In the absence of a unified LTC system in Brazil, LTC services are provided through health and social care systems separately, and in a few instances, jointly. These are mostly delivered through the Family Health Strategy (FHS). For example, those who are bed bound may receive home visits from healthcare professionals and community health workers routinely. LTC may also be provided via high and medium complexity home care services through the program “It is better at Home” (Melhor em Casa). Those who are registered with this service have continuous support from the care home teams via routine appointments and via telephone if needed. Services offered to older people should follow the guidance stated in a document that establishes an integrated care pathway for older people in the SUS (Brazilian Ministry of Health, 2018e, 2019d, 2019h).

As part of SUS, people living with disabilities should receive integrated healthcare such as rehabilitation, basic and complex treatments, etc. (Brazilian Ministry of Health, 2019q). SUAS provides LTC within long-term institutions for people aged 60 years and over who are independent, or who have some degree of dependence, who do not have the means to live in a family environment, in their own home, or who have suffered abuse, violence, negligence, or abandonment. However, moving to those institutions are considered by the government a measure of last resort and the number of bed available are very limited (Brazilian Ministry of Citizenship, 2015).

The SUAS also provides the “Special Social Protection Service for Disadvantaged People, Older People, and their Families” (Serviço de Proteção Social Especial para Pessoas com Deficiência, Idosas e suas Famílias). This service aims to help older people with some degree of dependence, people living with disabilities, their carers, and those who have suffered violation of their rights (for example: lack of proper care from their carers, discrimination from family members, high level of stress from the carer etc.). The service aims to identify the needs of the older persons and their carers and make it feasible for them to access cash transference programmes, cultural and leisure activities, and public policy services. The service is offered by professionals and may be delivered in patients’ homes, day centres, Special Reference Centre for Social Assistance (CREAS) or Referenced Units. The service can be accessed following spontaneous demand or by referral from other social-assistance services (Brazilian Ministry of Citizenship, 2014). We could not identify data on the proportion of the population uses the public long-term care system. However, it is known that in 2014, 53,600 older people were living in long-stay institutions affiliated to SUAS (Alcantara et al., 2016).

In Brazil, very often family members are the main providers of care (unpaid care). However, private options such as paid carers, day care centres (getting quite popular in the last years) and long-stay institutions (the most traditional model of long-term care in Brazil, after the provision of care by family members) are available in the country (Alcantara et al., 2016). Data about the size of the private sector could not be found. However, according to data from the Institute for Applied Economic Research (IPEA), in 2017 there were 2,163 long-stay institutions in Brazil (33% were philanthropic, 64% were private and 0.03% were public/mixed) (Camarano, 2017). There are differences in the characteristics of people using public and private institutional long-term care. While some older people live in public long-stay institutions usually because of lack of financial and family support, older people with better financial resources are institutionalized in private institutions mainly when they present more severe health situation (Camarano, 2017).

References:

Alcantara, A. de O., Camarano, A. A., & Giacomin, K. C. (2016). Política Nacional do Idoso: Velhas e Novas Questões. http://repositorio.ipea.gov.br/bitstream/11058/9146/1/Institui%C3%A7%C3%B5es%20de%20longa%20perman%C3%AAncia.pdf

Brazilian Ministry of Health. (2018e). Orientações Técnicas para a Implementação de Linha de Cuidado para Atenção integral à Saúde da Pessoa Idosa no Sistema Único de Saúde—SUS. Ministério da Saúde do Brasil.

Brazilian Ministry of Health. (2019d). Estratégia Saúde da Família (ESF).

Brazilian Ministry of Health. (2019h). Programa Melhor em Casa.

Camarano, A. A. (2017). Cuidados para a população idosa: Demandas e perspectivas.

Public elderly services in Hong Kong are broadly divided into Community Care Services and Residential Care Services. Community Care and Support Services are provided by 41 District Elderly Community Centres (DECC), 169 Neighbourhood Elderly Centres (NEC), 60 teams of Integrated Home Care Services (IHCS), 34 teams of Enhanced Home and Community Care Services (EHCCS) and 77 units of Day Care Centre/Unit for the Elderly (DE/DCU). Only IHCS for frail cases, EHCCS and DE/DCU are categorised under LTC services. Residential Care Services consist of two types of residential care homes, namely, Care-and-Attention (C&A) Home and Nursing Home (NH). As of  31^st of December 2019, there are 28,160 subsidised residential places (37% of total residential places) (Social Welfare Department, 2019c).

Both the needs for community and residential care services generally increase with age. In 2015, 70.3% of Community Care Services users and 79.4% of Residential Care Services users are aged 80 and over (Working Group on Elderly Services Programme Plan, 2017).

In 2016, it was estimated that the demand for subsidised LTC services was 59,572 places, yet, there was only 37,957 places available. It was also projected that the demand for subsidised LTC services will increase to 77,989 places in 2030 and reaching a peak of 124,609 places in 2051. With the rapid increase in the ageing population, together with the decrease in capacity of family carers in the coming decades, there will be a severe upward pressure on the demand for LTC services, especially for Residential Care Services (Working Group on Elderly Services Programme Plan, 2017). On the 31^st December 2019, a total of 10,573 applicants had been on the waiting list for subsidised community care services with the average waiting time of 14-15 months (Social Welfare Department, 2020f), and 41,011 applicants for residential care services with the average waiting time of 20-22 months (Social Welfare Department, 2020j).

The Social Welfare Department also launched the Pilot Residential Care Services Scheme in Guangdong, a nearby province in the mainland China, which gives elderly persons the opportunity to chose to live in the subsidised residential care homes for the elderly (RCHEs) in Shenzhen and Zhaoqing, both operated by two Hong Kong-based NGOs (Social Welfare Department, 2019, September 30).

References:

Social Welfare Department. (2019, September 30). Pilot Residential Care Services Scheme in Guangdong. Retrieved from https://www.swd.gov.hk/en/index/site_pubsvc/page_elderly/sub_residentia/id_guangdong/

Social Welfare Department. (2019c). Provision of Residential Care Services for the Elderly (Subsidised versus Non subsidised Places) as at 31.12.2019. Hong Kong: Social Welfare Department, HKSAR Retrieved from https://www.swd.gov.hk/storage/asset/section/632/en/Dec%202019/3.Provision_of_RCHEs_(Subsidised_versus_Non-subsidised_Places)(31.12.19).pdf.

Social Welfare Department. (2020f). LTC Statistics CCS-Eng (Dec_2019).  Retrieved from https://www.swd.gov.hk/storage/asset/section/2789/en/LTC_Statistics_CCS(Eng)(Dec_2019).pdf.

Social Welfare Department. (2020j). Statistics on waiting list for subsidised residential care services for the elderly (Dec 2019).  Retrieved from https://www.swd.gov.hk/storage/asset/section/632/en/LTC_statistics_HP-Eng(201912).pdf.

Working Group on Elderly Services Programme Plan, Elderly Commission of Government of Hong Kong SAR,. (2017). Elderly Services Programme Plan. Hong Kong: Elderly Commission of Government HKSAR Retrieved from https://www.elderlycommission.gov.hk/en/download/library/ESPP_Final_Report_Eng.pdf.

Older persons receive services from both the public and private sector. The National Sample Survey shows an increase in private and non-governmental services for older people in both hospital-based and other long-term health care (UNESCAP, 2016).

Table 3.1. The following table summarises the programmes and schemes offering care for older persons.

Source:  (Borah et al., 2016); (MoHFW, 2016a, 2016b; National Mental Health Programme, 2017; Vikaspedia, n.d.; MSJE, 2018b, 2022).

According to a 2009 directory compiled by HelpAge India, there are 1,279 old age homes in India. Of these, 543 provide services free of cost, while 237 are on a pay & stay basis. Another 161 homes have both free as well as pay & stay facilities (HelpAge India, 2016). Additionally, 214 old age homes accept medical/constant care cases and 133 homes are exclusively for older women (HelpAge India, 2016). Despite growing numbers of care homes for older people, these services are largely unregulated, making it difficult to estimate the number of homes or the number of older persons covered by formal services. It has been reported that 62.1% of the ageing population do not have access to long-term or palliative care (Agewell Research & Advocacy Centre, 2018). According to a review by the International Labor Organisation, no persons in India have legal entitlement to long-term care (Scheil-Adlung & Xenia, 2015).

Gaps are observed in terms of coverage, accessibility, and quality care in the provision of services under the public sector, which results in health care costs to be borne largely by private households (UNESCAP, 2017). National data on the proportion of the population that makes use of these services is not available.

References:

Agewell Research & Advocacy Centre. (2018). Independence in old age – with special focus on long-term & palliative care in india. New Dehli. Available from: https://www.agewellfoundation.org/images/Independence-in-Old-Age-Long-term-n-Palliative-care-in-India-June-2018.pdf

Borah, H., Shukla, P., Jain, K., Kimar, S., Prakash, C., & Gajrana, K (2016). Elderly in India 2016. Ministry of Statistics and Programme Implementation, Government of India.

HelpAge India (2016). Senior Citizens Guide. HelpAge India. Available from: https://www.helpageindia.org/wp-content/uploads/2017/06/senior-citizens-guide-2016.pdf

Ministry of Health and Family Welfare. (2016a). Department of Health and Family Welfare. Available from: https://main.mohfw.gov.in/sites/default/files/8072971981455275414.pdf

Ministry of Health and Family Welfare. (2016b). National Programme for Health Care of the Elderly.

Ministry of Social Justice & Empowerment. (2018b). THE MAINTENANCE AND WELFARE OF PARENTS AND SENIOR CITIZENS. New Delhi.

Ministry of Social Justice and Empowerment (2022). Scheme for Welfare of Senior Citiizens. Press Information Bureau. Available from: https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1806506

National Mental Health Programme. (2017). The Mental Health Care Act. Available from: https://www.nhp.gov.in/national-mental-health-programme_pg

Scheil-Adlung, & Xenia. (2015). Long-term care protection for older persons : a review of coverage deficits in 46 countries. ILO Working Papers.

UNESCAP. (2016). Long-term Care of Older Persons in India. Available from: https://www.unescap.org/resources/long-term-care-older-persons-india

UNESCAP. (2017). Addressing the Challenges of Population Ageing in Asia and the Pacific. Available from: https://www.unescap.org/sites/default/files/publications/Addressing%20the%20Challenges%20of%20Population%20Ageing%20in%20Asia%20and%20the%20Pacific.pdf

Vikaspedia. (n.d.). National Social Assistance Programme. Ministry of Electronics and Information Technology. Government of India. Available from: https://vikaspedia.in/social-welfare/rural-poverty-alleviation-1/schemes/national-social-assistance-programme#:~:text=National%20Family%20Benefit%20Scheme%20(NFBS)%20%3A%20Rs.,the%20family%20eligible%20for%20assistance

The  government of Jamaica through the Ministry of Local Government and Community Development provides non-institutional as well as institutional care to adults and children. The Poor Relief Department (embedded in the Ministry of Local Government) was established to relieve poverty and destitution. Non-institutional care refers to Jamaicans who are able to care for themselves or receive assistance from others but  may be destitute and in need of temporary assistance. On the other hand, for institutional care, clients are wards of the state and receive care in infirmaries or golden age homes. As previously mentioned in part 2, the Poor Relief Department also provides provisions to give temporary assistance to all Jamaicans.

In terms of public institutional care, there are 16 infirmaries in Jamaica that provide care for the poor and destitute who are unable to take care of themselves due to mental or physical causes. The exact number of those who utilise this system is unclear. However, the Minister of Local Government, Desmond McKenzie reports that the infirmaries have over 2500 residents and workers such as nurses and community health workers (Jamaica Observer, 2020). In fact, the Minister recently asserted that 90% of its residents are over the age of 65 (JIS, 2020).

 References:

Jamaica Information Service (JIS). (2020). COVID-19 Digital Town Hall Meeting for Senior Citizens March 25, 2020. Available from: https://jis.gov.jm/videos/covid-19-digital-town-hall-for-senior-citizens-march-25-2020/

Jamaica Observer. (2020). Government limits access to infirmaries, golden age homes, May 14, 2020. Available from: https://www.jamaicaobserver.com/news/government-limits-access-to-infirmaries-golden-age-homes/

There are no public services specific for older people. Furthermore, most of the public health facilities accessible to the older persons do not have the appropriate services (Waweru et al., 2003). The basic inpatient and outpatient facilities are not sufficient to accommodate the long-term health needs of older persons (Wanja, 2016).

References:

Wanja, N. L. (2016). The viability of long term care insurance in Kenya. Strathmore University. https://su-plus.strathmore.edu/handle/11071/4475

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

There are some permanent LTC residences (care homes) for older people in the country. However, given that there is no single and mandatory public registry, except for a few publicly funded institutions, there is high uncertainty about the total number of institutions, the type of services they offer, their cost and the number of people who use them, as well as the quality of the services they provide and their impact on the well-being and quality of life of its residents. Some of the institutions are managed by public institutions and civil society organisations and there are also some homes ran by for profit organizations.

With respect to public services, in Mexico, it is important to note the differences between national-level public services (funded and provided by central budget and government) and those provided and financed at the local level, by the state or other municipal authorities.

Public institutions

With respect to national, centrally funded services, the National Institute for Older Adults (INAPAM), and the National System for the Development of the Family (DIF), both part of the federal level of government, have a total of ten institutions that provide permanent housing for older adults. INAPAM has six permanent housing/residential institutions (four in the Federal District, one in Guanajuato and another in Oaxaca) and DIF has 4 (two in Mexico City, one in the state of Morelos and one in the state of Oaxaca). Regarding the admission to these public institutions, priority is given to people in extreme conditions of vulnerability such as older people in situations of abandonment or without housing. Voluntary admission can be requested and there is usually a waiting list for the few places available. The services are offered at no charge or cost to the resident, and they generally provide accommodation, food, laundry services, cleaning, general medical care and referral to second or third level health services. They also offer support for the basic activities of daily life, as well as for recreational, sports, and cultural activities.

In addition, some municipalities (local public financing) have day centres (recreation mostly) for older adults. However, given the lack of a national level regulation agency and of a national mandatory registry of institutions, no precise information on the total number of public (or private) institutions is available. As a result, in order to gather information on institutions administered at the state level, there are few sources that can be consulted for information, and since different sources have to be consulted, consequently, data can be over or underestimated. The latest data from the National Statistical Directory of Economic Units, DENUE^[1] (Directorio Estadístico Nacional de Unidades Económicas) reports 819 permanent housing institutions for elderly individuals. Of these, 85% are private and not-for profit organisations and only 15% are publicly funded. The number of institutions per state shows important variations, with 6 states (Jalisco, Ciudad de México, Nuevo León, Chihuahua, Guanajuato, Michoacán, San Luis Potosí, Sonora,  and Yucatán) concentrating 64% of all institutions.

[1] The DENUE offers information on the identification, location and economic activity of the economic establishments currently in operation in the national territory and includes a category for “asylums and other residences for the care of the elderly” (INEGI 2011). It is a broad definition that includes permanent institutions and temporary stay institutions such as day centres. In the case of permanent housing institutions, it includes a wide variety of local used terms such as care homes, rest homes, retirement homes, long-stay for seniors, among others. It registers publicly and privately funded institutions as well as civil society organisations. Last access 5 July 2019 https://www.inegi.org.mx/app/mapa/denue/

Long-term care may be provided in an institutional setting or at home and may be formal, informal, or a combination of these. Much long-term care is provided informally by family members. The Government’s role may involve direct delivery of care services, the provision of respite services and carer support, or financial assistance.

Aged residential care

Aged residential care facilities are mostly owned by private firms and non-profit organisations. Providers operate within a fixed-price environment, with different fees for different levels of care, rest-home care being the lowest level. A resident’s contribution towards the cost of their care is capped at a maximum amount (unless they choose to purchase additional services). The maximum amount is based on the fixed price of rest home level care, regardless of the amount of care required. This covers a range of services, including accommodation and assistance with activities of daily living, food, laundry, nursing care, GP visits, and prescribed medication and healthcare. It does not cover spectacles, hearing aids, dental care, unfunded medical treatments, or personal items such as toiletries. Residents with assets over a threshold pay the cost of their care, up to the maximum amount. Their DHB pays for the additional cost of dementia, hospital, or psycho-geriatric care. Residents with assets below the threshold qualify for the residential care subsidy. People who fail the asset test because they own their own home may qualify for an interest-free Residential Care Loan. The loan is repayable when the home is sold or 12 months after the person’s death, whichever is earlier.

Home based support services:

Home-based support services for older people fall into two main categories: household management support, which provides help with activities such as housework and shopping, and personal care, which covers care needs, including assistance with showering and dressing. A person wishing to receive home-based support services funded by a DHB must first have their needs assessed by NASC. Personal care services are provided free regardless of a person’s financial position, while household management support is means tested and generally limited to people on low incomes holding a Community Services Card.

Disability Support Services

Disability Support Services for most people aged under 65 and their families, are centrally funded by the Ministry of Health. Services include home-based support, residential care, supports for carers in the home, and respite services. Provision of services is subject to a needs assessment carried out by NASC. Income and asset testing does not apply.

Long term care following injury

Long-term care needs resulting from accidents are dealt with by ACC through its National Serious Injury Service (NSIS).

Other support services:

Respite care services may be allocated as part of the service co-ordination process following a needs assessment and can take the form of residential respite in an aged care setting, or authorisation of a certain number of days of Carer Support Subsidy, or day care, including dementia day care. Where Carer Support Subsidy allocations are made, the older person requiring care, or the informal carer, makes their own arrangements for respite either in-home or in a residential care setting.

The Carer Support Subsidy is funded by a DHB to provide subsidised funding to assist informal (unpaid full-time) carers to take a break from their caregiving role. The Carer Support Subsidy contributes toward the cost of alternative care (e.g., in-home care, residential respite care, day care) for the client, for a specific number of days per year based on the assessed need (Ministry of Health, 2011; The Treasury, 2013; Ministry of Health, 2019).

All NASC assessments are carried out using the interRAI – a suite of clinical assessment instruments designed to comprehensively assess individuals’ abilities and functioning (Ministry of Health, 2018). For the 2019/2020 year, 13% females and 8% of males aged 65+ had at least one interRAI assessment completed. The median age for home care assessments was 83yrs and for long term care facilities (LTCF) was 85yrs. Those aged 85+ years accounted for almost half (47.5%) of all interRAI assessments.

Table 32 shows the proportion of the different types of interRAI assessments carried out and table 33 displays the proportion of each type by ethnicity. While the number of Māori and Pacific people getting any interRAI assessment approximates their proportion of the 65+ population, they are slightly over-represented in home-care assessments and under-represented in LTCF assessments (Table 32) (interRAI, n.d.).

Table 32: Proportion of interRAI assessments by type (interRAI, n.d.)

Table 33: Proportion of interRAI assessments by type and ethnicity (with proportion of 65+ population as a reference (Ministry of Health, 2018)

Long term care costs in NZ were estimated by Treasury in 2013 to be ~1.5% of GDP and accounted for ~18% of the health spend for the country (The Treasury, 2013). This expenditure is projected to rise as the population ages to 2.3% of GDP and 21% of health expenditure in the next 30 years.

References:

interRAI. (n.d.). Data visualisation. interRAI New Zealand website. Available from: https://www.interrai.co.nz/data-and-reporting/.

Ministry of Health. (2011). Needs Assessment and Support Services for Older People: What you need to know. Wellington Ministry of Health.

Ministry of Health. (2018). interRAI. Minstry of Health website. Available from: https://www.health.govt.nz/our-work/life-stages/health-older-people/needs-assessment/interrai#:~:text=interRAI%20is%20a%20suite%20of,and%20in%20aged%20residential%20care.

Ministry of Health. (2019). Long-term Residential Care for Older People: What you need to know (revised 2019). Wellington Ministry of Health.

The Treasury. (2013). Long term care and fiscal sustainability. New Zealand Treasury. Available from: https://treasury.govt.nz/sites/default/files/2013-07/ltfs-13-bg-lcfs.pdf.

There are an estimated 1150 residential care homes for older persons in South Africa, of which 415 are officially registered with the Department of Social Development (as mandated by the Older Person’s Act) (Mahomedy, 2017). Residential care is largely run by Non-profit organisations (NGOs) and Faith-based organisations (FBOs), and only 8 of these registered facilities are managed directly and fully subsidised by the State (Lloyd-Sherlock, 2019a; Mahomedy, 2017). All registered facilities can apply for subsidies for individual residents, and will only qualify for this financial support if the older person is frail and destitute, in need of full-time care, 60 years and older, and is a South African resident (South African Government, 2019). If the resident dies or leaves, that subsidy is lost. Reductions in the subsidy received from the Department of Social Development have led to facilities failing to provide services to poor, frail persons (who are eligible), while admitting more wealthier persons (who pay themselves) (Lloyd-Sherlock, 2019a).

There are about 4.6 million persons aged 60 years and older in South Africa. However, no data were found on the proportion of this population that is taken care of within the public long-term care system.

References:

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

Mahomedy, Y. (2017). Residential Facilities for Older Persons. Who Owns Whom: African Business Information.

South African Government. (2019). Old age pension. 1–7. Available from: https://www.gov.za/services/social-benefits-retirement-and-old-age/old-age-pension