Why families are drowning and what the government must do

The family structure has undergone a seismic shift in India in a relatively short period of time. Family was meant to ensure care for the elderly in India. But the top-down system of a patriarch and many sons pooling their earnings into a common fund has withered in the face of modernization.

The growth of nuclear families, accompanied by unceasing youth migration in search of opportunities—from rural to urban and urban to other countries—has left many old people flailing. The certainty of family-based care is ending, but there’s nothing to replace it—except for paid care of often-dubious quality.

But here’s the catch: Even when sons and daughters want to look after their ageing parents in their own homes, the absence of insurance cover, pension, adequate savings and state support emerges as a formidable challenge.

A series of searing social media posts by Rituporna Chatterjee, a Noida-based writer and journalist from Kolkata, got me thinking about the need for state, private and social intervention in elderly care.

In the UK, Scandinavia and elsewhere in Europe, as well as in Australia, basic state support is taken for granted. Not so in India, where I know dozens of people, single and married, who have struggled to fulfil what should be a basic commitment—to look after their parents till their last days.

This gap primarily affects low-income households, say in villages and small towns. Wealthy elders, on the other hand, can be expected to be taken care of through a variety of personalized services and private care facilities in nursing homes or at home. It is the middle class that is squeezed.

Here are some excerpts from Chatterjee’s posts on X:

On 10 August: “We are at end-of-life care for mum. We have been fighting this battle for a year. We are looking at ₹4,000/day oxygen cylinder cost at the rate she needs + round the clock nurse. Those in similar situations, grateful for any advice or resources bec I’m financially struggling.”

On the same day: “We have had not a minute to process emotions just endless cycle of running between hospitals, insurance, flights between cities, managing crisis after crisis. Now she wants to be at home. Which means round the clock high flow oxygen support.”

On 11 August: “Palliative care cost in an affordable city like Kolkata—day nurse + night attendant, on-rent concentrator, hospital bed, O2 cylinders, medicines, household expenses—easily ₹60-70k a month. Old folks without pensions, or children nearby or children without finances are drowning.”

On 15 August, Chatterjee’s mother passed away. Such a situation is unimaginable in the UK, which gives financial support to all pensioners (men and women aged 66 plus) as well as carers.

Hospital stay, treatment and medicines—even expensive cancer drugs—are free for pensioners. However, care is means tested. In England, local councils help pay for care costs if the pensioner’s savings and assets amount to less than £23,250. This may not look generous, but the council will not count the value of your house if you need to stay in it for care. This is meant to benefit the poorest, but an ageing population—the proportion of the aged is set to grow from 19% in 2022 to 27% by 2072—has seen many turn to private care, which is strictly regulated.

In Australia, a friend’s father-in-law, suffering from dementia, is in a care home, with the stay entirely funded through his state pension of around 27,000 Australian dollars a year. This allows the friend and his wife to chip in with looking after their grandchildren. State intervention thus allows families to grow, protects the elderly from lack of care and ensures that those who are able to can continue to work—a virtuous cycle. In the US and India, people are often forced to consider quitting work in order to look after their parents.

In India, senior citizens, defined as those aged above 60, are projected to reach 300 million by 2050. Yet, the elderly care sector is unregulated, and abuse or theft by ‘carers’ is not unheard of. You need a hospital doctor’s recommendation for home care, but many doctors are reluctant to do that for a variety of reasons, while the hospital makes you sign a self-discharge form.

To be sure, there are schemes, including for dementia care in nursing homes, for the poorest. However, India’s health insurance scheme for the elderly, PM-JAY, only covers hospitalization, not nursing home or home-based care. India is home to 8.8 million people with dementia, according to Dementia India Alliance. The current cost of care, ₹1.18 trillion, is expected to triple by 2036. I’m not sure India is prepared for this epidemic.

The author is a former European and UK correspondent for the Hindustan Times.