DESK REVIEWS | 03.01.02.01. Does the country have a public long-term care system? If so, please provide a description of its coverage: is it universal, or residual? What are potential barriers to access?
DESK REVIEW | 03.01.02.01. Does the country have a public long-term care system? If so, please provide a description of its coverage: is it universal, or residual? What are potential barriers to access?
Yes. The Unified Social Assistance System (SUAS) provides some long-term care services to the population, such as long-term care institutions, day centres, palliative care, advance care directives, and others. The system’s coverage is means tested, provided to people without means to pay for their care or without family support (Brazilian Ministry of Citizenship, 2015). Poor people, without family support and with disabling health conditions may benefit from SUAS. Lack of information among the population regarding the existence of such services may be a potential barrier to access. The SUS may also provide some kind of LTC services through the Family Health Strategy (FHS). Although both SUAS and SUS may provide some LTC services, the provision is unsatisfactory and disintegrated.
Brazilian Ministry of Citizenship, A. (2015). Unidades de acolhimento [Página]. MINISTÉRIO DA CIDADANIA Secretaria Especial do Desenvolvimento Social. http://mds.gov.br/assuntos/assistencia-social/unidades-de-atendimento/unidades-de-acolhimento/unidades-de-acolhimento
Hong Kong has a public long-term care (LTC) system, which is a universal system built on the principle of social equity. LTC services in Hong Kong are regulated by the Social Welfare Department and provided by various NGOs under public subvention to elderly citizens (aged 65 and over) with proven care needs which are assessed under the Standardised Care Need Assessment Mechanism for Elderly Services (SCNAMES). The Mechanism covers applications for subsidised community care and residential care services. Assessors under this Mechanism are professionals from various disciplines, such as social workers, nurses, occupational therapists, and physiotherapists, who are required to be trained and to be accredited for the use of the assessment tool. Older people are eligible for subsidised LTC services if they are assessed as moderately or severely impaired (e.g., defined by age, physical and cognitive functional disability, and dependency) under SCNAMES. If subsidised care places are not readily available, eligible older people will be placed on the Central Waiting List on a first-come-first-served basis according to their registration dates and preferences. The major potential barrier to access LTC services in Hong Kong is its insufficient supply, which results in long waiting times for different types of service (Social Welfare Department, 2019a). Since public LTC service in Hong Kong is universal as well as almost fully subsidised and distributed over the territory, factors such as gender, race, income, and geographical location do not contribute as barriers to access LTC services.
Social Welfare Department. (2019a). List of Self-financing Day Care Centres for the Elderly (as at March 2019). Hong Kong: Social Welfare Department, HKSAR Retrieved from https://www.swd.gov.hk/storage/asset/section/616/en/List_of_self-financing_DE_(March_2019).pdf.
There is no organised, public service delivery system in India that specifically addresses long-term care needs. However, several governmental policies and programmes enshrine the principles and components of long-term care, outlining services for chronic illness, injury, disability, and aging. Some examples include the National Mental Health Programme (2017), which supports long-term treatment and rehabilitation for persons with mental illness and the National Programme for Palliative Care (2012), which outlines care for persons with terminal cancer and AIDS.
There are also governmental initiatives targeted for the welfare of older individuals. The National Policy for Older Persons, formulated in 1999, affirms the government’s commitment to the well-being of older persons, and outlines the responsibilities of the family and the State in providing care for the elderly. The goals set out in the policy are operationalised through several programmes and schemes. For instance, the Integrated Programme for Older Persons (IPOP) initiated by the Ministry of Social Justice and Empowerment (MSJE) in 1992, and revised in 2018, offers financial support to governmental and non-governmental organisations providing basic services (food, shelter and healthcare) and institutional and non-institutional care for older persons, encouraging active and productive aging, and engaging in activities including research and advocacy (Ministry of Social Justice and Empowerment (MSJE), 2016; 2018a). In addition, the National Programme for Healthcare of the Elderly (Ministry of Health and Family Welfare (MoHFW), 2011), launched in 2010, aims to provide long-term, comprehensive, and dedicated care services to older people in ways that are affordable and accessible. This programme lists out strategies for preventive, promotive, curative and rehabilitative healthcare for older people, through its integration with the public healthcare systems at primary and secondary levels, as well as the setting up of specialized geriatric medical services at tertiary levels. More recently, the government has re-affirmed its commitment to senior citizens by announcing the implementation of an umbrella scheme known as Atal Vayo Abhyudaya Yojana (AVYAY) (MSJE, 2022). This scheme converges some existing schemes and programmes such as the Rashtriya Vayoshri Yojana (MSJE, 2022).
The limited long-term care services provided by the public health care system include nursing homes and other residential care facilities, day-care centres, and geriatric care in selected public hospitals (Ponnuswami & Rajasekaran, 2017; Sharma & Marwah, 2017). However, as in many developing countries, much of the long-term care mechanisms in India are institutionalised under the healthcare system, with its limited resources and functional capacities (UNESCAP, 2016). For instance, in psychiatric hospitals across the country, many “long-stay” patients are abandoned by families unable to care for them. With the absence of State-run long-term care facilities, hospitals play a custodial role for such patients (Daund et al., 2018). A survey of 43 mental hospitals across India, reported that over 36% of patients had been residing in the facilities for a year or longer, with a large number spending over 25 years in the hospital (Narasimhan, et al., 2019).
In the context of a limited number of long-term care facilities, and healthcare systems struggling to fill this gap, long-term care for older persons is mostly provided by the family. Sociocultural norms and traditions dictate family care for older persons, and the State enforces it by law (United Nations Department of Economic and Social Affairs, 2015). The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 (Ministry of Law and Justice, 2007) defines the obligation of children and relatives in the maintenance of the older person, including the provision of food, clothing, residence, and medical attendance and treatment. According to this law, abandonment or failure to provide for a parent or older person is punishable by fine and imprisonment. Therefore, much of the long-term care in India is provided through unpaid care work by family members (UNESCAP, 2016).
A recent review suggested that a home-care model has several advantages to a hospital-based or nursing home-based model of care in India, as it is less expensive and more attractive to the service users, reducing inappropriate admissions, improving quality of life, and decreasing dependence on resources (Goel & Ramavat, 2018). However, the mere presence of home carers does not assure quality of care and must be supplemented with state-sponsored, integrated health care services to help older people and their carers, and ensure continuity of care (Bhattacharya & Chatterjee, 2017).
Care for older persons is primarily provided by the extended family. Institutional and state support are considered as alternatives for persons in exceptional circumstances such as when they are chronically/terminally ill, bed-bound, or without family support, and under the National Policy on Older Persons (NPOP). Public hospitals carry primary responsibility of care for such persons, with assistance from public charities and voluntary organisations (UNESCAP, 2016).
Traditionally, old age homes were meant for the poor and were mostly run by charities, but more recently, paid services have emerged to cater to older persons from the upper and middle class, who can afford them (Datta, 2017). There is also significant variability in the availability of services across the country due to inter-state differences in demographic characteristics, availability of eldercare infrastructure, and other contexts (Bhattacharya & Chatterjee, 2017).
The central (federal) government relies on the state governments to implement its policies and programmes for the welfare of older people. Programmes such as the National Programme for Health Care for the Elderly (NPHCE), while being novel and comprehensive, have been criticised for failing to consider regional disparities that could possibly impede implementation (Verma & Khanna, 2013). While most states have begun implementing the policies with enthusiasm, the measures adopted, and the standards of implementation are not uniform. Indeed, some states are yet to begin implementation due to financial and operational difficulties (United Nations Population Fund, 2017)
Moreover, UNESCAP (2016) lists other potential barriers to long-term care. Public and private hospitals are not equipped to provide long-term care. The private sector does not encourage patients with long standing illness or functional decline, especially in old age homes. The management tends to request the family/next of kin to withdraw from the service as they are ill-equipped and not trained to provide care for severe health conditions. The Indian health care system lacks financial mechanisms to support long-term care. Most of the hospices available are cancer-oriented which lack expertise to care for people with other illnesses.
Bhattacharya, T. and Chatterjee, S. C. (2017). Exploring elder care in different settings in West Bengal: a psycho-social study of private homes, hospitals and long-term care facilities. International Journal of Psychological & Behavioural Sciences, 11(6), 1639-44
Datta A. (2017) Old Age Homes in India: Sharing the Burden of Elderly Care with the Family. In: Irudaya Rajan S., Balagopal G. (eds) Elderly Care in India. Springer, Singapore
Daund, M., Sonavane, S., Shrivastava, A., Desousa, A., & Kumawat, S. (2018). Mental Hospitals in India: Reforms for the future. Indian Journal of Psychiatry, 60(Suppl 2), S239.
Goel, A. & Ramavat, A. S. (2018). Absence of a formal long-term healthcare system for a rapidly ageing population is likely to create a crisis situation in the near future. Natl Med J India, 31, 1034.
Khurana, M. (2013). COVER STORY: Reaching the Unreached in Uttarakhand Donations to HelpAge India for Uttarakhand Flood Relief are eligible for 50% tax exemption under section 80G of Income Tax Act 1961. (Applicable in India only) (Vol. 12).
Kumar, P., Das, A., & Rautela, U. (2012). Mental and Physical Morbidity in Oldage Homes of Lucknow, India. DELHI PSYCHIATRY JOURNAL.
Ministry Of Health And Family Welfare (MHFW). (2011). OPERATIONAL GUIDELINES National Programme For Health Care Of The Elderly (NPHCE). Available from https://main.mohfw.gov.in/organisation/Departments-of-Health-and-Family-Welfare/national-programme-health-care-elderly-nphce
Ministry of Law and Justice. (2007). Maintenance and welfare of parents and senior citizens Act. Government of India.
Ministry of Social Justice & Empowerment (MSJE). (2018a). Integrated Programme for Senior Citizens. New Delhi. Government of India. Available from: http://socialjustice.nic.in/writereaddata/UploadFile/IPSrC%20English%20version.pdf
Ministry of Social Justice and Empowerment (MSJE). (2016). INTEGRATED PROGRAMME FOR OLDERPERSONS A Central Sector Scheme to improve the quality of life of the Older Persons. New Delhi . Available from: http://socialjustice.nic.in/writereaddata/UploadFile/IPOP%202016%20pdf%20document.pdf
Ministry of Social Justice and Empowerment (MSJE). (2022). Scheme for Welfare of Senior Citiizens. Press Information Bureau. Available from: https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1806506
Ministry of Statistics and Programme Implementation (2016). Elderly in India – Profile and Programmes 2016 New Delhi Central Statistics Office, Government of India:26–9
Narasimhan, L., Mehta, SM., Ram, K., Gangadhar, B.N., Thirthalli, J., Thanapal, S., Desai, N., Gajendragad, J., Yannawar, P., Goswami, M., Sharma, C., Ray, R., Talapatra, S., Chauhan, A., Bhatt, D., Neuville, E., Kumar, KVK., Parasuraman, S., Gopikumar, V. and NILMH Collaborators Group. (2019). National Strategy for Inclusive and Community Based Living for Persons with Mental Health Issues. The Hans Foundation: New Delhi
National Mental Health Programme. (2017). The Mental Health Care Act. Available from: https://www.nhp.gov.in/national-mental-health-programme_pg
Ponnuswami, I., & Rajasekaran, R. (2017). Long-term care of older persons in India: Learning to deal with challenges. International Journal on Ageing in Developing Countries (Vol. 2). Available from: https://www.inia.org.mt/wp-content/uploads/2017/09/2.1-8-India-59-to-71-1-rev-RFB.pdf
Sharma, R. & Marwah, E. B. (2017). Rising demand for community based long-term care services for senior citizens in India. Indian Journal of Gerontology, 31 (4), 519-528.
UNESCAP. (2016). Long-term Care of Older Persons in India. Working Paper Ageing Long Term Care India v1-2.
United Nations Department of Economic and Social Affairs. (2015). GROWING NEED FOR LONG-TERM CARE. Available from: https://www.un.org/esa/socdev/ageing/documents/un-ageing_briefing-paper_Long-term-care.pdf
United Nations Population Fund. (2017). ‘Caring for Our Elders: Early Responses’ – India Ageing Report – 2017. UNFPA, New Delhi, India
Verma, R., & Khanna, P. (2013). National program of health-care for the elderly in India: A hope for healthy ageing. International Journal of Preventive Medicine, 4(10), 1103–1107. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24319548
Indonesia is in the process of developing a public Long-Term Care (LTC) system. Policies developed under the umbrella of long-term care fall into services that would commonly be identified as social security mechanisms (i.e. old age pensions), and services that fall under the realm of health care (i.e. services and interventions to delay or reduce the number of people with long-term care needs), while other care services (i.e. day care, respite care, institutional care) are limited in availability (UNESCAP, 2014, p.12). BAPPENAS describes this split between health care and social security mechanisms as the provision of financial (social security) and non-financial (health care, long-term care, and legal protection) (Kementrian Koordinator Bidang Pembangunan Manusia dan Kebudayaan RI, 2020).
The core features of the Indonesian long-term care system are based on the Puskesmas (community health centres providing primary health care services) and Posyandu (integrated community health service posts that focus on preventive health services provided by midwives, nurse assistants, vaccinators, and health volunteers who visit communities monthly) system. Both types of services fall under the regulation of local governments (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014). In 2009, the Ministry of Health and the Ministry of Home Affairs declared the Puskesmas Santuan Lansia to be the first-line providers of health and long-term care for older people. Furthermore, between 2018-2019, the Ministry of Health has issued a LTC guideline for the Puskesmas (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018) that provide directions on the implementation of LTC in Puskesmas.
Even though the Ministry of Health and the Ministry of Home Affairs already in 2009 declared the Puskesmas Santuan Lansia to the core service provider for older people, insufficient support from provinces and cities meant that only around 42.3% of Puskesmas were able to implement the concept by 2011 (Badan Litbangkes Kementrian Kesehatan RI, 2012). Furthermore, it has been reported that there is a shortage in services provided through Puskesmas in the East of the country and in more rural regions due to concerns about workforce availability and quality (Kadar et al., 2013). Shortages could also be found in the provision of Posyandu Lansia services. The Ministry of Health stated that in 18 out of 34 provinces there were no Posyandu Lansia services available, and 11 provinces did not provide health services through the Puskesmas Ramah Lansia (Pusat Data dan Informasi Kementerian Kesehatan RI, 2017).
Ministry of Health Data (from December 2018) states that there were Puskesmas and Posyandu Lansia available in all provinces (Kementerian Kesehatan Republik Indonesia, 2019a). However, a study from 2018 suggests that there are varying levels of functioning among posyandu lansia across provinces (Pratono & Maharani, 2018). There is anecdotal evidence from the cities Malang and Surabaya about the lack of regular services, volunteers, and health workers, which suggests limited interest and commitment by the community members in the posyandu lansia. Posyandu lansia also sometimes charge additional transaction costs although services are supposed to be free. Based on data from the Program Report of the Directorate of Family Health (2017), there were 3,645 Puskesmas that provided santun lansia services (Kementerian Kesehatan Republik Indonesia, 2018).
Lack of coordination on national level, public underfunding, and high out-of-pocket expenditure are creating barriers to accessibility and availability of services for older people in Indonesia, where the government allocated only about 0.1 per cent of GDP (2006-2010) to long-term care (Rahardjo & Yerly, 2014; Scheil-Adlung, 2015, p.xi). The report further elaborates, that in Indonesia, as of 2015, 87.3% of the population aged 65 and older were excluded from accessing LTC services because of financial resource deficits (Threshold, 1.451.8 PPP$) (Scheil-Adlung, 2015, p.83).
Regulations and bills
Between 2009 and 2018 nine regulations and bills have been activated under the umbrella of long-term care to support older people with care needs.
In addition, the provision of long-term care to older people was included in the National Medium-term Development Plan 2015-2019 and is expected to also be included in the consecutive long-term development plan. Responsibility for LTC policy was given to the National Commission for Older People, which was established in 2004 (UNESCAP, 2014).
Badan Litbangkes Kementrian Kesehatan RI. (2012). Ringkasan Hasil Riset Fasilitas Kesehatan (Rifaskes) 2011.
Kadar, K. S., Francis, K., & Sellick, K. (2013). Ageing in Indonesia – Health Status and Challenges for the Future. Ageing International, 38(4), 261–270. https://doi.org/10.1007/s12126-012-9159-y
Kementerian Kesehatan Republik Indonesia. (2018). Provil Kesehatan Indonesia 2017 (Vol. 1227, Issue July). https://doi.org/10.1002/qj
Kementerian Kesehatan Republik Indonesia. (2019a). Data Dasar Puskesmas.
Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.
Kementrian Koordinator Bidang Pembangunan Manusia dan Kebudayaan RI. (2020). Tanggapan Terkait White Paper “Pemenuhan hak-hak lansia untuk hidup setara, sejahtera dan bermartabat.” Presentasi.
Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732
Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).
Pusat Data dan Informasi Kementerian Kesehatan RI. (2017). Analisis Lansia di Indonesia.
Rahardjo, T. B. W., & Yerly, A. N. (2014). A trend for establishing community care system in Indonesia. Forum on Conception of Harmonization of Long Term Care Certificate Between Japan and Indonesia.
Scheil-Adlung, X. (2015). Long-term care protection for older persons: A review of coverage deficits in 46 countries. In Extension of Social Security (Issue 50). http://www.ilo.org/wcmsp5/groups/public/—ed_protect/—soc_sec/documents/publication/wcms_407620.pdf
UNESCAP. (2014). Report of the Regional Expert Consultation on Long-term Care of Older Persons. https://www.unescap.org/sites/default/files/Report%20Reg-Consultation.pdf
At the launch of the NHIP Green Paper (2019), the Minister of Health and Wellness, the Hon. Dr Christopher Tufton, addressed the question of whether long-term care services were being considered as a benefit under the national health insurance scheme. While the finalisation of particular services that will be covered by this scheme are yet to be determined following upcoming stakeholder consultations and may include not only long-term care facilities, but also services to support in-home care, Minister Tufton noted that the public health system is currently piloting a private-public partnership with private care homes for a residual system to address ‘social cases’ of persons who are abandoned at public hospitals by family members.
Later in 2019, this partnership was further elaborated on with the announcement of the Ministry of Health and Wellness’ decision to pursue legal action against families of the approximately 200 persons currently in hospital beds across Jamaica who should in fact be in an infirmary or released to their relatives, but their relatives have abandoned them, in some cases for as long as seven years. It is hoped that such court action will compel relatives to ‘take care of their own’ (Jamaica Gleaner, 2010). This challenge indicates the consequences of a lack of a public long-term care system in Jamaica that can adequately meet the needs of older persons.
The Jamaica Gleaner. (2010, November 10). Want to be caregiver | Lead Stories |. https://jamaica-gleaner.com/gleaner/20101109/lead/lead93.html
The Constitution of Kenya 2010, Article 57, mandates the state to take steps to make sure that the rights of older people are protected (Government of Kenya, 2010). Kenya’s Vision 2030 also aims to establish a Consolidated Social Protection Fund which is relevant to the care and protection of older persons through cash transfer programmes. Other vulnerable groups will also be a beneficiary to these funds (discussed under overall country context – social protection schemes) (Kenya vision 2030, 2019). The disbursement of funds to these groups is ongoing.
The care and protection of older members of society bill, 2018 part III provides for the care of older members of society, defined as those who have attained the age of 60 years. Specifically, it provides the establishment and implementation of community and home-based care programmes for older members by the government and prohibits their abuse (Republic of Kenya, 2018b).
At the moment, Kenya is developing a universal health coverage policy but older people have not been adequately factored into it (“Kenya Trends in ageing and health,” n.d.). The care of older people living with disabilities and chronic health problems is mainly undertaken by unpaid family members. Older people are expected to receive health care from public general hospitals, as there is only one geriatrician based in the national government (policy level) in Kenya. By 2017, 16 residential care homes that are run by religious organizations and mostly located in urban or peri-urban areas were unaffordable to family members. As a result, some homes become underutilized. For example, during a 2016 audit of residential institutions, the Fatima Home with a capacity of 20 persons had only housed three older persons (National Gender and Equality Commission, 2016). It is not clear from literature the current average bed capacity of residential homes in Kenya. In addition, so far no long-term care public insurance scheme is available in Kenya as of yet, limiting access to costly private health insurance to those who can afford it (L. Maina, 2017).
High levels of poverty, distantly located health facilities, poor attitude of health workers and a lack of confidence in the services provided in health facilities are some of the factors deterring older persons from accessing services in public health care settings (Waweru et al., 2003). Furthermore, older people are expected to receive the same public health services provided for all life cohorts, there are no specific arrangements in place for older people. This has resulted to increase in confidence in spiritual care (Waweru et al., 2003). In future, strategic attention should be paid to geriatric health requirements or the ability to tackle one or more chronic illnesses at health facilities (Wairiuko et al., 2017).
The Focus Area of The IX Session of the Open-Ended Working Group on Ageing, established by the General Assembly on 21st December, 2010 for the purpose of strengthening the protection of the human rights of older persons identified the following challenges facing older people in accessing Long Term Care (Republic of Kenya, 2016b), page 3-4:
- “Prohibitive medical costs and limited Human Resource and health center capacities” – page 3
- “Communities and family members have very little (indigenous) knowledge on how to manage long-term care” – page 3
- “Facilities available do not meet the required standards” – page 3.
- “The private institutions are very expensive to be afforded by many” – page 3.
- “High costs of diagnostic, medication and transport costs to access LTC services” – page 3
- “Assistive devices are expensive, should one need one” – page 3.
- “There are few formal centers offering long term care. Most of them depend on the social systems i.e., relatives for long term care” – page 3.
- “Non-existence of a regulatory or policy framework on long term care system”- page 3.
- “Ageism that results to stigmatization and discrimination of older people by society and policy makers” – page 3.
- “Lack of adequate resources hinder the provision for long term care and support” – page 3.
- “Lack of information and understanding on LTC and wider rights of older people by the older people themselves, community and policy makers. Manifested in lack of demand for action by the citizens and older people, which is necessary to improving the policy and programmatic change” – page 4.
The working group, considers the existing international framework for the human rights of older persons and identifies possible gaps and solutions (United Nations Department of Economic and Social Affairs (UNDESA), 2019).
Government of Kenya. (2010). The Kenya Constitution, 2010. Kenya Law Reports. http://www.kenyalaw.org/lex/actview.xql?actid=Const2010
Kenya vision 2030. (2019). Consolidated Social Protection Fund. https://vision2030.go.ke/project/consolidated-social-protection-fund/#
Maina, L. (2017). How Kenya can ensure adequate health care for its older people. The Conversation, 25 January. https://theconversation.com/how-kenya-can-ensure-adequate-health-care-for-its-older-people-70163
National Gender and Equality Commission. (2016). Audit of Residential Institutions of Older Members of Society in Selected Counties of Kenya. Nairobi, Kenya. https://www.ngeckenya.org/Downloads/Audit%20of%20Residential%20Homes%20for%20Older%20Persons%20in%20Kenya.pdf
Republic of Kenya. (2016b). Focus Area of the IX Session of the Open-Ended Working Group on Ageing. Republic of Kenya. Nairobi, Kenya. https://social.un.org/ageing-working-group/documents/ninth/Inputs%20Member%20States/Kenya_LTC.pdf
Republic of Kenya. (2018b, June). The Care and Protection of Older Members of Society Bill, 2018. Kenya Gazette Supplement No. 73 (Senate Bills No. 17), pp. 333–363. Nairobi, Kenya. http://www.parliament.go.ke/sites/default/files/2018-08/The%20Care%20and%20Protection%20of%20Older%20Members%20of%20Society%20Bill%2C%202018.pdf
United Nations Department of Economic and Social Affairs (UNDESA). (2019). Open-ended Working Group on Ageing for the purpose of strengthening the protection of the human rights of older persons.
Wairiuko, J. M., Cheboi, S. K., Ochieng, G. O., & Oyore, J. P. (2017). Access to Healthcare Services in Informal Settlement: Perspective of the Elderly in Kibera Slum Nairobi-Kenya. Annals of Medical and Health Sciences Research, 7(1), 5–9. https://www.amhsr.org/articles/access-to-healthcare-services-in-informal-settlement-perspective-of-the-elderly-in-kibera-slum-nairobikenya.html
Waweru, L. M., Kabiru, E. W., Mbithi, J. N., & Some, E. S. (2003). Health status and health seeking behaviour of the elderly persons in Dagoretti division, Nairobi. East African Medical Journal, 80(2), 63–67. https://doi.org/10.4314/eamj.v80i2.8647
In Mexico, strategies for dependent or disabled people are practically inexistent. The country does not have a publicly funded long-term care system at national level nor specific public services that provide care for people with loss of functional ability/capacity (disabled); and, as it will be described below, Mexico only offers very few day-centre services for older adults.
Regarding care legislation, there are no specific laws that guarantee the right to receive care, regardless of the age group or condition for which care is needed, or that give the health and social security system responsibility to provide them. Thus, there is a clear lack of public programs at the national/federal level that aim at providing care services for those with care needs, nor for their carers. On the other hand, strategies have been developed to address aging and disability that seek to influence the well-being of these population groups, encourage their participation, and maintain or recover their independence, but without intending to guarantee or provide care to these groups of the population.
While at national level no long-term care system is in place, there are different working groups collaborating towards the generation of a National Care System. Two main groups are working together, one led by the National Institute for Women (INMUJERES) focused mainly on a gender equity perspective. A second one within the health system is led by the General Health Council, CSG (Consejo de Salubridad General) at the Ministry of Health and the National Institute of Geriatrics (INGER) and focuses on attending care needs of people with disabilities and their carers. The work led by INMUJERES has recently focused on generating an analysis of care needs whilst targeting three groups: infants, people with disabilities, and older adults. Their aim is to raise awareness on the need to establish care as a right in local legislations as well as to identify current public programmes where new strategies could be included to generate a National Care System. On the other hand, in some forums (but still not in official communications), other institutions like the Social Security Institute IMSS, have presented their efforts towards generating care services for their affiliates, particularly older adults and people with disabilities.
After slightly more than a year of meetings with representatives from all the institutions/sub-systems that form the National Health System within the CSG-INGER collaboration, an agreement was achieved at the national level to define, design, and implement long-term care health policies within the National Health System and health and social security institutions. This agreement was published in the National Official Gazette in August 2018.
At the moment, both groups are joining efforts and exploring future pathways to generate one system where the health and social development work together. In 2016, Mexico City, changed its administrative status from a Federal District to a Federal Entity (state) at the local level. This changes its legal and administrative rights and obligations within the Federal Republic.
As part of these changes, Mexico City has now its own stale-level approved Constitution since 2017. This represents the first to include the right to care in the country (Article 9, Item B). As for now, the specific policies and programmes that will be implemented are in the planning stage and will constitute the first universal (within the City) and publicly funded programs to support those who need care and their carers.
At the moment, there are only two strategies, one at the Mexican Institute of Social Security (IMSS) and one from Mexico City’s Health Secretariat that provide domiciliary services for people with functional disabilities. First, the IMSS Chronic Patient Care Program which began in 1990, aims at providing follow-up medical care after hospital discharge and/or palliative care for patients in terminal stages (Espinel-Bermúdez et al., 2011). According to the IMSS’ reports, the main conditions treated are chronic degenerative diseases and their sequelae, such as cerebral vascular type, chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney failure, Alzheimer’s disease, and terminal cancer conditions.
Secondly, in Mexico City, the program ‘The Doctor in your House’ (Medico en tu Casa), has been in place since 2016. The main goal of the program is to provide ambulatory care by multidisciplinary staff, to all vulnerable individuals who, due to their disease condition or disability, cannot attend medical services. However, under the new federal government administration, this program is being modified and its specific attributions and scope is still unknown.
The absence of a public long-term care system, of a national level regulation agency and the lack of a national mandatory registry of institutions in Mexico has generated an absence of precise information on the total number of public or private permanent and temporary care institutions available in the country. As a result, in order to gather information on such institutions, there are few sources that can be consulted; however, data can be over or underestimated. Some of these sources are described below within the public and private services subheadings in items 03.01.03 and 03.01.04.
 Diario Oficial de la Federación ACUERDO por el que se establecen las acciones para el diseño e implementación de la política pública en salud para el otorgamiento de cuidados a largo plazo por las instituciones públicas del Sistema Nacional de Salud, published on 2 August 2018. [https://www.dof.gob.mx/nota_detalle.php?codigo=5533729&fecha=02/08/2018 ]
 Constitución Política de la Ciudad de México, p. Article 9, Item B. Right to care: Every person has the right to the care that sustains his life and gives him the elements material and symbolic to live in society throughout his life. The authorities will establish a care system that provides public services universal, accessible, relevant, sufficient and quality and develop policies public. The system will give priority attention to people in situation of dependency due to illness, disability, life cycle, especially childhood and old age and those who, in an unpaid way, are in charge of their care.
Espinel-Bermúdez M.C., Sánchez-García, S., Juárez-Cedillo, T., García-González, J.J., Viveros-Pérez, A., & García-Peña C. (2011). Impacto de un programa de atención domiciliaria al enfermo crónico en ancianos: calidad de vida y reingresos hospitalarios. Salud Publica Mex , 53, 17–25. https://www.redalyc.org/pdf/106/10619407004.pdf
New Zealand has a public long term care system, coordinated by the Needs Assessment Service Coordination (NASC) agency, which is contracted by the MoH Disability Support Services unit to allocate ministry funded disability support services and to provide assistance with access to other supports (NASC, n.d.). This is a universal service available to all NZ citizens or residents who qualify for publicly funded health services.
Every person who wishes to receive funded disability support services must have a needs assessment to assess their requirements and this is prioritised based on need. The NASC role is to work with individuals and their families to identify their support needs, outline what services are available, and determine their eligibility for publicly funded support services. Any help received from existing supports such as other family members is taken into account during the assessment. Some services such as household support are means tested, but others including “personal cares” (e.g., assistance with showering, dressing, medications) are not.
Ministry of Health. (2011). Needs Assessment and Support Services for Older People: What you need to know. Available from: https://www.health.govt.nz/system/files/documents/publications/support-services-older-plev2.pdf.
Needs assessment Service Coordination (NASC). (n.d.). Needs assessment Service Coordination services (website). Available from: https://www.health.govt.nz/your-health/services-and-support/disability-services/getting-support-disability/needs-assessment-and-service-coordination-services
Yes. South Africa provides old-age pensions to individuals who are financially needy (WHO, 2017). All older persons are entitled to free primary healthcare, while access to hospital care is only free for those who do not have the means to pay for these services – including long term care services such as residential care services. Long-term care in South Africa reflects the legacy of Apartheid whereby availability and access to residential care services (usually in the more affluent, urban areas) cater primarily for the older white population, while promoting family care for black South Africans and positioning care for the older persons as primarily a family responsibility (Lloyd-Sherlock, 2019a).
Long-term care services in South Africa are characterised with much variation in services available between the public and private sector. The South African government funds public long-term care for older persons, for which the majority of care is through residential facilities (WHO, 2017). Public services cater only for a small portion of the older population and are largely confined to urban areas (WHO, 2017). Persons who seek residential care, need to undergo a rigorous assessment process in which only those eligible will be admitted (i.e., frail and destitute). Demand for these services is beyond what the public sector can cater for and long waiting lists are significant barriers for eligible individuals accessing long-term care (WHO, 2017). Private care limits access to services for those who can afford it, and as a typical feature of the private sector in South Africa, it is expensive and inaccessible to most South Africans. Another barrier refers to the lack of training among nurses at primary healthcare level that undermines an integrated health and social care system for older persons, especially in rural areas (Lloyd-Sherlock, 2019a).
All registered facilities can apply for subsidies for individual residents, with eligibility restricted to the frail and destitute (South African Government, 2019). Reductions in subsidy amounts paid out by the Department of Social Development have in itself become a barrier to care as they have led facilities to fail to provide services for the poor and frail individuals (who are eligible), while opting to admit more wealthier persons (who are able and can pay themselves) (Lloyd-Sherlock, 2019a). Currently DSD subsidies cover 51.9% of costs of care for frail care, with non-profit organisations left to cover the remaining costs amounting to R3800 per person (TAFTA, 2019b).
Furthermore, historical racial discriminatory practices and cultural preferences in admissions restrict racial transformation and the care of all population groups at facilities. An audit of residential care homes in 2010 revealed that: (1) Only 4% of residents across 405 homes were black; (2) 10 homes physically separated residents between white and black with clear evidence that residents were not receiving the same standard quality of care; (3) in some instances family members threatened to remove older persons should homes be integrated; and (4) that there were evidence of very little sensitivity and knowledge displayed of different religions and cultural practices (e.g., language and food preferences) (Department of Social Development, 2010; Lloyd-Sherlock, 2019a; WHO, 2017).
Department of Social Development. (2010). Audit of Residential Facilities. April, 1–87. Available from: https://social.un.org/ageing-working-group/documents/FINAL%20REPORT%20DSD%20Audit%20of%20Residential%20Facilities%20April2010.pdf
Lloyd-Sherlock, P. (2019a). Long-term Care for Older People in South Africa: The Enduring Legacies of Apartheid and HIV/AIDS. Journal of Social Policy, 48(1), 147–167. https://doi.org/10.1017/S0047279418000326
South African Government. (2019). Old age pension. 1–7. http://www.services.gov.za/services/content/Home/ServicesForPeople/Socialbenefits/oldagegrant/en_ZA#Cost
TAFTA. (2019b). The Care “Gap.” https://www.gov.za/services/retirement-and-old-age/admission-older-persons-residential-facilities
WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care on healthy ageing. Available from: https://www.who.int/publications/i/item/9789241513388