How to finance and deliver care for a population that is ageing fast is a politically fraught subject. In the United Kingdom, for example, many Westminster analysts say that Prime Minister Theresa May lost her governing majority in 2017 in response to her proposed social-care reforms, dubbed a ‘dementia tax’ by political opponents. In September 2021, the administration led by her successor, Boris Johnson, was criticized over its social-care policy for raising the rates of national insurance, a social-security tax paid by working adults and their employers, in a bid to raise £36 billion (US$48 billion) to fund long-term social care.

Furthermore, the huge number of people dying from COVID-19 in care homes around the world highlights how social-care systems can fail their residents. So how should health care be reconfigured to accommodate the needs of an ageing population? In the United Kingdom, one-quarter of the population will be over the age of 65 by 2050, up from one-fifth in 2019. In the United States, 95 million people will be over 65 by 2060, up from 52 million in 2018.

All advanced economies, and some rapidly developing ones, face similar challenges. India has the world’s second-largest population after China. The challenge of caring for its ageing population is currently manageable, but the sheer scale of India’s demographic shift — almost 320 million Indians will be older than 60 by 2050 — is already driving change. Japan’s extremely old or ‘super-aged’ society offers other nations a glimpse of what might be coming (see ‘Japan’s super-aged society’). Its population is expected to drop from 127 million to 88 million between 2015 and 2065, with one-third of the population being aged over 65 by 2036 — a situation caused in part by falling birth rates and less immigration.

“If you look at how India’s elderly are cared for now, it’s primarily done from within the family. Old-age homes are still very rare,” says Kuriath James, who studies demographics and is director of the International Institute for Population Sciences, an autonomous governmental organization in Mumbai. Extended families in India typically live close to each other, he says, often sharing the same space or occupying different floors of a house, making it easier to care for older people at home. But this system is being challenged by demographic trends.

A family affair

India is the world’s largest source of international migrants. The number of Indians seeking work abroad has more than doubled since the early 1990s, reaching 15.6 million in 2015, according to the Pew Research Center in Washington DC. More workers are also moving within India. The 2001 census recorded that 30% of the population were not living where they were born, a figure that rose to 37% in 2011. This migration typically involves young adults who leave their parents behind, says James, making it harder for older people to be cared for at home.

The 2020 Longitudinal Ageing Study in India — a report on the consequences of India’s ageing population, produced every three years by the International Institute for Population Sciences and others — suggests this is already a problem¹. Some 26% of people over the age of 60 already live either completely alone or with just their spouse. For now, however, family living is still relatively common in India, with 41% of over-60s living with both their spouse and adult children, and 28% living with adult children but no spouse.

At-home care comes at a cost, however. “Caregivers are primarily women and there are serious problems in India with female work participation in the economy because women aren’t going for work outside the home,” says James. In late 2020, just 16% of women in the urban parts of India were formally employed, compared with 57% of men.

If the upward trend in migration continues, more of India’s elderly population will have no family