9 min read.Updated: 10 Dec 2020, 06:15 AM ISTGoutam Das
With older Indians the worst hit this year, the geriatric care business is booming. What are the missing links?
By 11am, Lal Jagtiani, 84, was done with most of his morning rituals: a cup of tea on the balcony that overlooks a lawn; listening to Indian classical music; a trek down and up the stairs to his fourth-floor apartment in a senior living development in Bhiwadi, a town in Rajasthan’s Alwar district. Now, he’s settled down at the library in the society’s club house.
“I like to sing and dance," Jagtiani said, pulling down a grey mask to his chin. He played a video on his phone of his wife Sushila and he singing Uran Khatola Pe Udh Jaau, a song from the 1946 film Anmol Ghadi. The couple, both doctors, practiced in Mumbai. Their two children are abroad. “Our kids thought Mumbai wasn’t safe or comfortable for seniors to live in," Jagtiani said.
Then there is Vandana Agrawal, 66. She taught in a school near Pilani and lived in the staff quarters. After retirement, she didn’t want to be lonely. She is single.
Both the Jagtiani couple and Agrawal moved in at Ashiana Housing Ltd’s senior township in Bhiwadi. “It is hassle-free for me to live here," Agrawal said. “I have made friends, learned to cycle, and play badminton. I have knitted 900 masks for the staff and other residents in the township."
The township offered a bit more than a simple retirement home. It is based on a concept known as Continuing Care Retirement Community (CCRC). One can carry on living independently; seniors who require higher degrees of help can avail support for eating, bathing, dressing, toileting, medication management, and health monitoring, among others.
All of this has become even more important in the context of the pandemic, which has impacted seniors and those with disabilities the worse. Seniors living alone suffered an emotional crisis, anxiety and trauma—locked up for over six months, they had little access to hospital care or even everyday needs.
Neighbours and relatives living in the same neighbourhoods were reluctant to visit; seniors had trouble using grocery apps. The news of deaths didn’t help either. According to the ministry of health and family welfare, those aged 60 and above account for 53% of covid-19 deaths while those in the age group of 45 to 60 years for 35% of the fatalities. Typical anxieties relate to how they would get cremated or the fate of their properties.
“There are over 100 million elders (India currently has about 120 million people over the age of 55) who are scared. The sons and daughters of the elders are going through trauma too. We often don’t recognise that," Saumyajit Roy, co-founder and CEO of Ignoxlabs Pvt. Ltd, a Gurugram-based company that provides emergency support and health monitoring services to elders under the brand Emoha Elder Care, said. “The anxiety is peaking now."
Covid-19 is therefore accelerating what is called the silver economy with the demand for many geriatric products and services spiking. The 15-year-old industry started with just real estate but now includes hospitality and healthcare. Indeed, a big chunk of the economy is also about caring for seniors not at senior living developments but at their homes.
Selling real estate, healthcare, financial services and other products to this demographic is a $10-billion opportunity, a study by McKinsey & Co. for geriatric care firm Antara, a subsidiary of Max India Limited, found. Home healthcare services are the largest bucket at $4 billion, followed by financial services ($3.5 billion) and assisted living ($1 billion).
Gaganpreet Uppal, a chartered accountant living in Gurugram, has parents who are over 90 years old. On September 12, her father, sister and a domestic help were diagnosed with covid. All hell broke loose.
“My father has heart, kidney, and diabetes issues. Even though he had a mild case, he had to be admitted," Uppal, who is the primary caregiver in the family, said. She called Emoha Elder Care. “Their emergency team landed with PPE kits. They helped me isolate my mother, guided me," she continued. “At times, the caregiver also needs help. You need both emotional and physical support."
Emoha sells subscription packages that offer a range of elder support services. In January, the firm had about 40 paying subscribers; by November, the number swelled to 600.
Other geriatric care providers have similarly noticed the pandemic push. Antara ‘soft launched’ its new senior-living residences in Noida amid the pandemic, in April. The company sold 120 apartments of the planned 330 in its first phase until now. In comparison, Antara said it took three years to sell 100 in an older development in Dehradun, although it is strictly not a similar property. Dehradun is more luxurious versus the Noida residences.
“For projects under development, the pandemic has altered demand in two significant ways. There has been a 4x increase in enquiries and organic visits to our website," Mohit Nirula, CEO of Columbia Pacific Communities, a developer of retirement homes, said. “Furthermore, there has been a distinct increase in the number of couples in the age group of 50-60 who are looking for homes in communities where all their day-to-day needs are being fulfilled by one service provider," he added.
Epoch Elder Care, a company into assisted living and dementia care, leases homes rather than selling them. It launched 25 new homes in Gurugram in February and is nearly running full. For some companies such as Tribeca Care, a home healthcare company focused on geriatric care in eastern India, supply was the bottleneck rather than demand—the firm’s billings are up 15% in November compared to February. The company faced a shortage of nurses, attendants, physiotherapists and psychologists during the lockdown.
An integrated play
Once, geriatric care in India used to be old age homes run by charitable institutions. Once, it was too much of a taboo to move into such a home. That has changed thanks to young Indians working and living in other countries burdened by what is referred to as “NRI guilt" of not being able to look after their parents back in India.
“People in the age group of 60-70 years have disproportionately invested in the education of their children. They sent them to better schools and colleges than they could afford," Mohit Nirula of Columbia Pacific Communities said. “These children are no longer sitting across the same dining table. They are in different cities, in different countries," he added.
Circumstances, therefore, are shaping the geriatric care industry, with professional operators replacing the family as the caregiver. There are fewer stigmas today than a decade ago. For now, the numbers point to greater acceptability of geriatric services—at least the residences model—in south India. Of the 40 senior living projects in India by 14 large developers, nearly 65% are in south Indian cities, a report from Anarock, a real estate services company, stated.
Senior living projects are thriving in Coimbatore, Puducherry, Chennai, Bengaluru, Kodaikanal, Mysuru, Kochi and Kanchipuram. “Coimbatore has the maximum number of projects (around seven). The city seems to have emerged as one of the top retirement havens in India due to excellent healthcare facilities, trained staff availability and salubrious climate," the report noted. In the west, Pune has six large projects for senior citizens. Other hotspots are in Vadodara, Chandigarh, Jaipur, Dehradun, Faridabad, Kasauli and Bhiwadi.
The future will most likely be an integrated play, whether it is retirement communities or at-home care. Seniors prefer a single window. At-home geriatric care providers, for instance, have to offer more than just healthcare support. It could mean concierge or shopping services, help with hospital paperwork or even travel assistance. And like mentioned earlier, residential developments are developing a strong healthcare and hospitality services thread.
The real estate part is about acquisition of land, and design of the living communities. Senior living facilities are designed differently. They have anti-skid flooring and walls without sharp edges, for instance. Many homes have fall sensors and emergency buttons installed. Often, these communities have open spaces that promote social interactions in small groups. Operators of such facilities require hospitality expertise since they have to provide security, housekeeping, maintenance, food and beverage.
Many seniors don’t like to cook or can’t cook. The day this writer visited Ashiana Housing’s senior living society in Bhiwadi, the cafeteria was buzzing at lunch time. The food cooked is simple and less spicy but chefs are trained to be patient – elders can get pesky with suggestions on how they like their food.
The healthcare part covers nursing support, understanding the medical history of residents and managing relationships with neighbouring hospitals.
The missing links
While the ecosystem appears to be falling in place, there are sizable gaps that need work. Nearly all the private geriatric care providers target elders who can afford between ₹20,000 and ₹50,000 a month. This implies a need for financial products for the elderly, nearly non-existent. Insurance for at-home healthcare is a suggestion doing the rounds.
A more radical thought is extending the retirement age, considering the higher life expectancy. A recent study published in The Lancet stated that India has gained 10 years in life expectancy over three decades—from 59.6 years in 1990 to 70.8 years in 2019. “Since life expectancy has gone up and retirement continues to be 58-60, there is a long period of time for the seniors to fund their retirement," Rajit Mehta, CEO and MD of Antara Senior Living, said. “One of our suggestions to the government is to start increasing the retirement age, which can help reduce the burden on pensions borne by the government as well," he added.
That’s a suggestion which needs careful consideration. It is counter-intuitive because of India’s stressed labour markets and youth bulge. The World Bank’s South Asia Economic Focus Spring 2018 report stated that between 2015 and 2025, India’s working age population or those above the age of 15, is expanding by 1.3 million a month. Therefore, India is under pressure to create jobs for millions of youth.
The geriatric care industry is arguing that the seniors aren’t really competition; they are not interested in the jobs the youth aspire for. With their experience, some can counsel, consult and coach, for instance—not the domain of the young.
As of now, there is a stronger case to re-skill and meaningfully engage seniors for what the World Health Organization calls ‘active ageing’, a process to enhance quality of life. Sugandhi Baliga, head of Geriatric Programme at Tata Trusts, a philanthropic organisation, suggested a senior equivalent of the Anganwadi (rural child care centres) to keep the older population mentally agile. This could work both in rural and urban areas and is a solution for the bottom of the pyramid, or those who can’t afford much, let alone the ₹20,000-a-month spend private companies target.
“In areas we operate, we are running activity centres for seniors. The panchayat gives us space at their offices. We mobilise elders who come and talk about various issues," she said. In urban areas, every ward could similarly have an activity centre for the elderly. “Let us promote the idea of active ageing in a big way; else elders will get comorbidity issues. We can think of re-skilling, re-employment, and volunteering," she added. To make activity centres for the bottom of the pyramid work, India may need to devise a Public Private Partnership (PPP) model.
For healthcare-related support in rural areas, Baliga suggested states tap into the National Programme for Health Care of the Elderly (NPHCE) scheme, which was designed in 2010. The scheme has funding support from the Centre and seeks to address preventive healthcare, management of illness, medical rehabilitation and therapeutic interventions among the elderly. In addition, the scheme can also be tapped to train medical and para-medical professionals in geriatric care.
“It is a beautifully designed scheme and is a clear way forward. We have to make some of these schemes work," she said.