DESK REVIEWS | 03.01.03. Public long-term care system

DESK REVIEW | 03.01.03. Public long-term care system

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.

 

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.

Name of the Scheme/ Programme Short description
The National Senior Citizen Health Scheme (Rashtriya Varishta Jan Swasthya Yojana; RVJSY)

(Ministry of Health and Family Welfare [MoHFW], 2016a)

The scheme includes support for home-based and telephone-based care, yoga therapy, screening for early diagnosis of health conditions (for those aged 75 years and older, information, education and communication activities and training for caregivers, among many other activities).
National Programme for Health Care of the Elderly (NPHCE)(MoHFW, 2016b)

 

The vision of the NPHCE is to provide accessible, affordable, dedicated and high-quality long-term, curative, and rehabilitative care services to an ageing population. It also promotes active and healthy ageing.

 

 

The Integrated Programme for Older Persons (IPOP) (Borah et al., 2016) Under this programme, the government proposes to provide financial support to homes for older persons, respite care homes and continuous care homes; the programme runs multi-service centres for older persons where it provides day care, educational and entertainment opportunities, health care and companionship; it maintains mobile medical units for older persons living in rural or isolated areas; it provides specialized care by running day care centres for Alzheimer’s disease and related disorders as well as multi-facility care centres for older widows, physiotherapy clinics and help lines and counselling centres for older persons.
The Rashtriya Vayoshri Yojana (MSJE, 2022). This scheme provides physical aids and assisted-living devices for senior citizens who are below the poverty line.
Maintenance and Welfare of Parents and Senior Citizens Act (MSJE, 2018b) This Act calls for responsibilities of the family and the state in providing care for older persons. Section 19 of the act envisages the provision of at least one old age home for indigent older persons, with a capacity of 150 persons, in every district of the country.
Indira Gandhi National Old Age Pension Scheme (IGNOAPS) (Vikaspedia, n.d.) A pension scheme for those below the poverty line. Provides a pension of Rs. 200-500/- per month to persons above 60 years.

 

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

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/