(March 2012) India’s older population will increase dramatically over the
next four decades. The share of India’s population ages 60
and older is projected to climb from 8 percent in 2010 to 19
percent in 2050, according to the United Nations Population
Division (UN 2011). By mid-century, India’s 60 and older
population is expected to encompass 323 million people, a
number greater than the total U.S. population in 2012. This
profound shift in the share of older Indians—taking place in
the context of changing family relationships and severely limited
old-age income support—brings with it a variety of
social, economic, and health care policy challenges.
The National Institute on Aging (NIA) supports research
on the health, social support, and economic security of India’s
elderly population. This newsletter highlights some of the
recent research by NIA-supported investigators and others
that can inform policy decisions as India and other developing
countries plan for aging societies. Also included in this newsletter
are findings from the recent pilot phase of the nationally
representative Longitudinal Aging Study in India (LASI).
India, now home to 1.2 billion people, is projected to overtake
China in about a decade to become the world’s most
populous country. Bloom (2011a) calls the share of India’s
population ages 50 and older relatively small at 16 percent,
but notes that India will experience rapid growth among this
age group. The United Nations Population Division projects
that India’s population ages 50 and older will reach 34 percent
by 2050 (UN 2011). Between 2010 and 2050, the
share 65 and older is expected to increase from 5 percent to
14 percent, while the share in the oldest age group (80 and
older) will triple from 1 percent to 3 percent.
The population dynamics fueling India’s growth and
changing age structure are rooted in the combined impact of
increasing life expectancy and declining fertility. Life expectancy
at birth in India climbed from 37 years in 1950 to 65
years in 2011, reflecting declines in infant mortality and survival
at older ages in response to public health improvements
(Arokiasamy et al., forthcoming; Haub and Gribble 2011).
By 2050, life expectancy at birth is projected to reach 74
years. Fertility rates in India have declined to 2.6 children
per women, less than one-half the early 1950s rate of 5.9
children per woman (Haub and Gribble 2011).
As India’s population ages, the nation will face a shrinking
pool of working-age people to support the elderly population.
Arokiasamy and colleagues (forthcoming) report that
the old-age dependency ratio—the number of people ages
60 and older per person ages 15 to 59—is expected to rise
from 12 per 100 to 31 per 100 by 2050. By 2042, the share
of Indians 60 and older is projected to exceed children and
youth ages 14 and younger (Chatterji et al. 2008). Bloom
(2011a) notes the burden of old-age dependency “will be
substantially offset by the decline in youth dependency associated with declining fertility.” Indeed, some studies suggest
that in India, the burden of old-age dependency may be less
than usually assumed.
India’s national trends mask tremendous regional variation.
Pointing to India’s 16 languages, Haub and Gribble (2011)
describe India as a “collection of semi-independent countries
united under one democracy.” Fertility rates in India’s southern
states of Kerala and Tamil Nadu were a low 1.7 children
per woman in 2009, while the fertility rates in the northern
states of Bihar and Uttar Pradesh were twice as high. Bloom
(2011a) notes that the ratios of the working-age population
to the nonworking-age population for Tamil Nadu and Bihar
are widely different, comparing that difference to the gap
between the ratios for Ireland and Rwanda today. These stark regional differences will mean that the impact of a shifting
age structure and population aging will not unfold uniformly
throughout the country.
Health and Health Care
Economic development and urbanization have brought lifestyle
changes that have led to unhealthy nutrition, physical
inactivity, and obesity contributing to the prevalence of diabetes.
Chatterji and colleagues (2008) report a high rate of
smoking (26 percent) and inadequate physical activity (18
percent) among Indians. These behaviors will likely translate
into future ill health.
Almost one-half (47 percent) of older Indians have at
least one chronic disease such as asthma, angina, arthritis,
depression, or diabetes (Chatterji et al. 2008). The aging
of India’s population will lead to increases in the prevalence
of chronic conditions such as diabetes and hypertension.
By one measure, nearly one-half (45 percent) of
India’s disease burden is projected to be borne by older
adults in 2030, when the population age groups with high
levels of chronic conditions will represent a much greater
share of the total population.
Fewer than 10 percent of Indians have health insurance
from private or public sources, and about 72 percent of
health care spending is paid out-of-pocket, according to
national surveys (Bhattacharjya and Sapra 2008). India’s
health insurance scheme for the poor only covers those ages
65 and younger, leaving India’s elderly population particularly
vulnerable. Within the older Indian population,
women face additional risks: They tend to have poorer
health and less access to health care than men of similar
backgrounds (Roy and Chaudhuri 2008). The Indian government
and several states have begun a variety of programs
designed to increase access to health care or health insurance
for the majority of the population that lacks sufficient
access (Bloom et al. 2010)
Rising numbers of older people will put new and increasing
demands on the health care system. Chatterji and colleagues
(2008) suggest that the “health care services will
need to shift resources and services to respond to an aging
population.” An analysis by Farahani, Subramanian, and
Canning (2010) linked public health spending in India to
increased survival of the elderly and other vulnerable groups.
They found that a 10 percent increase in public health
spending decreases deaths by about 3 percent among the
elderly, women, and children. India has committed new
public funds to its health care system. An analysis by Yip
and Mahal (2008) documented wide disparity in access to
health care for aging Indians who are poor or live in rural
areas. They suggest health care reforms should not just
increase funding but also address inequality of access and
include regulations to limit cost inflation, writing: “Money
alone, channeled through insurance and infrastructure
strengthening, is inadequate to address the current problems
of unaffordable health care and the future challenges posed
by aging populations that are increasingly affected by noncommunicable
Living Arrangements and Social Support
The 2005-2006 National Family Health Survey in India
examined living arrangements by household, which is defined
by having separate cooking facilities even if older parents and
adult children live in adjacent structures. The survey found
that more than four out of five (78 percent) Indians ages 60
and older lived in the same household with their children,
while about 14 percent lived with only a spouse and 5 percent
lived alone (Kumar, Sathyanarayana, and Omer 2011).
This represents a doubling of the share of older Indians living
with only a spouse or alone since the early 1990s.
During the same period, the share of older Indians living
with their children declined by about 7 percentage points.
A number of trends may explain these changes in living
arrangements, including declining fertility leaving fewer children
available to care for older parents, rural to urban migration
for employment that separates families, and changing
social expectations regarding intra-family obligations (Bloom
et al. 2010). Recent surveys confirm this shift in attitudes,
with a 40 percentage point decline in the share of adult children
who said caring for their elderly parents was their duty—from 91 percent in 1984 to 51 percent in 2001
(Ramamurti and Jamuna 2005, cited in Uppal and Sarma
2007). Intergenerational conflict may also explain why elderly
live in separate residences from their offspring. Both generations
may prefer living separately, and there is evidence
that even when they reside apart, adult children and elderly
parents remain economically and socially interdependent
(Husain and Ghosh 2011).
Work, Retirement, and Income Security
Despite India’s recent rapid economic growth, the living conditions
of a majority of older Indians remain poor (Husain
and Ghosh 2011). Less than 11 percent of older Indians
have a pension of any sort, according to national surveys
(World Bank 2001; Uppal and Sarma 2007). Saving is difficult
or impossible for a majority of Indians because earnings
are low, some economic activity in the informal sector does
not involve currency exchange, and a large share of the aging
population lives in a rural area where banking is unavailable.
With little old-age income support and few savings, labor
force participation remains high among Indians ages 60 and
older (39 percent), and particularly high among older rural
Indians (45 percent) (Uppal and Sarma 2007).
Paradoxically, initiatives to increase the well-being of older
Indians may lead to higher poverty rates, if impoverished
Indians remain poor but begin living to older ages rather
than dying young as many now do (Pal and Palacios 2011).
Expanded access to health care and increases in social pension
benefits may bring improvements in survival but not in
poverty rates. Evaluating these programs solely on the basis
of changes in poverty rates among the elderly would not adequately
capture the benefits to society.
In the future, Bloom (2011a) argues that India’s system of
family-based support will not be able to withstand the
increased numbers of older Indians, “especially given
increased female labor force participation, smaller numbers
of more mobile children, widening generation gaps, and
increasing burdens of costly-to-treat diseases such as diabetes,
cancer, and stroke.” Even with the findings that adult children
still receive support from their elderly parents, such social changes would affect the status quo
because increases in chronic diseases affect the needs of the
elderly and their ability to continue to work. The other factors
affect the availability of kin to provide care. Bloom suggests
that India will benefit from gathering high-quality data
on population aging and using it to inform policies to create
and expand income support and health insurance programs
for older Indians. Also, by investing now in the education and training of today’s youth, India can lay the groundwork
for increased economic productivity and “ease the process of
caring for growing numbers of older Indians in the future”
Paola Scommegna is a senior writer/editor at the Population Reference Bureau.
Please refer to PDF of report.