (Boyosko Vata in Bengali) for financially vulnerable older adults. However, this means-tested OAA scheme has been criticised for lacking both coverage and impact (Rafin, 2023). The OAA programme was started in the fiscal year of 1997–98, and its benefits are distributed by local governments under the Department of Social Services (DSS) of the Ministry of Social Welfare (MoSW; Hossain et al., 2006). The eligibility requirements state that the oldest, financially vulnerable, physically disabled, socially destitute, landless older adults have priority for the allowance over other older adults (DSS, 2021).

In 2020, the OAA was received by 30 per cent of the older population, which, according to the DSS (2021), was slower growth than anticipated (Table 1). Even after this coverage, almost 70 per cent remained excluded from the programme and thus from any form of support from the government (Hamiduzzaman et al., 2018). At the same time, the impact of the allowance remains limited, even for those who receive it: it is a flat-rate benefit that is valued at only around $5 per month, which is equivalent to eight kilograms of medium-quality rice.

Table 1 Numbers and projections of older adults receiving the Old Age Allowance in Bangladesh, 2011–2025.  Source: Population Monograph, Bangladesh Bureau of Statistics, 2015
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One eligibility criterion is that the income of the older person should be below US $100 (approximately) per year (DSS, 2022). This condition excludes most urban dwellers because they need to earn more to survive, as the cost of living is much higher than in rural areas. Even for rural people, an annual income of $100 is by no means enough, as it is significantly lower than the global poverty threshold of $2 per day. Overall, most of the older population has to survive without any support from the public sector, even if they have no family members capable of helping them.

Healthcare provision is a major challenge in Bangladesh (Rana et al., 2009). In 2016, Bangladesh had only 0.79 hospital beds per 1,000 inhabitants, which indicates insufficient resources for hospital services (World Bank, 2020). According to the World Health Organization (WHO, 2016), following the Sustainable Development Goal (index threshold, there should be at least 4.45 doctors, nurses and midwives per thousand inhabitants; however, in 2012, this number was only 0.47 in Bangladesh (World Bank, 2020).

While healthcare is often unavailable and expensive for older adults in Bangladesh, formal long-term care is almost non-existent (Health Economic Review (HEU), 2012). Despite the large absolute number of older adults (over 14 million), publicly funded formal home care is unavailable, and even institutional care for older adults is rare and quite new in Bangladesh (Barikdar & Lasker, 2016). Therefore, long-term care in Bangladesh is almost synonymous with informal family care. However, due to demographic and socio-economic changes, family care in Bangladesh is not without its problems: it is not always available, and, in many cases, it is ‘provided only at the cost of undue strain of relatives’ (Rahman, 2017; Kröger et al., 2019, p. 2).

Inattention to Care for Older Adults in Bangladesh: Policy Perspectives

The concept of inattention has been used in the social science literature from different perspectives. A few public policy publications have investigated the conditions for which policy-makers give more or less attention to a certain social issue (Boydstun et al., 2014; Engström et al 2008; Lam & Chan, 2015; Lukes, 2005; McConnell & Hart, 2019). Engström et al. (2008), for example, suggest that although the importance of an issue is one of the main conditions, it is not sufficient for receiving policy attention. The level of knowledge and organisation of stakeholders within the sector are also vital preconditions for policy attention. However, to the best of our knowledge, the concept of policy inattention has not yet been used to analyse care or ageing policies. With our article, we propose to introduce this conceptual perspective to this field of research, as it can help to highlight policy areas that, despite their importance, have received insufficient attention.

In his ‘multiple-stream theory’, Kingdon (1995, 2011) explained why some issues receive more attention than others. According to him, three separate streams (problem, policies and politics) influence policy attention separately or interconnectedly. The problem stream is primarily concerned with how policy-makers consider the issue. The second stream is concerned with policies that are based on numerous ideas and proposals, which are then filtered through the lenses of legitimacy, feasibility and support from the government and other stakeholders. Finally, the politics stream calculates multiple factors, for example, citizens’ demands, stakeholders’ interests and political gains. In policy-making, there are always plenty of issues, of which only a limited number receive attention. Therefore, only when all three streams are in alignment, does the issue have a high chance of getting attention. On the other hand, the power of policy-makers (see Lukes, 2005) sometimes diverts policy attention to partisan interest (Aminuzzaman, 2013). Lukes (2005) identified how power works as ‘three faces of power’: in decision making, agenda setting and establishing prescribed issues through domination.

The Cambridge Dictionary lists not paying attention and being absent-minded, misfocused, sidelined or careless as synonyms of inattention (Cambridge Dictionary, 2023). Policy inattention can thus be defined as social problems or issues that are sidelined or neglected by policy-makers, NGOs, media, researchers and other stakeholders. It is common for the government of any country, especially of a developing nation, to have numerous issues on its agenda that do not all receive equal attention. However, in some cases, inattention and policy inaction may cause serious consequences for certain groups of people.

Concerning the case of population ageing in Bangladesh, the Constitution of Bangladesh asserts the rights of older adults in Part II, Section 15, ‘Provision of Basic Necessities’ (The Constitution of the People’s Republic of Bangladesh, 1972):

It shall be a fundamental responsibility of the State to attain. .. the right to social security, that is to say, to public assistance in cases of undeserved want arising from unemployment, illness or disablement, or suffered by widows or orphans or in old age, or in other such cases.

However, until now, no specific health or social care services have been built for older adults.

Although the country has, since the last decade, had a steady GDP growth of over six per cent on average and Bangladesh used three per cent of GDP for health expenditures in 2015, government expenditure was only 0.69 per cent (WHO, 2020). This is the lowest level of public health spending among Southeast Asian countries (WHO, 2016). Due to this marginal government investment in healthcare, households need to pay as much as 74 per cent of healthcare costs out of their own pocket, which is much higher than in the nearest country, Maldives 22 per cent (WHO, 2015; World Bank, 2020). The WHO has been very concerned about such a level of out-of-pocket health expenditures in a country where the average income level is low (Shahen et al., 2020). It has been noted that 6.4 million of the country’s citizens fall into poverty due to excessive healthcare costs every year (Nayak, 2018). In addition, along with urban concentrated health infrastructure, health service providers concentrate more on making money than on providing proper treatment and promoting patient satisfaction (Shahen et al., 2020).

NGOs play a vital role in Bangladesh in filling gaps, especially in social issues that are overlooked or given low priority by the government (Aminuzzaman, 2013). However, very few have any initiatives that provide support for the older population (Khoda 2020). The most known NGOs that are active in the field, all working in close cooperation with the government, are the Bangladesh Association of Aged and Institute of Geriatric Medicine (BAAIGM) founded in 1960, Help Age International founded in 1991, the Resource Integration Center founded in 1989, the Service Centre for Elderly People founded in 1994, and the Elderly Development Initiative founded in 1995. However, these NGOs have very limited coverage and provide commercial health and social care services.

Public policies usually reflect the political structure of a country and the way it deals with internal and external actors (Wagner, 1991). Therefore, attracting attention to a social issue requires interested stakeholders in the policy-making process. To analyse the lack of attention to ageing and care policy in Bangladesh, this study collected semi-structured interview data from key policy-makers and other stakeholders.

The research question that this study attempts to answer is as follows: To what extent are policy-makers in Bangladesh aware of the rapidly growing older population and care needs, and how is this awareness reflected in their policy initiatives?

Data and Methods

This study focuses on ageing and care initiatives undertaken by the government and other local stakeholders. Therefore, empirical data were collected from key policy-makers in the government of Bangladesh and other local stakeholders between 26 November 2019 and 2 January 2020. Open-ended interviews were conducted using a semi-structured questionnaire (Dawson, 2002). Table 2 shows the backgrounds of the participants, including age, sex, education, working position and departments, and duration of work by the time of the interview.

Both procedural ethics and ethics in practice (Guillemin & Gillam, 2004) were maintained in accordance with the guidelines of the University of Jyväskylä and the Finnish National Board on Research Integrity (TENK). To ensure that ethical standards were met, permission was obtained from all interview participants in the form of written consent for audio recording and using the data for research purposes. The consent form stated that participants could withdraw this permission at any time, which built trust and ensured voluntary participation and that the respondents would be safe from any harm (Ryen, 2004). There were no objections to using the participants’ detailed information in research publications.

Table 2 Participant details
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In Bangladesh, the DSS under the MoSW is primarily responsible for providing support for older adults (BBS, 2015). Therefore, appointments were sought from the key decision makers of the ministry and the responsible department. In Bangladesh, reaching bureaucrats and policy-makers is challenging. Therefore, a snowball approach was used to collect data (Naderifar et al., 2017; Polit-O’Hara & Beck, 2006). Contacts with some of the interviewees were already made before arriving in the study area. However, after arriving in Bangladesh, reaching them included many difficulties and some humiliation.

The first contact was a parliament member who had been an assistant personal secretary of the prime minister for around eight years. He was told about the research and asked for an appointment. He promised to make an appointment after arriving in Bangladesh. Unfortunately, it proved almost impossible to reach him by phone in Bangladesh. After a lot of effort, he was reached at his office inside the Parliament House. However, obtaining a full interview required several meetings, as the interview was repeatedly disturbed. He helped to get an appointment with the minister of social welfare, but meeting the minister proved difficult. He gave an appointment but cancelled on the spot, apologising for his busyness and setting a new time. This happened several times. A meeting was finally organised, but it was possible to ask only a few questions due to his being in a rush. However, in this short time, his views on key issues were asked. The most interesting part of the interviews was meeting the director general (DG) of the DSS. The interview session with him was around one hour long and very informative. This department is primarily responsible for care and other services for older adults.

Interviews were also conducted with the secretary and two additional secretaries from the Ministry of Welfare along with a joint secretary from the Planning Commission. To obtain field-level experience, two local government officials were interviewed. In addition, interviews were conducted with top executives from two leading NGOs (one domestic and one global). Different questionnaires were used for different types of participants. In addition, observation notes were kept while visiting different offices to collect data.

The main objective of this research is to investigate whether the government of Bangladesh and other stakeholders are aware of the rapidly increasing older population and their social and healthcare needs. As a result, the main questions asked in the interviews with the policy-makers were as follows: 1) Are they concerned about the rapidly growing number of older adults in Bangladesh? 2) What policies have been enacted to support the high number (over 14 million) of older adults in Bangladesh? 3) Are these policies working effectively? 4) What are some challenges associated with these policies? 5) What level of support do they provide? 6) What are some future plans related to these policies? Although some responses were detailed and provided plenty of information, some were quite short and restricted due to the caution of the interviewees. Along with the interviews and field notes, statistical data and information were collected from the BBS and other relevant sources, such as population census data for 1991, 2001 and 2011, World Bank country data and World Development Indicators data.

The interviews were audio-recorded and transcribed verbatim. Interview data and observation notes were processed by systematically coding them before analysing them (Charmaz, 2001). An inductive approach was used to analyse the data, which ‘refers to approaches that primarily use detailed readings of raw data to derive concepts, themes, or a model through interpretations made from the raw data by an evaluator or researcher’ (Thomas, 2006, p. 238). In the first step, descriptive and in vivo coding approaches were used. In the first phase of coding, all transcribed data were processed in an understandable format for further coding. In the second stage, all the data were processed as a ‘pattern code’ to identify themes, causes, relations and theoretical constructs for analysis (Miles & Huberman, 1994).

Finally, the formulated thematic data were analysed according to our own interpretations and theoretical discussions. The dataset collected from the respondents was quite large and included several different perspectives. Therefore, the data presentation and analysis mainly focused on addressing the specific research question and objectives of this study (Punch, 2005). In addition, the themes that emerged were repeatedly reviewed to determine whether they reflected the aims of the interview.

Findings

Lack of Knowledge and Awareness of the Care Needs of Older Adults

The interview data and observation notes suggest that ageing and care support for the older population is a rather new issue for policy-makers in Bangladesh. The policy-makers and other stakeholders are rather ignorant about the care needs of older adults. Except for a few scattered programmes mostly run by NGOs, there is no specific care provision available for older adults in Bangladesh. While asking about ageing and care policies, most of the interviewees mentioned the 2007 NPA, 2013 PCA, 2014 Senior Citizen declaration by the President of Bangladesh and the OAA programme. However, none of these policies are effectively formulated for implementation or ensure universal health and social care coverage for older adults in Bangladesh (Begum & Islam, 2019).

The government of Bangladesh initiated the NPA in 2007, which was the first significant effort to ensure dignity, social security and healthcare for the older population. Although this policy made a number of recommendations, no specific measures have so far been taken by the government (Hamiduzzaman et al., 2018). Instead, in 2013, the government passed the PCA to ensure that children take proper care of their parents and do not abuse them. Instead of ensuring good care for seniors, this shows that the government leaves full responsibility to the family. In addition, this act has not yet been formulated in detail for implementation. Both the Minister of Social Welfare and the DG of the DSS confirmed and gave similar types of statements: “There is a committee working on the act. And hopefully this year [2020] or early next year, the act will be formulated for full implementation.” (Minister, MoSW)

Unfortunately, until the end of 2023, there was no development in implementation the Act, primarily due to lack of awareness and manpower in the law enforcement department (The business Standard, 2023). The latest newspaper article indicated that lack of manpower for enforcement, awareness of citizens and cultural attitudes are the main reasons for the shortcomings: first, understaffed enforcement Recently, there have been news stories about the abuse of older persons in Bangladeshi newspapers and other social and electronic media. These incidents took place for many different reasons, including economic poverty, exploiting parents’ assets, physical and mental abuse and dynamic family issues. Regarding the abuse of older adults by offspring, one NGO executive said the following:

In a survey of around 550 respondents over the age of 60 in a slum area in Dhaka city, we found that over 80 per cent of older adults think that they are abused in some way. Among them, 39 per cent said they were physically abused, and 54.5 per cent of them were women. Fifty-four per cent said they were financially abused. Financial abuse takes many forms. For example, although they are the owners of the assets, they have no control over their assets due to poor health. In addition, older adults get humiliated by their offspring for asking for their own assets when they need them. (Manager, HelpAge International)

Most of the interviewees said that the PCA is not functioning due to its lack of clarity in formulation and implementation. Other reasons include social status, affection to their children and dependence on them. Many parents think that making a complaint may put their children in trouble, which they cannot endure because of their love for their children. Another reason is that parents think that complaining about their children is socially shameful, not only for their children but also for themselves. In addition, even if children abuse their parents, they have no other shelter and must remain with them. The managing director of BAAIGM said the following:

Interestingly, parents, except very few, do not want to file any complaints against their children and put them in trouble even if they have been abused. Another important reason for not reporting is that they do not have an alternative place to live.

On 29 November 2014, the president of Bangladesh declared people aged 60 and above ‘senior citizens’. Although it was an official declaration, it was not accompanied by any benefits or rights. It is also notable that, although 60 years of age has been declared as the start of old age by both the NPA in 2007 and the President in 2014, the eligibility for OAA is 62 for women and 65 for men. Such examples depict a lack of coordination among different governmental departments and uncertainty between policy formulation and implementation in Bangladesh. Concerning the issue, one NGO expert said the following:

It is very unfortunate that we do not have any separate ministry for our older adults. Although old age involves health issues, the Ministry of Health has no programme for the older population. Women in our country suffer more in old age, but the Ministry of Women’s Affairs has no programme for older women. The same goes for the Ministry of Education, Information and Religion. Surprisingly, there are no gerontology courses in medical colleges.. .. It seems that everyone thinks they never get old. It’s a shame for us. (DG, BAAIGM)

Although the policies mentioned above have little impact on care for older adults, the current government reorganised the National Committee on Older Persons in 2017 to implement a national policy of care for older adults. This committee has finalised a draft for a development foundation for old people, the Probin Unnayan (Elderly Development) Foundation for developing support for people in old age (Hamiduzzaman et al., 2018). However, due to a long bureaucratic process, the draft has not yet been approved by the responsible departments. Concerning this issue, one international NGO executive said the following:

We have been trying our best to convince the government to pass the law. It is now in a bureaucratic process and is hoping for the best soon. If this happens, there will be a significant impact on the development of care for older adults. We can then raise funds from many sources – from the government, international organisations, donors and many others. We may not need help. We can receive repayable interest-free loans form the government and donor organisations, recycle the money with interest and return the original funds to the donor. This will help the foundation to be financially sustainable. Most importantly, older adults will have a public shelter. (Manager, HelpAge International)

All the participants, including NGO executives, said that this foundation would be a milestone for older adults’ development, as it would be an independent legal institution for taking care of older adults. In the interviews, both the minister of social welfare and the DG of the DSS were asked about the plan and they agreed on its importance. The minister said, “We are working for a separate foundation for elderly care development. It’s now on the priority list”. However, unfortunately, by the end of 2023, no further progress had been made in establishing the foundation.

The Old Age Allowance Programme: Mismanagement of the Only Means of Support

When asked about care provisions for older adults, almost all the interviewees mentioned the OAA income support programme when discussing old-age care services. This shows that policy-makers are not very aware of the diverse care needs of older adults. In addition, the OAA is only a low-level flat-rate benefit (approximately $5 per month) and yet provides only around 30 per cent coverage (DSS, 2021). When asked about the quality and quantity of this income support, the key policy-makers provided conflicting opinions. The DG of the DSS said the following: “The OAA is a kind of honouring of older adults. It is not for their subsistence but a sign of respect so that other family members can value them as the government does.” However, he also said that ‘public money has weight’, in which he wanted to mean that the amount is not small for subsistence. Among the government officials, only the secretary of the MoSW admitted the limitations of resources of the government and said the following: “You must understand that we are not like the developed world. Our resources are limited.” (Secretary, MoSW)

Along with limitations in the amount and coverage of OAA, there are problems in the management of its distribution. For example, political bias and corruption seem to influence the selection process. Local government officials may favour supporters of the ruling party despite having more vulnerable people among the population. In addition, local government officials often take bribes when selecting recipients of OAA. One local government official said the following:

There might be some nepotism. People who work hard for the party automatically get priority. However, in my ward, you can see that I have given the benefit to the real poor people. Maybe they are from the Awami League (ruling party), but they are poor. (Official, Local government)

When asked about corruption, he said, “I heard some officials take bribes to put some people’s names on the benefit recipient list, but I did not take any.”

The OAA scheme is centrally funded and regulated by the local governments. The central government distributes the funds to the district level, where local governments receive and distribute the money at their discretion. Therefore, the central government has no control over the selection process.

Scarce Basic Healthcare Provisions for the Old-Age Population

Although healthcare needs are highest in old age, all the participants admitted that there are no specific healthcare facilities provided by either the government or NGOs for older adults in Bangladesh. One NGO expert said the following:

The middle old-age group, starting from the 70s, needs both social and health care services. Their health starts deteriorating, and they need more healthcare provisions. However, the government does not have any specific initiatives for health issues. The condition of people over 80 is unbelievably the worst in our country. They suffer seriously from their worsened health conditions and negligence by their family and society. (Manager, HelpAge International)

In public hospitals, which are usually located only in cities and district towns, there is a specific unit for physically disabled citizens of all ages along with freedom fighters. In addition, there are several community clinics in rural areas that provide healthcare services, especially for pregnant women and young children. These community clinics consist of one or two nurses. They also provide compulsory vaccines for children. The public officials mentioned these community clinics and hospital services and confirmed that they provide no special arrangements for older adults. One NGO executive said the following:

In public hospitals, we have a corner for disabled people. Why should we not provide the same type of service for our older adults? The president declared people over 60 senior citizens, but there are no benefits for them yet. A huge number of older adults in our country suffer from non-communicable diseases. For example, if the government appointed one or two extra nurses in a community clinic to serve older adults, it might have a huge positive impact. Thousands of older adults die in our country only due to ignorance. Say, for example, a great number of people in rural areas do not know that they have diabetes, high blood pressure and so on. If there is a blood pressure measurement machine available, and even if the nurse gives only basic medications, we can save thousands of lives. (DG, BAAIGM)

One NGO executive gave a similar statement and said the following:

We must work together. The government, NGOs, the community and the family need to work together. We must create community caregivers. Maybe we can appoint some women in the community to give care to older adults in the community. It helps in two ways: women get jobs and older adults get services. We must open clubs, gyms and voluntary organisations, and most importantly, we must transfer our values to the young generation for a better future for older adults. (Manager, HelpAge International)

When asked about the older adults, one key policy-maker said the following: “We are planning to increase the OAA as high as 3,000 taka ($30) for older adults aged over 90 and to offer them free healthcare services.” (DG, DSS)

Most participants thought that older adults’ treatments should be free in public hospitals and that medicines should be heavily subsidised or free. According to World Bank data, Bangladeshi citizens pay 74 per cent of healthcare costs out of pocket (World Bank, 2021). In addition, most healthcare facilities are in big cities and district towns. Due to economic hardships and long distances, the majority of older adults are deprived of access to healthcare services.

Home Care and Care Homes: Unexplored Vulnerability for Older Adults

Old age is an inevitable biological process that leads to chronological health deterioration and many challenges in life. Therefore, old-age care needs are not solved by a modest economic benefit such as the OAA. Both health and social care are essential needs, but they have to a large extent been overlooked by the government and third-sector organisations in Bangladesh. Due to significant demographic and socio-economic changes, along with considerable migration from rural areas to cities and abroad, many older parents are left alone in rural areas. Therefore, the available support for basic ADLs and instrumental activities of daily living has become very limited. In addition, many of them have gerontological health conditions that require extra care.

Concerning care homes, the government has recently established six old-age homes in six regions to provide shelter, healthcare and medical care (Hamiduzzaman et al., 2018). However, the total capacity of those units is only 300 beds, whereas the total older population in Bangladesh is over 14 million. In addition, the quality of these institutions is so poor that older adults are reluctant to stay there. When asked about the scarcity of old-age homes, the DG of the DSS said the following: “I would like to ask you to give me 10 older adults for our old-age homes” (DG, DSS). With this statement, he wanted to say that old age homes are not scarce because most of them are still empty. However, some other interviewees said that beds in very few old-age homes are unoccupied because of the living conditions in these premises. One NGO executive even said: “The conditions of public old-age homes are not good for living. I heard some people are using some old-age home buildings for their cattle”.

Along with government programmes, a few national and international NGOs have been developing residential care for the older population. However, their combined efforts remain inadequate in terms of quantity and quality. In addition, private care homes operate commercially and charge fees from care recipients, which ultimately excludes economically poor older adults.

Financially solvent older adults seem to prefer to go to private care homes instead of government care homes if family members or relatives are not available to take care of them. Culturally, older adults in Bangladesh prefer to live with their children or grandchildren. However, nowadays, many of their children move to cities or abroad for education and jobs. In addition, a significant number of women are currently entering the labour market and therefore are not taking the role of an unpaid family carer. As a result, parents remain at home in old age, often without adequate care from health or social services or their offspring. Often, families cannot afford medical care due to their poverty. While bringing attention to these issues, one key policy-maker said the following:

We initiated the PCA to ensure parental care. However, in many cases the situation is different. For example, due to the young parents’ busyness with their jobs, they bring their parents to stay with them so that they can spend their time with their grandchildren. We give poor families an OAA. In addition, currently we have 85 shishu poribar [family environments for street children]: 41 for girls, 83 for boys and one mixed in Khagrachori [a district where ethnic tribes live]. We accommodate some older adults in these shishu poribar to play the role of parents. It helps both ways: the older person gets children and the children get parents. (DG, DSS)

This initiative may have positive social care outcomes. However, according to the DG, many of these units are just in the planning stage. Overall, it should be noted that society often has a negative perception of old-age homes. Due to cultural values and family ties, older parents in Bangladesh are unlikely to move away from their children. There are also conflicting views among policy makers on the establishment of residential care for older adults.

Most policy-makers think that children must take care of their parents for two main reasons. First, the norms and values of Bangladeshi society insist that children take care of the senior members of the family. Second, the government has limited resources for taking care of this large population group, which makes it an unpopular political agenda due to the ruling parties’ partisan interests (Aminuzzaman, 2013). Other stakeholders expressed mixed opinions. To explain the necessity of old-age homes, the manager of HelpAge International said the following:

I argued with Atiq sir (the DG of BAAIGAM) that elderly people should not live in old-age homes because this is not our culture. Besides, the parents certainly would not like to live there. However, after a thorough discussion, I realised that we should have some old-age homes because every older person might not have children or it may be convenient for older adults to live in an old-age home. (Manager, HelpAge International)

Another NGO executive identified cultural and religious issues that affect the provision of health and social care services:

Old-age care needs are very diverse. Providing care for older adults is also very challenging. In particular, due to cultural issues, providing services to women is more difficult in our country. And, for example, if they have a disability, this difficulty becomes doubled or tripled. (DG, BAAIGAM)

A larger number of Muslim women are reluctant to receive physical treatment from male caregivers, even when it is needed. Due to a lack of digital equipment, health workers provide many services manually where physical contact is required, such as holding or lifting from the bed, but women refuse this for religious and cultural reasons, preferring to be cared for by their family members.

Discussion

This article primarily aimed to shed light on ageing and care policies in Bangladesh, which have received limited attention from the government, third-sector organisations and academics. It is difficult to measure precisely how much attention the government of Bangladesh has been paying to ageing and care for older adults. However, following the perspectives of inattention in the literature, we can discuss the extent to which the government and other stakeholders in Bangladesh have paid attention to the issue.

The findings of this study show that the government of Bangladesh has launched a few initiatives to secure care for older adults, including the NPA in 2007, the PCA in 2013 and the Senior Citizen declaration made by the president in 2014. However, both the interview data and available literature suggest that none of these policies is functioning effectively due to their lack of clarity in terms of formulation and implementation (Barikdar et al., 2016; Begum & Islam, 2019). Our findings show that policy-makers and other stakeholders in Bangladesh have to some extent neglected the topics of ageing and care for older adults. Aminuzzaman (2013, p. 455) argues that ‘the political leadership of Bangladesh has treated some of the major policies more as rhetoric than commitment, and the Parliament has been more preoccupied with partisan concerns than with engaging in serious debate on policy issues.’

Based on the literature and our findings, we argue that policy-makers’ negligence is due to a lack of knowledge concerning the scope and diversity of old-age care needs and the circumstances of older adults. For example, the government of Bangladesh initiated the PCA in 2013, which placed full responsibility on families to care for their senior members without any form of compensation. However, the traditional extended family and community care system has been broken down by rapid socio-economic and demographic transitions, mass poverty, changing social and religious values, the influence of Western culture and other factors, such as the nuclear family system, family planning for one or (maximum) two children, children’s migration to cities and abroad, and job mobility (Hossain 2006). Engström et al. (2008) have argued that a certain level of knowledge has to be attained before an issue can attract awareness.

Both Kingdon (1995) and Underdal (1989) claimed that robust knowledge of an issue is needed to lead to a high level of attention. Although policy-makers’ knowledge on ageing and care cannot be precisely measured, their policy actions indicate a lack of knowledge and awareness of social and health care. For example, the limited flat-rate OAAs, which are distributed under the Social Safety Net Program for poverty reduction, have been treated as old-age care. This tiny financial benefit could be a positive policy response in terms of financial well-being, but it is not at all enough to secure care for the older population. Besides this, even if the government tripled the current OAA, which is now only 0.13 per cent of GDP, and offered it to the entire older population, it would cost only a little over 1% of GDP (Rahman, 2017).

The findings also show that no specific healthcare policy exists for older adults in Bangladesh (Islam and Nath 2012). Over the last few years, the government has cut health budgets significantly. Consequently, older adults, especially those who are financially vulnerable, must live with unmet healthcare needs. Most older adults suffer from non-communicable diseases, which they often ignore due to their poor economic condition (Hossain et al., 2006). Furthermore, the lowest quantile is most affected by various diseases (Shahen Islam and Ahmed 2020). As even their basic healthcare needs are unmet, it is unsurprising that their long-term care needs are also largely unmet. The lack of adequate care is often related to economic conditions (Kröger, 2009), which is evident from the research findings.

We argue that despite the viable options available, healthcare for older adults in Bangladesh is being neglected. Our findings suggest that the government and other stakeholders could improve older adults’ healthcare provision by developing existing healthcare facilities. In doing so, the government would not need to make major investments in the health sector. For example, there are already community clinics in almost every village in Bangladesh. If the government would invest a little more in hiring additional healthcare workers, these community clinics could serve older adults without much government expense. In addition, an integrated health policy, which has been emphasised by public policy researchers, could have a major impact on the development of care for older adults (Cejudo & Michel, 2023; Haque, 2021).

Limitations of the Study

One of the key challenges to conducting research in Bangladesh is the availability and authenticity of the data. Unfortunately, there is very limited research available on ageing and care in Bangladesh. In addition, most of the available studies have been conducted from medical or gerontological perspectives. Therefore, social and policy perspectives are largely absent from these studies. Moreover, only very limited statistical data are available on the economic, social and health issues of older adults in Bangladesh (Barikdar et al., 2016). Therefore, it is difficult to compare their situation with that of older adults in other countries. In line with this, Hyde & Higgs (2017, p. 90) argue that there is a ‘real lack of comparative international data on the financial circumstances of older adults in the developing world’. In addition to these limitations, this study did not include data collected from older adults. Therefore, the perspectives of older adults on their care needs remain unexplored.

Regarding empirical data collection in Bangladesh, public officials seem to be very cautious when answering questions, especially about the limitations and shortcomings of the government due to the fear of job or career loss. For example, one key policy-maker stopped the audio recorder a couple of times during the interview so that some of his comments would not be recorded. He was assured that nothing that could harm him would be written. Still, he did not want any evidence to be kept. In some situations, the interviewees praised the government and its achievements instead of providing specific answers. All of this indicated that either the policy-makers were ignorant about older adults’s care needs or reluctant to provide authentic information.

Despite these limitations, this study contributes new knowledge because no such research has previously been conducted from policy-makers’ perspectives in Bangladesh. Therefore, the findings and recommendations can be used to reassess existing policies and develop the measures further. This article may also help third-sector organisations, international development agencies and academics understand the importance of extensively researching ageing and care, not only in Bangladesh but across the Global South.

Conclusion

We argue that the government of Bangladesh is paying insufficient attention to ageing and care policies because they do not yet constitute a popular development goal and thus fail to attract policy-makers’ partisan interests (Aminuzzaman, 2013). As a result, Lukes’ (2005) ‘three faces of power’ approach is applicable in understanding the Bangladeshi government’s policy inaction: policy-makers influence political decisions aligned with their partisan interests; in doing so, they use power to keep other agendas from being prioritised and to shape others’ preferences. Finally, to validate their activities, they use various tools, such as the media, to prevent important issues such as ageing and care from being seen as a social problem requiring immediate political intervention.