Care comes at a cost: India's ageing population exposes a broken caregiving system

For Pratibha Khemesra, an octogenarian architect living in Bengaluru, the high points of her day are the phone calls from her children from two ends of the world. Her son is in Brisbane, her daughter in Oslo. Since they cannot be with her, they have employed two caregivers to look after her in shifts. They also monitor the CCTV footage of her home, to ensure her safety and comfort from thousands of kilometres away.

Yet the arrangement has brought its own anxieties. In the past year, the agency that provides caregivers has replaced four of them, including a 65-year-old driver who moved to caregiving after his reflexes deteriorated and driving became difficult. "The ground-level experience is pathetic," says Khemesra. "Many caregivers lack adequate training and are recruited merely to fill the gap."

(Names of care recipients, relatives and workers have been changed at their request.)


Khemesra is caught between two concerns. Alone with caregivers whom she barely knows, she worries about her safety. Her other worry is: What if they stop coming altogether? So she hesitates to complain even if they arrive late or fail to perform their duties properly.

Also read: India's ageing population calls for a new social contract on elderly care

Her children can afford the cost of care, which comes to ₹75,000-80,000 a month for both carers. Many families cannot.

The other side of the picture is grim too. Carers have to work long, demanding shifts for modest wages, with little respite or job security. An average caregiver earns ₹900-1,200 for a 12-hour shift, or around ₹27,000-36,000 a month, but agencies take a cut of 30-40%, which can even go up to 50%.

"When the middleman earns more reliably than the carer, supply will always be fragile," says Bhavana Issar, founder of Mumbai-based Caregiver Saathi. Agencies justify their share, saying they are providing training and operating on tight margins.

A carer's work is also physically and emotionally draining. In Mumbai, Sunita Raut, who was taking care of a dementia patient, says, "I had to be hypervigilant, but every time the patient would fall asleep, I was given household chores to do." The lack of breaks, exhausting commute and the patient's suspicious behaviour, including instances of physical and emotional aggression, took a toll on Raut's health. She said the agency did not adequately address her concerns about safety. After a year, she quit caregiving to start a sandwich stall.

Khemesra and Raut reveal the magnitude of crisis at the heart of India's caregiving sector: the demand for caregivers is massive and growing, but the workforce is poorly trained and paid, informally employed and frequently treated like domestic help.

India's nursing shortage is well known. Less visible is its shortage of trained caregivers who help older adults and patients with disabilities or chronic illnesses. As families shrink, children migrate for work and women enter paid employment, the traditional arrangement of relatives, usually women, providing unpaid care is coming under strain. Paid care has developed recently through informal labour networks, brokers, nursing bureaus and small agencies with uneven standards of recruitment, training and supervision.

Trained attendants

Issar says families often expect care attendants to be an extra pair of hands for both the household and the patient. Meanwhile, some carers struggle with basic monitoring, like checking blood pressure and blood glucose, while others are left to manage dementia-related behaviour without adequate training.

Pune-based Vidya Nair was alarmed when her elderly mother, who had dementia, grew unusually lethargic and spent long periods in bed. Tests raised concerns about medication overdose and possible effects on her liver. The family suspects the caregiver was administering sleeping tablets to make the woman easier to manage.

Tom George, founder of Guardian Angel Homecare in Kochi, says training is the panacea for the ills in the sector.

A doctor recently approached Guardian Angel Homecare about his 90-year-old father who is bedbound. He had been looked after by a well-meaning neighbour, who ended up feeding him heavy, unhealthy meals that made him listless, and hauled him between bed and wheelchair in a way that risked injuries to both. The son found it difficult to correct the elderly man who was known to the family for years.

A home nurse finally adjusted the nonagenarian's meals and demonstrated safer transfer techniques. Within three days, the man was sitting up and chatting with his family. "Training doesn't push family compassion aside; it gives that compassion the practical knowledge and safety it needs to work," says George.

He says fresh candidates at his agency undergo training at its Guardian Angel Institute of Caregiving. Its entry-level programmes costs ₹30,000, besides ₹10,000 for food and accommodation, for 18 days. Experienced caregivers are recruited directly after screening and skill tests, followed by a seven-day training programme.

These days, however, agencies find it difficult to retain trained workers. Like nurses, carers are flying to countries like Israel, UK, Germany and Japan where they get paid ₹2.5-4 lakh a month, although the work remains precarious in a foreign land.

Grey matters

For India, the challenge in the caregiving sector is growing alongside its elderly population. India had about 149 million people aged 60 and above in 2022, projected to reach 347 million by 2050, according to UN Population Fund's India Ageing Report 2023. Population aged 80 and above is expected to grow by about 279% in this period.

According to an analysis of the Longitudinal Ageing Study in India (LASI) by NITI Aayog, 75% of the elderly have one or more chronic disease and 48% of older adults have limitation in at least one instrumental activity like managing medications or shopping.

Vaibhav Tewari, cofounder of home healthcare provider Portea Medical, estimates that 20-25 million older people would require caregiving by 2050, including those with severe dependency, dementia and post-surgical or palliative needs. Portea has trained more than 50,000 caregivers over the past 12 years. Tewari says supply "needs to be augmented on a war footing" to meet demand over the next two decades.

Industry estimates cited by NITI Aayog put India's care market at $29.6 billion in 2023, projected to reach $72.3 billion by 2030. The opportunity is there. The workforce to realise it is not.

Cost of care

For Pallavi Joshi, a bank employee in Gurgaon, the need for care arrived alongside a personal tragedy. After her husband died in a car accident, she was left to support herself while caring for her 75-year-old mother-in-law who required palliative and post-hospitalisation care. She returned to work to pay off her home loan while her savings went into care. A caregiver for a 12-hour daily shift cost her ₹25,000 a month.

Joshi's experience illustrates the financial burden on households that need assistance for months or years. Round-the-clock care is expensive, while live-in assignments for patients with advanced dementia, nighttime wakefulness and heavy physical dependency are difficult to fill and retain.

The Ministry of Skill Development and Entrepreneurship and the National Council for Vocational Education and Training have developed qualifications to establish benchmarks across the care sector, but no action is visible on the ground. Training programmes and certified assessors remain a distant dream. "The endeavour is to make credible training accessible across India, backed by structured career progression opportunities for young aspirants," says Mona Gupta, CEO of Delhi-based nonprofit Home Management and Care Givers Sector Skill Council.

The employment model needs to change. The low social status attached to the job is the biggest barrier. Workers placed through informal intermediaries often have no written contracts, paid leave, insurance, or grievance mechanism.

The consequences extend beyond the care sector. Lack of affordable carers forces working women to turn down promotions, cut down working hours, or leave employment altogether to care for parents or parents-in-law. Employers lose experienced workers and incur replacement costs, yet few offer structured caregiver support or homecare benefits.

Job to profession

The government is waking up to the problems of a greying country. The Union Budget 2026-27 announced an initiative to train 150,000 multi-skilled caregivers in a year. A national registry, transparent recruitment, written employment terms, reasonable hours and grievance mechanisms would further protect workers and families. Meanwhile, the Keralam Senior Citizens' (Care and Protection of Rights) Bill, 2026, proposes a phased expansion of certified caregivers in agencies-25% by the second year, 60% by the third and 100% by the fourth.

Tewari argues that caregiving needs a recognised career ladder, allowing workers to progress from caregiver to senior caregiver, field supervisor and care coordinator. Specialisations in dementia, palliative care and post-acute recovery could create opportunities for higher wages and greater responsibility.

NITI Aayog has also identified the potential for India to become a global hub for skilled caregivers amid a projected worldwide shortage of 11 million health and care workers by 2030. India and Japan have agreed on a plan to facilitate the movement of 50,000 skilled Indian workers over five years, with caregiving among priority areas. But India needs them back home too. Better wages, safer working conditions and professional recognition are essential to retain them.

Arvind Mathur, president of Caregivers Asha Society, Jodhpur, says, "India's caregiving challenge is not merely a shortage of people willing to provide care. It is the absence of a sufficiently organised, affordable, professionally supported and accountable care system."

Mathur says professional recognition does not mean turning every caregiver into a nurse. It means acknowledging that safe personal care requires specific knowledge, skills and responsibility, backed by competency-based training, supervision and decent working conditions.

India's challenge is no longer the number of carers. It is whether caregiving can become a profession that workers want to enter, families can afford and vulnerable people can trust.

Khemesra's children can arrange shifts and monitor cameras from far away. What they cannot remotely guarantee is the quality of care their mother receives. Closing that gap will be one of the defining tests of India's ageing future.