With birth rate in decline, India must change

With the fertility rate falling below replacement, challenges of higher dependency, burgeoning healthcare and social security needs will emerge. India must mount the necessary policy-response

By Prabhu Pingali and Shubh Swain

The time has come for India to turn a new leaf on population policy. The country’s fertility rate has already fallen below the replacement level, 2, according to the latest data from the National Family Health Survey, which was largely collected before the nation felt the heat of Covid-19. The ongoing shock and uncertainty caused by the pandemic will likely drive down birth rates even further. Decreased fertility has many rewards, but this demographic achievement might come with a price. The coming demographic transition has profound implications for India’s health, fiscal and gender policies.

With a lower number of births, the youth population will keep shrinking. As the size of the youth population falls, the number of older adults will surpass the young. India will need to reassess its social-security focus and make investments to provide the growing number of older adults with improved access to healthcare, income-security and social safety-nets.

Emerging health challenges

Drawing on the 2000 Population Policy, India’s health policies and programmes have focused on family planning, maternal and child health and communicable diseases. Yet, with the increased number of older adults, the number of non-communicable diseases is already outgrowing infectious diseases. According to the WHO, nearly 60% of deaths in the country can be attributed to non-communicable diseases. That share will continue to increase in the near future, demanding a significant policy shift towards preventing and managing morbidities like diabetes, cardiovascular diseases and cancer.

India has achieved many milestones in mitigating food insecurity since the 1970s, and the focus is now slowly moving from under-nutrition to the rising problem of obesity in the general population. But, older adults are still at risk of food and nutrition insecurity, as their declining social and economic bargaining power often makes them dependent on social security; 6% of Indians over the age of 45 have experienced insufficient food in the household, according to the Longitudinal Aging Study in India. That number can be expected to grow with the increasing older adult population.

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Healthcare for all has been always a challenge for India. Increasing medical costs, difficult-to-afford health insurance and transportation constraints have negatively impacted healthcare access among the underserved population in India. With the expanding older adult population, these challenges are going to get harder.

Older adults have reduced incomes, less access to health insurance and restricted mobility. Several studies have shown that the inaccessibility of specialised services is one of the major constraints for healthcare-seeking behaviour among older adults. Less than 1% of older adults have health insurance, and ageing-related morbidities are a grey area in terms of coverage. Most older adults depend on families and immediate relatives for healthcare. As family size shrinks due to declining births, such informal safety nets may not be a viable option in the near future.

Added fiscal costs

The decreasing fertility rate will also pose a fiscal challenge in the form of an increasing dependency ratio. Measured as the number of people aged 65 and up compared to the population aged 15-64, the dependency ratio in India moved from 5.4 in 1960 to 9.8 in 2020 and will increase to more than 20.3 in 2050.

The quality of life among older adults is already unsatisfactory at the current dependency ratio, with a government report scoring income security and financial well-being among older adults at 44.7 and 33 out of 100, respectively. With the growing dependency ratio, it will be more difficult to improve this situation. As the younger population declines, resource investment in the youth will shrink, too. Demand for work within the older adult population will grow and may result in delayed retirement, leading to a “job squeeze” in which the young and old alike compete for a limited number of jobs.

A new gender issue

As the older portion of the population grow, the number of older adult women will be greater than the number of men. Although life expectancy has increased dramatically in India, it has not benefited men and women equally. In three decades, it is expected that the life expectancy of women, at 65 years, will be two years more than that of men. According to a UN projection, by 2050 women will make up 56% of India’s population at the age of 80.

Due to the difference in life expectancy, more women will live as widows in the later stages of their lives. Historically, widowhood is closely linked to the social and economic insecurity in India. Many studies have suggested that older and widowed women are at greater risk of both chronic and acute health disorders and less likely to engage in health-seeking behaviour.

Additionally, the average years spent in school among women aged 40-45 is not very encouraging. There will be many older women who are less empowered and vulnerable to social insecurity.

Young and old both hold the key

India needs to move simultaneously towards two goals: investing in today’s youth to build a healthy and empowered population in long run, and creating a more protected platform to provide immediate benefits for older adults. By doing so, India can achieve “healthy ageing” and flatten the curve where disease, disability and disempowerment accumulate with age.

The current social, financial and health security of young adults will decide the well-being of tomorrow’s older adults, but the news about India’s young adults is not very promising. In the past two decades, the youth unemployment rate has increased from 17.7% to 22.8% and obesity is increasing among people aged 15-34 years. A recent sample-based study found that one-third of young adults under 35 are at moderate risk of diabetes.

India must invest more on youth to help them secure good employment and incomes, and ensuring healthy lifestyles should be the top priority of youth welfare schemes. Strengthening the education system to make it globally-competitive is the first step towards increasing the market value of the youth. Flagship skill-growing schemes like Pradhan Mantri Kaushal Vikas Yojana and Deen Dayal Upadhyaya Grameen Kausalya Yojana should be allocated greater funds and shift their focus to the youth. Promoting healthy investment behaviours among young workers will help in economic empowerment at a later age. Targeted behaviour-change communication for healthy life practices will enable the youth to grow healthier.

Shifting policies toward older adults not only brings an immediate result but will also create a sustainable older-adult-friendly society in future. Making specialised health services available at the primary care level, improving the older-adult-friendly transportation system, replicating the model of ASHA workers, and creating a cadre of health outreach workers trained in first-line care of geriatrics will be helpful.

There is a strong push from nutrition and food-system scholars across the globe for India to address malnutrition by making more diversified food available and accessible to its population. Going forward, scholars involved in this discourse should address the situation of older adults as a matter of social and nutritional justice.

India must work collectively towards a structural shift in order to capitalize on the coming wave of demographic change. The negative cultural view of old age must come to an end. Government policies and departments should converge around the goal of promoting active aging to keep older adults economically productive. Senior workforce participation can be an added advantage when older adults bring their experience and wisdom to the workplace to optimise youth energy.

Moving forward, the gendered approach to health care, food security and overall well-being must include a new dimension: old age. India must increase its old age pension share, which is currently 1% of the GDP. Old-age pension schemes and other social safety-nets should make a deliberate effort to provide health and nutrition security to women who are older and underserved.

Even though the effects of the demographic transition will not be felt tomorrow, India must get the ball rolling early, as the shifting in the sociocultural landscape towards those of advanced age will take time.

Pingali is founding director, Tata Cornell Institute, and professor, Applied Economics, Global Development, Cornell University, and Swain is research associate, Tata Cornell Institute, Cornell University

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