Long Term Care in India: Key Drivers

Long-term care (LTC) refers to support that is needed by older persons with limited ability to care for themselves due to physical or mental conditions, including chronic diseases and multimorbidity. In this essay, we will look at four drivers of long-term care in the Indian scenario.

1st August, 2021
Mahesh Venkateswaran

What is Long Term Care?

Here are two definitions, one from the WHO and the other from the ILO.

“Long term care encompasses activities undertaken by others to ensure that those with a significant ongoing loss of physical or mental capacity can maintain a level of ability to be and to do what they have reason to value; consistent with their basic rights, fundamental freedoms and human dignity.”
Source: World Health Organization (2015). World Report on Ageing and Health

Long-term care (LTC) refers to support that is needed by older persons with limited ability to care for themselves due to physical or mental conditions, including chronic diseases and multimorbidity. The needed support, depending on the degree of limitation, can be provided at home, in the community or in institutions and includes for example assistance with daily living activities such as dressing, medication management but also basic health services. 

Source: ILO

Drivers of long-term care in India

While the Indian family continues to be primary caregivers for most elders, the role of secondary support systems, led by home care services, assisted living companies and institutional care facilities, is emerging as possible alternatives for families seeking specialized and long-term care. This article by journalist Malini Goyal captures her journey with her septuagenarian parents who have been part of a senior living community since 2015, and how their quality of life has improved, contrary to the initial skeptcism. While such transitions, largely triggered by the pandemic, have brought much needed attention to challenges faced by elders, it is also important to recognize that we are at an early stage in addressing holistic needs of the ageing cohort, particularly the less affluent and poor. Long-term care is an expensive proposition but with better policies, higher public health spending, affordable services and innovative solutions, we could lower the overall cost of care. In this post, I elaborate four such key factors driving the long-term care market, and how they can shape access and affordability over the next decade.

1. Hospitals with Geriatric Specialities

Established hospitals with renowed geriatricians have led the cause for eldercare for many decades now, and greatly inform our understanding of age-related ailments and conditions, be it due to longevity or lifestyle. While the ratio of geriatricians to seniors is abysmally low in India, and very few medical colleges offer speciality/super-speciality programs, courses and activities conducted by the Geriatric Society of India offer a silver lining in addressing this gap. Further, and except for a few academic options (TISS, SRCC, etc), there is a dearth of trained and practising gerantologists to evolve a more scientific understanding of ageing and its impact on a hetergeneous population group. Both these areas offer an opportunity for universities and online learning companies to design, develop and offer courses that could reduce this shortage.

While large hospital chains, like Apollo, are expanding their services focused on the elderly beyond the hospital setup, a few like St Johns National Academy of Health Sciences in Bengaluru are expanding their geriatric care facilities. The newly launched Geriatric Centre in March 2021, a novel initiative supported by philanthropists and through general contributions, aim to fill a much needed gap in the sector. Sama Hospital, led by renowed geriatrician Dr O P Sharma, has been at the forefront of providing long-term instititional and palliative care for medically dependent seniors in the capital for many years now. Similarly, Vardaan Health Care, started as a senior care home by Vardaan Hospital and HelpAge India in 1999 and established in proximity to the hospital facility, provides a more comprehensive set of services in a senior-friendly environment, including short- and long-term stays.

Similar to how real estate players and eldercare companies have enabled the creation of various senior living formats over the last decade, one is likely to see hospitals utilize special purpose vehicles to unlock opportunities to cater to medically challenged seniors, and further invest in at-home services directly or through partners to ensure the care continuum.

2. Eldercare Clinics and Specialized Care Centers

La Femme is a maternal care clinic owned by Fortis Hospital, and a prominent player in the ~100B USD maternity and child care market in India. Outside the hospital setup, and setup as a specialized facility, it provides a plethora of pre- and post-natal services focused on women serving a large addressable market. For example, India added ~20 Mn babies in 2020 alone. The fertility industry in India is a growing sector with over 2 lakh IVF cycles in a year. Similarly, the diagnostics industry in India is estimated at USD 9 Bn and includes a network of labs owned by companies like Thyrocare, SRL, Metropolis, etc. Much of this evolution has happened in the last two decades, and today, a customer has various diverse facilities and services to meet her needs.

Along the lines of the maternity and child care industry, one is also seeing the emergence of multiple care models in the elder/senior care space. A family with a medically dependent senior may choose a hospital for geriatric or intensive care, a home care service to support activities of daily living, a specialized care facility or at-home service to support medical dependencies, an online group for dementia support and caregiving, and access assistive and accessibility aids through an ecommerce portal. Independent age and care clinics and specialized senior care centers, driven by entrepreneurial teams and fresh capital is likely to drive the growth in this space.

One specific area, dementia care and management is seeing a lot of activity in India and with very low awareness and limited diagnosis, there is much road to cover . What used to primarily reside within the confines of medical and research institutions is today being serviced through eldercare companies and initiatives. The Nightingale Medical Trust offers support to families and persons with dementia through regular screenings, assessments, etc. while Samvedna, a senior care service provider, offers multiple programs focused on dementia care. Aaji Care, a Pune-based company, has an innovative companionship model, to provide at-home care for elders with dementia while Epoch Eldercare has integrated a dementia program in its’ assisted living facilities. Tanvi Mallya, a trained neuropsychologist and her team, offer a unique facility, a Neuro Clinic with programs catering to people with Parkinson’s, Dementia and needing Post-Stroke care. Initiatives like Project Stride take a multi-country approach and evaluate country-specific dementia plans that inform policymakers and practitioners on the urgency of the issue, and the need for a more robust national plan.

3. Care Economy: Availiability of Skilled Caregivers and Caregivers Mental Health

Caregiver Saathi is a a unique social enterprise, and as the name suggests, are companions for caregivers. Founded by Bhavna Issar, the team takes an ecosystem approach and engages with caregivers through workshops, coaching, counselling and support groups. Their YouTube channel is a wealth of knowledge for those trying to understand caregiving in the Indian context, and to hear first-hand experiences of caregivers.

Insititutions like the Healthcare Sector Skill Council, a PPP initiative between the government and the private sector, formulate pan-national standards for various allied health and support roles, and empanel skill development partners to recruit youth and train them on these standards. For example, the standards for Geriatric aide captures skills required to work in a hospital, home or community setting, and many such job-role specific standards have been developed by the industry. Many home care services companies work closely with such organizations and also hire trained graduates from these programs. Others have their own in-house training centers that cater to specific needs.

While the care economy refers to age-agnostic care, and caters to various population groups (children, elders, persons with special needs and disabilities, etc) with short- and long-term needs, the role of family caregivers, trained caregivers and health professionals (lab assistants, diabetes educators, geriatric care assistants, senior home supervisor, dementia companions, mental health counselors, etc) with particular focus on the elderly in various care settings is likely to get more specific and sophisticated over the next couple of years.

This article highlights a very innovative care model where ageing parents with a child with disability in Chennai collaborate with a senior living company to create an inclusive living project to meet future caregiving and support needs. Quoting from the same article,

“SCAN launched its inclusive housing initiative with a private real estate builder, Akshaya Homes who will construct the project to be disabled-friendly. The adults with special needs can live with their peers and caregivers in a shared accommodation with the apartment having accessible amenities. The caregivers would be certified by a prominent NGO working across various sectors for people with disabilities, Vidya Sagar (formerly The Spastics Society Of India).”

Divya Chandrababu in Hindustan Times

4. Long Term Care Planning and Financial Management

In a previous Silver Angels’ essay, longevity impacts on retirement planning, I briefly touched upon the financial implications of longevity and how retirment planning tools do not capture age-linked medical costs. Particularly for elders with medical needs, and coping with multiple health conditions, a long-term care plan could help improve their quality of life and alleviate care burden among family members. This study by AgeWell Foundation identifies poor or inadequate financial resources and loneliness due to breakdown of family systems as major challenges faced by elders in getting a long-term care plan. This report authored by a prominent group of Indian researchers as part of the International Long Term Care Policy Network articulated the impact of the pandemic on long-term care situation in India, and the need to devise a long-term care policy.

Long-term care planning and management is broadly untouched in India, and thus presents an opportunity for businesses, eldercare companies and startups to build both B2B and B2C solutions focused on various end users (hospitals, families, caregivers, seniors, etc). One is also likely to see products offering personalized care plans that address various aspects, stages and conditions, and this could play a crucial role in wider reach, adoption and rise in demand for many of the services. Technology could play a critical role in wider adoption of such products.

In conclusion

Long-term care is an essential and critical part of ensuring that people, particularly seniors with medical challenges and multiple health conditions, have a predictable quality of life aided by family members and secondary support systems. Whereas the entry points to serving this audience may arise from players in different sectors – real estate, hospitals, home care, technology, communities, etc – they are likely to converge into a more integrated and bundled solution, and offered through partnerships to address various specialized needs.

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