India may well become old before it becomes rich. That is simply a demographic, and economic, reality. Fertility has fallen rapidly, child survival has improved dramatically, and the population over 65 is expanding faster than our systems are adapting. Much of the world’s increase in life expectancy over the past century came from preventing child deaths, and this has been true in India as well. However, the next frontier is about preventing premature adult mortality, and extending survival and health beyond age 65.
A 65 year-old citizen in India around the time of Independence could have expected to live another 11 years, roughly the same as in Vietnam and about a year more than in China. However, in 2020, the remaining expected years of life for a 65 year-old was 17 for the Chinese and Vietnamese, and only 14 for India. We have gained only three years of survival at age 65 over nearly eight decades of economic and social progress.
Three broad forces determine survival at older ages. The first begins in childhood — nutrition in pregnancy, infancy and childhood shapes lifelong metabolic risk. Low birth weight, childhood undernutrition, stunting and anaemia alter cardiovascular and metabolic pathways in ways that increase susceptibility to hypertension, diabetes and heart disease decades later. When early deprivation is followed by adult caloric excess and sedentary living, the result is a particularly high burden of non-communicable disease. As strange as it may seem, a heart attack in the sixties is often rooted in the nutrition of the first 1,000 days of life. A strategy for healthy ageing must, therefore, begin with maternal nutrition, child growth and school-age diet, not merely geriatric medicine.
The second determinant of survival at older ages which include behaviour and environment is therefore central. Tobacco remains one of India’s most lethal exposures, whether smoked or consumed in smokeless forms. Cardiovascular disease, chronic lung disease and cancers follow predictable risk patterns. Alcohol contributes to liver disease and injuries. Diets rich in refined carbohydrates, salt and ultra-processed foods are accelerating metabolic risk. Physical inactivity compounds the burden. And air pollution, particularly fine particulate matter, silently amplifies the risk of heart attack and stroke in the course of one’s life.
Reducing these exposures will determine the state of the nation in 2047. Every stroke avoided and heart attack prevented preserves not only life, but also household savings. Air quality improvements are a longevity policy. Tobacco taxation is fiscal policy that pays twice — once in revenue, again in reduced disease. A serious Viksit Bharat agenda would treat risk-factor reduction with the same urgency once reserved for child immunisation.
The third determinant is the quality and orientation of the nation’s health system. India has expanded financial protection for hospitalization through Ayushman Bharat. That is important but in low- and middle-income countries, the gains in old-age survival are more strongly driven by prevention and midlife risk management, than by high-technology care. The decisive interventions that extend life expectancy at 65 which include detecting and controlling high blood pressure, ensuring affordable statins for high-risk individuals, managing diabetes early, providing smoking cessation support, vaccinating older adults against influenza and bacterial pneumonia, and screening for cancers at treatable stages, are all features of a much-needed primary care system.
But health alone is not enough. If India ages before it is rich, it must also rethink how it finances old age. The European model of broad, pay-as-you-go pensions built on large formal workforces is difficult to replicate in an economy where informal employment dominates. Here are three ideas for ensuring that the elderly can be financially independent.
First, a tax-funded basic pension that prevents destitution in older age, especially for informal workers and women who have had interrupted earnings. Second, contributory savings mechanisms that are flexible enough to accommodate irregular incomes and include the informal sector, which is currently left out. Savings plans, where the government provides matching contributions to voluntary ones made by informal sector workers could help. Several countries, including New Zealand, Singapore and China, already provide government matching contributions or targeted top-ups to encourage retirement savings among low-income and informal workers. India could adopt a similar approach.
Third, attention to long-term care, simply because the most financially devastating aspect of ageing is often not acute disease, but prolonged dependency. Financing long-term care, whether through insurance models, community-based services, or family support augmented by public subsidies, will be necessary.
These financial reforms are inseparable from health reform. A healthier 65-year-old is less likely to require years of dependency. The cheapest pension reform is disease prevention. The most sustainable social security system is one in which older adults remain functionally independent for longer.
That is why life expectancy at age 65 should be an explicit goal of Viksit Bharat. GDP growth is necessary, but insufficient. A country can grow rapidly while accumulating silent vascular damage in its population. It can build highways and airports while 55-year-olds develop uncontrolled hypertension and households slide into debt after repeated hospitalizations. Life expectancy at 65 forces the system to confront the full pipeline: maternal nutrition, childhood growth, mid-life risk, environmental exposures, primary care performance, financial protection, and long-term care.
It is also a measure of respect for accumulated human capital. A 65-year-old Indian has decades of acquired knowledge, skill and social memory. That represents a significant investment by families, the education system and society, all of which could be cut short by premature mortality. A nation becomes developed not when its aggregate GDP is greater, but when it makes ageing with health and dignity possible for all citizens.
Ramanan Laxminarayan is president, One Health Trust. The views expressed are personal
