Absence of a formal long-term healthcare system for a rapidly ageing population is likely to create a crisis situation in the near future

Introduction

Over the past few decades, the population pyramid of India has acquired a relatively narrower base, becoming increasingly top- heavy. It should sound alarm bells for the country due to the unique relationship between its healthcare delivery systems and sociocultural structure. Conventionally, large joint families take care of older parents and relatives. Over the past century, smaller families have become the norm and the joint family systems have become increasingly nuclear.^[1],[2] While the average size of the Indian household was 5.5 in 1991, it is now estimated that 56% households have <4 members.^[3]·^[4] The share of older individuals in the Indian population has also increased progressively. It is expected to rise from 8% in 2010 to 19% in the next three decades.^[5] Consequently, the elderly dependency ratio of India has increased from 6 to 8 as reported over the past two decades and is expected to rise to 11 per 100 in the next decade.^[6] An increasing share of older individuals on a background of changing family structure, limited social and financial support is expected to unfold harsh health policy challenges. We highlight that in the absence of long-term care facilities, in the context of a rapidly expanding older population, the Indian healthcare system is staring at a not-too-distant collapse. While some developed countries have time-tested long-term care systems, these cannot be directly implemented to Indian sociocultural contexts.^{[7],[8],[9],[10],[11],[12]} We also suggest areas for further exploration.

Methods

An initial PubMed search in August 2016 for long-term care facilities or models in India using keywords ‘term care’ and India identified 67 citations. None addressed models or facilities of long-term care, but we identified five that were relevant for our review.^{[13],[14],[15],[16],[17]}

A search using ‘long term care’ and ‘model’ identified 1997 publications. Limiting keywords to appear in the titles of English articles, we identified 109 articles. Articles that were screened for relevance and those found too focused, relating to particular diseases, or too broad, were excluded. The abstracts of 55 articles were reviewed and 16 were identified for further examination. Data were collected on the nature of long-term care model, the cost of implementation and the advantages and disadvantages of each model.

Agreement and Disagreement in Literature

Among the reviewed literature, there is considerable agreement that the nursing home-based model of long-term care delivery is not the ideal approach and is riddled with problems in terms of coordination, financing, fragmentation, long-term sustainability and end-user dissatisfaction.^{[18],[19],[20]} It has been felt that medical facility-based care model results in neglect of elders, the individuals whom these institutions were set up to care for. Options for ageing in place (home care models) with community participation are not only less expensive but also more attractive to elderly end-users, prevent inappropriate hospital admissions, improve quality of life and decrease dependence on private resources.^{[9],[21],[22],[23],[24],[25]}

There is little agreement on the nature and methodology for an ideal long-term care delivery system. However, there is a definitive shift towards an integrated system of acute and long-term care for frail older people with multiple comorbid conditions and disabilities requiring assistance in more than one activity of daily living.^[22] Systems such as Program of All-Inclusive Care for the Elderly (PACE) that integrate community participation and focus on home-based care are becoming increasingly popular.^[826] The role of personal care and social care within the home care models also remains controversial.^[27] In addition, the role of providing the long-term benefits in cash as against the indemnity model has not been adequately addressed.^[28]

Analysis of Strength/Quality

We did not find any systematic review or meta-analysis that has reviewed the quality and advantages of long-term care systems across the world. Most articles are observational studies and non- systematic reviews of published literature. We used only the PubMed database and cross-references from articles, and the use of other databases may strengthen the content further.

Gaps in Literature

We did not find a systematic study on long-term care in India, and there is considerable ambiguity in the terminology of long-term care and nursing home care in the literature across the world.^[29] In addition, the role of integration of social or personal care with long-term healthcare has not been adequately addressed. The possibility of linking long-term benefits to a cash-based incentive model needs further exploration.

Conclusion

Our review emphasizes that in the face of a rapidly ageing population, it is essential that a system of long-term care should be established. An inclusive system integrating facility-based institutions with home and community care developed upholding autonomy of the participant and promoting cost-ownership approach, which is not only self-sufficient but also self-sustained, will be a crucial healthcare challenge for the policy-makers in India.

Conflicts of interest None declared