The global population is growing as well as ageing. Globally, there are 1.1 billion persons aged 60 years or above in 2022, comprising 13.9 percent of the total population of 7.9 billion. Over the next three decades, the number of older persons worldwide is expected to double to 2.1 billion by 2050, with the share rising to 22 percent of the total population.

This increase in the number and share of older persons will be visible across all regions of the world. In more developed regions, the share of older persons will increase from 26 percent in 2022 to 34 percent in 2050, while in less developed regions, it will increase from 11.5 percent to 20 percent during the corresponding period.

India is not an exception to this phenomenon. There are 149 million persons aged 60 years and above in 2022 (as on 1 July), comprising around 10.5 percent of the country’s population. By 2050, the share of older persons will double to 20.8 percent, with the absolute number at 347 million.

This unprecedented rise in the ageing population will have significant implications for health, economy and society in India.

As seen in Japan and in European countries, this inverted aging pyramid will lead to 3 distinct challenges

• Increase in the load and burden on the Healthcare system
• Necessity to increase working age groups to maintain nation building activities
• Social Security and benefits related impact on the government

India is currently poorly equipped to manage this transition both from infrastructural and resource availability. We are short by 0.12 million beds and more than 5 million trained medical and paramedical personnel as per WHO standards.

Looking into the aspect of healthcare challenges alone we have 4 specific and monumental challenges with respect to the rapidly increasing ageing population:

• Care for Chronic illness and frail elders
• Accessibility for acute illness management
• Managing costs for Hospitalisation and Medication
• Wellness and Quality of life management for Healthy Elders

Care for Chronic illness and Frail Elders

This segment includes bedridden elders and those who are unable to perform their activities of daily living.

Taking into account the incidence of these (approx 0.25% of total population based on the index of frailty used) these account for nearly 3.5 million people who require either full time or part time caregivers.

Home healthcare services provide this gap and over the past decade there is a shift from unorganised to organised home healthcare services with few organisations like HCAH, Portea etc leading the way.

However, the home healthcare industry is plagued with critical challenges with availability of trained resources for the providers and at price points varying between Rs 20000 per month to Rs 1,50,000 per month based on the services needed brings forth significant affordability challenges in an environment where insurance is almost unheard of. 

Where affordability is a constraint, this effectively means that for every elder who requires caregiving one family member remains unemployed to take care of them. Most home healthcare organisations are now migrating to assisted living models where resource availability concerns are being addressed to a certain extent. With the market growing at over 25% annually we have still not penetrated more than 3% in this space.

Accessibility for acute illness management

Currently this is well addressed in Metros and Tier 1 cities with a mushrooming of private hospitals, however lack of geriatricians and trained nursing staff continues to impact the elder care space. Corporate hospitals guided by lower ALOS (average length of stay) metrics and pressure to increase ARPOB (average revenue per occupied bed) lead to early discharges with almost no transitionary care or continued care facilities available to ensure better outcomes.

Once you are outside the metros and Tier 1 cities accessibility is a major challenge both from the availability of hospital beds and trained doctors and nurses. Covid as well as seasonal issues like dengue show the vulnerability of our system with severe shortages in bed availability, medicine availability and high mortality rates

The goal of care for elders is still very transactional right now in hospitals rather than a preventive and holistic care cycle.

Managing costs for Hospitalization and Medication

India has one of the lowest insurance penetration for senior citizens. With out-of-pocket payments continuing to be around 60-70% of healthcare expenditures, falling sick is becoming a financial nightmare for many families.

Low sum insured also contributes to this with an average of under 3 lakhs per person. This effectively means that insurance struggles to cover more than 5-6 days of stay or 1 major procedure (hip/knee replacement etc) for the elders.  However, we have seen that the insurance space is growing at over 30% per annum in the age groups of 60 and above especially with progressive companies offering insurance for the parents of their employees.

The critical challenge is the penalty for pre-existing diseases with ensures that a large number of medical issues remain unaddressed for anywhere between 1-3 years of the policy, which again feeds the vicious cycle of out-of-pocket payments and co-payment.

Wellness and Quality of life management for Healthy Elders

This is currently the most under served area with fragmented services. Between clinics/diagnostic centres/health camps, these services are offered in bits and pieces without synergy.

We feel that this is an area where a country like India needs to invest significantly, as this will reduce the burden of disease and frailty and bridge the gap between life span and healthy lifespan (around 16% of lifespan today).

The core tenets of early identification, appropriate management and regular tracking is a space that is sorely absent in the country today. The healthcare system today is rewarding transactional care over holistic care and evolved into fragmented ownership of the patient’s outcome among various healthcare channels instead of consolidating the same and re-visiting the family physician concept.

Basic screening+ diet+ fitness+ medication management is missing and this will be the differentiator between a healthy country and an unhealthy country.

The onus should be on reduction of hospitalisation especially for preventable causes like malnutrition/ physical fragility and medication mismatch rather than rewarding hospitalisation among the private and governmental institutions.

About the author-

Dr Harsha Guduru is the founder of Restory and a passionate physician in the space of geriatrics and quality of life in elderly. He has over a decade experience in the geriatrics space across Home Healthcare, Critical care and Hospital management.