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.
Source: Statistics Dashboard, Government of Japan
“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 close by and will need to be cared for in care homes. This will cost money, which could mean that more women will need to seek work in the economy to help pay for the costs.
Older people in India express a strong preference for living with their extended family — 80% of those who do so are satisfied with their living arrangements, compared with just 53% of those who live alone — but it is also a question of gender equality. If care at home comes at the expense of women pursuing their careers, it is difficult to argue that India’s current model is entirely successful. “We don’t have any data on nursing-home satisfaction, but I suspect family care would be much more highly valued because that’s what society expects,” says James.
But change might be needed if migration trends continue, and as the longer-term impact of the COVID-19 pandemic in India is felt. Care homes in many parts of the world have been reservoirs of infection for the virus, but there are few data to quantify the scale of the problem in India. The International Long Term Care Policy Network, based at the London School of Economics and Political Science, carried out a review into COVID-19 and India’s social-care situation2. It highlighted the extra strain placed on families when their older relatives contracted COVID-19. The pandemic has showcased the limitations of a system that largely relies on family to look after older people.
Women at work
Neglecting half a country’s workforce in favour of at-home care is a serious drag on the economy, which is why Japan has reformed the way it looks after its older people. Japan has a lower internal migration rate than India does, with 20% of people not living in the prefecture where they were born, but it used to share the issue of relatively few women working in the formal economy. In 2000, 67% of Japan’s women between the ages of 25 and 54 were officially employed — 10 percentage points below the United States. Japan was also faced with a dwindling workforce in general.
“Lots of women were saying it wasn’t fair,” says Natasha Curry, deputy director of policy at the Nuffield Trust health think tank in London, who co-authored a 2018 policy review on what England can learn from Japan’s system of long-term care3.
A young girl and her grandmother embrace in Thiruvannamalai, India.Credit: Claudine Klodien/Alamy
At the start of the millennium, Japan launched its Long-Term Care Insurance (LTCI) scheme with the aim of shifting care away from the family-dominated system that still prevails in India to an insurance-based one.
“Demographically, the UK is about 20 years behind Japan and so is its care system,” says Curry. “We’re in a different place with more women working, but we definitely have some similarities with Japan in 2000.”
Under the LTCI, everyone older than 65 who needs care for any reason is offered support — they don’t need to have a significant disability. Entitlement is initially determined by a survey followed by input from a medical doctor and a decision from the long-term care approval board. The claimant is then assigned a level of care specific to their individual requirements, ranging from nursing-home residence to welfare visits at home to help with day-to-day tasks such as bathing.
The LTCI is paid for by a 50/50 mixture of tax revenue and mandatory insurance premiums for the over 40s. “This age threshold was chosen specifically because you probably have an elderly relative in need of care by the time you reach 40, so you can appreciate the benefit of such a system,” says Curry. The budget is topped up by those receiving care, who are required to pay 10% of the costs.
If the approval board decides that someone does not need long-term care, they might be offered ‘preventive care services’, which can include rehabilitation and physiotherapy. Prevention is important because the LTCI has become a victim of its own success. Enrolment in the scheme has skyrocketed since it was first introduced. In 2000, the Japanese government spent roughly ¥3.6 trillion (US$32 billion) on LTCI payments. By 2017, that figure had swelled to ¥10.7 trillion, and models forecast it could be close to ¥15 trillion by 2025.
To help control the cost, the government watered down some of the benefits in 2005, requiring contributions to meal costs. It also introduced a higher 20% co-payment fee in 2015 for wealthier people. The government also tried to lower the age of premium contributions from 40 to 20, but that was met with large-scale opposition, largely from employers who also contribute to the scheme.
The lesson here is that the cost of a scheme that is as comprehensive as Japan’s is liable to increase. But the high level of enthusiasm for the LTCI didn’t come easily, says Curry. It required a major change in public opinion because there was a feeling of shame in not looking after older relatives. “They designed the system to be quite generous, so the benefits were obvious,” she adds. “I think this made people realize that old people weren’t being given a substandard system.”
The government also ensures that individuals are not given cash but are instead allotted a budget that goes directly to the professional care establishment of their choice. This stops people taking their allowance but remaining in the sole care of their family.
“I admire how well designed it is,” says Curry. “When you’re assigned your care level, you get a care manager who helps you decide where to spend your allowance, and this helps people to navigate what could otherwise feel like quite a complicated system.”
Is it a success? Many of the problems that Japan sought to offset with the LTCI are still there, but they have abated since the system was introduced. Japan’s working-age population shrank by more than 11 million people between 2000 and 2018, but the workforce increased by 600,000. This rise is attributed to increased numbers of women in the workplace — possibly because the LTCI reduced their family care concerns and so levelled the playing field, says Curry. “With the shrinking working population, the government became aware it had a lot of women tied up in informal care,” she says. “One objective of the LTCI was to shift this burden of care.”
The demographics of an ageing population remain, however, so Japan’s labour-market woes are not over. Despite the gains made in employing more women, the country’s Health, Labour and Welfare Ministry predicts a national workforce of just 53 million by 2040 — a 20% decrease from 2017 figures. Meanwhile, the number of older people eligible for LTCI support is expected to grow in line with the nation’s ageing population, raising the question of how to fund the scheme in future decades (see ‘Top 10 ageing nations in 2020’).
No silver bullet
The death rate in US care homes was 17% higher in 2020 than in 2019. This statistic swelled to 24% in the 10 states hardest hit by COVID-19. “Many people began to wonder again if their elderly relatives wouldn’t be better off at home with them,” says France Légaré, a family physician and health-practices researcher at the Université Laval in Quebec, Canada.
The answer is far from clear. In 2017, Légaré conducted a meta-analysis4 of 19 systematic reviews based in 7 countries in an effort to work out whether patient outcomes are best when care is delivered at home by extended family, at home by a visiting professional, or in an institution by a professional. However, no clear pattern emerged. “Unfortunately, there isn’t a lot of evidence that points to a definitive answer,” she says. It is possible, however, that COVID-19 has since tipped the balance in favour of home-based care.
Perhaps a hybrid model is the way to go, says Légaré, in which older people are empowered to stay at hom e for as long as possible, perhaps even within the extended family, but not at the expense of their daughters’ careers. Japan’s LTCI has tried to cater for exactly this, with preventive services aimed at reducing the amount of care an elderly person will need.
Researchers in Japan and elsewhere are also looking at the potential of robotics to further this goal and improve care for older people more generally (see page S8). In 2016, the LTCI included a robot-assisted walker in its list of reimbursable technology. The list of approved robotics has since expanded because the government estimates that Japan will have a shortage of 370,000 nurses and other care professionals by 2025.
Despite this, the uptake of robots has been slow because most people in Japan still think that care should be carried out by humans, says Hiroo Ide, a health-care policy researcher with an interest in robotics at the University of Tokyo’s Institute for Future Initiatives.
In a 2021 study5, Ide sought the views of 444 professional care-givers who work in home settings. Their answers were classified as positive, negative or mixed. “Only three care workers answered that they had experience using robotics,” says Ide. “One might think robots are more widely used in Japan, but this is the reality.”
Attitudes varied considerably depending on the proposed activity of the robot. For example, 100% of people harboured concerns about robots being used for after-care follow-ups, whereas just 44% of respondents took a negative stance on robots providing physical support, and just 40% had a negative opinion on robots being used for medical monitoring. “Caring is a people business, and while tech might help improve care and make it more efficient, you can’t replace the people,” says Curry.
It is unlikely that a single silver bullet, such as robots or using one form of care for everyone, will solve the long-term care crisis many countries are facing. A combination of care options might be needed. One reason the comparative outcome data on various health-care settings isn’t conclusive could be because it depends on the individual, says Légaré. “Maybe this sounds obvious, but I think you need to personalize care, be it in a private residency or home care.”
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