DESK REVIEWS | 03.01.04. Private long-term care sector
DESK REVIEW | 03.01.04. Private long-term care sector
The government implements the policies and programmes for the elderly in close collaboration with non-governmental and civil society organisations. The national policy envisages apex associations of older persons as a partner to the State. The All India Senior Citizens’ Confederation is one such organisation. Several NGOs are actively involved in planning as well as grassroots implementation to improve the quality of life of older persons. Some of them are also involved in providing long-term care components.
Table 3.2 shows private/ non-government organisations offering long-term care.
|Name of organisation||Services/programmes offered||Capacity of the services|
|Nightingale Medical Trust||Day care, institutional care and medical assistance to homebound older persons.||98 bed respite care, 48 bed Kolar, day-care catering to 50 people with dementia everyday (each in the Bangalore and Hyderabad chapters).|
|Apollo Group of Hospitals||Home care services, formal caregivers||No specific data available.|
|Alzheimer’s and Related Disorders Society of India (ARDSI)||Institutions and day carers.||22 active chapters across the country.|
|Max Group of Hospitals||Home health-care programme in Delhi.||No specific data available.|
|Sama Nursing Home in Delhi||Long-term medical and nursing interventions.||No specific data available.|
|NIKISA Dementia Village||Dementia village and Alzheimer’s Hospital.||A 50-bedded dementia speciality facility.|
Source: (UNESCAP, 2016; Nikisa Dementia Village, n.d.; Nightingales Medical Trust, n.d.)
Note: Please refer to Part 7 for a larger list of available services.
Most of the listed organisations, except ARDSI, come at a considerable cost and prioritise post-acute care over long-term care. Long-term care in the private sector is less affordable, and older patients are generally discharged from hospitals early, often before adequate recovery. The public sector and the non-profit institutes appear not to be under so much pressure to discharge patients, and this incentivises older patients to access these facilities if they are able to afford it (UNESCAP, 2016). Inadequate housing conditions, lack of financial support, and lack of skilled caregivers are other problems associated with private care homes (Bhattacharya & Chatterjee, 2017).
There are several other organizations involved in providing hospice and palliative care services for cancer. A great number of such centres are concentrated in the state of Kerala. In 2008, Kerala was the first state in India to launch a palliative care policy (Khosla, Patel and Sharma, 2012). CanSupport in Kerala (Gupta, 2004), the Guwahati Pain and Palliative Care Society (GPPCS) in Assam, Karunashraya Bangalore Hospice Trust, and the Chandigarh Palliative Care service provide comprehensive, home-based cancer care (Khosla, Patel and Sharma, 2012). Similar models of care for older persons have not been reported.
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. https://doi.org/10.5281/zenodo.1131896
Gupta, H. (2004). A journey from cancer to’CanSupport’. Indian Journal of Palliative Care, 10(1), 32.
Khosla, D., Patel, F. D., & Sharma, S. C. (2012). Palliative care in India: current progress and future needs. Indian Journal of Palliative Care, 18(3), 149–154.
Nightingales Medical Trust (n.d.). Home page. Available from: https://www.nightingaleseldercare.com/
Nikisa Dementia Villiage. (n.d). Home Page. Available from: https://carefordementia.in/
UNESCAP. (2016). Long-term Care of Older Persons in India. Available from: https://www.unescap.org/resources/long-term-care-older-persons-india
The Indonesian long-term care policy emphasises the care of older people on kekerabatan, which refers to care through a kinship system in multi-generational households and bases its support structure on this assumption (Setioko & Pandelaki, 2015, p.57; Rahardjo & Yerly, 2014). This may explain the limited number of LTC services, such as day care, respite care, institutional care services. The Indonesian family focused approach is not without problems, as migration patterns outlined previously show that larger family structures become fragmented when younger generations move for employment opportunities and the traditional family unit providing LTC may not always be a feasible and appropriate assumption.
According to the Ministry of Health’s Director of Mental Health Development, out of the 9,599 puskemas in the country, there are about 528 puskesmas across 231 cities equipped with “santun lansia”/geriatric-friendly facilities (not dementia-specific) that include ground-floor rooms, toilets suitable for older people, and prioritisations of older patients in registration and medicine dispensing (Herman, 2015).
The second important long-term care role was given to the Posyandus, however, in contrast to the Puskesmas no specific role was outlined in the National Strategic Plan for older people (No.25/2016) (Pratono & Maharani, 2018). This community service, which is run by midwives and volunteers, initially focused on family planning and maternal health (Posyandu Balita). In recent years, the community service received an optional second task: the provision of health ‘promoting and preventive’ services to senior citizens (Posyandu Lansia). These include regular basic health services as well as other community activities, such as taking a medical history, physical examination, assessing people’s ability to complete activities of daily living independently, basic laboratory tests as well as the provision of information on nutrition and some services may provide home visits, health promotion activities, legal and social aid, day care, and social activities as well as religious and mental spiritual services (Metkono et al., 2017; Pusat Data dan Informasi Kementerian Kesehatan RI, 2014; Rahardjo & Yerly, 2014; UPTD Puskesmas Kandangan, 2015).
According to regulation No. 7/2007 issued by the National Ministry of Home Affairs, each Posyandu should cover between 30 and 50 households and be run by five to 10 volunteers.
Some Posyandu Lansia may also provide home care services in the community, however, the level of service provision was reported to vary considerably between areas. According to Rahardjo and Yerly (2014), there are 70,000 Posyandu Lansia services available in Indonesia. Another source suggests that there are 52,450 Posyandu Lansia operating in the province of East Java, while ten provinces are reported (Aceh, West Sumatra, Bengkulu, Gorontalo, Riau Islands, Lampung, South Kalimantan, Southeast Sulawesi, West Sulawesi, West Nusa Tenggara, and Papua) to not have any (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014)
Placing the responsibility of the Posyandu Lansia services on midwives led to challenges of expertise versus the high expectations of the local community, where midwives without appropriate training were expected to ‘provide guidance on preventive measures such as early detection of diseases, hypercholesterolemia and hypertension, as well as health and psychological counselling’ (Pratono & Maharani, 2018, p.1569). Shortage of medical workforce in some areas may exaggerate this as well as create overlap in workload between medical professions.
Pratono & Maharani (2018), following their study of role of posyandus in LTC in the East Java Province identified several limitations. It appears that in rural areas the monthly posyandus provide only social events as LTC (e.g., dance, prayer, and recreation) services in addition to basic health care provision. While health care services are free, participants are expected to pay for uniforms or to provide a contribution fee for their participation in activities, which limits accessibility. In addition, the reliance of volunteers means that posyandus may be run by religious groups, which may lead to exclusion of population groups (Handayani & Wahyuni, 2012; Pratono & Maharani, 2018, p.1566). Furthermore, the authors raised issues regarding accessibility of services due to distance and transportation costs as well as quality of services. They highlighted a report by the Ministry of Health (2015) that showed that ‘only 10% of Posyandu met the minimum standard and only 1% of Posyandu were able to independently manage their financial resources’ (Pratono & Maharani, 2018, p.1571). Reliance on volunteers meant that many Posyandu were unable to provide regular activities due to lack of volunteers and capability (Pratono & Maharani, 2018). ‘The long-term care requires health cadres or caregivers who support the health workers, however, health cadres or caregivers need to conceive a decent knowledge regarding long-term care on the elderly’ (Aquino Amigo & Nekada, 2019). Rahardjo et al,. presented in an LTC expert dialogue forum in Kitakyushu, Japan (2019), hosted by Economic Research Institute for ASEAN and East Asia the results of their unpublished data from West Jakarta, in which they found the lack of training for volunteers and low understanding of LTC among the volunteers (60%), despite previous training.
In addition to the health focused Puskesmas and Posyandu, the Ministry of Social Affairs provides nursing homes (Panti Wredha). These nursing homes services are provided to people without access to family or community support and in need of long-term care. Volunteers are likely to identify eligible people (Kadar et al., 2013). There are only very few publicly funded shelters and nursing homes managed by the Ministry of Social Affairs available to older people in Indonesia, as these services are not yet fully developed. Local governments, on the other hand, have been found to have established nursing homes across several provinces. However, there were some regions, including Bangka Belitung, East Nusa Tenggara, Central Sulawesi, and West Sulawesi that do not yet have institutional care facilities.
Aquino Amigo, T. E., & Nekada, C. D. Y. (2019). Pengaruh Edukasi Perawatan Jangka Panjang Pada Lansia Dengan Pengetahuan Kader Kesehatan Di Area Komunitas. Jurnal Ilmu Keperawatan Komunitas, 2(2), 1. https://doi.org/10.32584/jikk.v2i2.408
Handayani, D., & Wahyuni. (2012). Hubungan Dukungan Keluarga Dengan Kepatuhan Lansia Dalam Mengikuti Posyandu Lansia Di Posyandu Lansia Jetis Desa Krajan Kecamatan Weru Kabupaten Sukoharjo. Gaster, 9(1), 49–58. https://jurnal.aiska-university.ac.id/index.php/gaster/article/view/32/29
Herman. (2015). Puskesmas Didorong Beri Layanan Penyakit Pikun. Hero, Supermarket Ramah Lansia Pertama di Indonesia. (2018, June). PalapaNews.
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
Metkono, Y. S., Nusawakan, A. W., & Sujana, T. (2017). STRATEGI INTERVENSI KESEHATAN LANSIA DI POSYANDU. IKESMA, 13(1), 22–24. https://doi.org/10.19184/ikesma.v13i1.7026
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).
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.
Setioko B. & Pandelaki, E. E. (2015). Toward Housing for the Elderly in Indonesia. International Journal of Humanities and Social Science. 5(6). Pp. 53-60. http://www.ijhssnet.com/view.php?u=http://www.ijhssnet.com/journals/Vol_5_No_6_June_2015/7.pdf
UPTD Puskesmas Kandangan. (2015). Pedoman Pelaksanaan Posyandu Lansia di UPTD Puskesmas Kandangan.
An audit of residential institutions of older members of the society in selected counties conducted in 2016 found that there are very few faith-based and private institutions established for the care of older persons. The six counties included had no homes for older persons and none of the homes that were identified were run by the government. The institutions lack reliable and predictable means of funding (rely on donation from well-wishers and churches), yet play a crucial role in improving the quality of life for older persons as they provide services, such counseling, psychosocial support, healthcare services from resident nurses and feeding programmes (National Gender and Equality Commission (NGEC), 2016). It is however not clear how many people make use of the private long-term care services or the current size of the private sector.
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
The evidence suggests that the private long-term care sector is growing. Currently, there are no legal frameworks or mandatory standards of care and evaluation, which means that there is very little information about the types of services provided, their quality, the professions working for them, and their overall impact on the health and wellbeing of the people that live there. Therefore, the actual number of people that use these services and the size of the private sector is unknown, even though it is larger than the public sector.
Private non-profit institutions
Through the 2015 Social Assistance Housing Census, CAAS (Censo de Alojamientos de Asistencia Social) (INEGI, 2015a), 4,517 permanent housing institutions could be identified. Among these, almost 23% (1,020) are identified as permanent homes or residences for older adults. Regarding the average number of residents per facility, 37% of the total reported an average between 11-20 residents, 23% between 21-40 residents and the remaining 22% reported having between 5-10 residents. Regarding their legal nature, 75% are private non-profit facilities, 8% are public (government funded), 2.3% religious associations, and 2% private for-profit. Most non-profit institutions combine multiple financing sources: user fees (78%), personal donations (56%), private sector donations (32%), donations from faith-based organisations (28%), government funds (38%), and selling products made by the residents (3%).
Most non-profit institutions work under mixed schemes in which they offer free accommodation services for those older people who do not have resources, or a family network that supports them and for those who have some economic capacity. The group consisting of people without resources generally represents most of their residents. For those with economic capacity, recovery fees depend on the available resources of the older person (their relatives can also be charged). Fees are established according to the financial situation of the resident through a socio-economic assessment of the older person and their responsible family members, if there are any.
Private for-profit institutions
There are also private for-profit institutions that offer care to older people. While people become older and very likely disabled during their time in the institution, most have strict admission requirements that up front only admit “independent” older adults with no severe illnesses or disabilities. Their scale, type of services and quality are not documented. The services of private institutions vary in quality and costs. While there are institutions that offer common accommodation services in very small spaces, others offer spacious single rooms with an integrated bathroom. Similarly, non-professional caregivers and auxiliary nursing personnel constitute most of the personnel, with very few licensed nurses being hired. For more specialised and personalised nursing care, some institutions allow the resident or family member to hire external personnel for their care when needed, incurring in an additional cost. In addition, nursing or other specialised care services contracted out (and paid) by family members are sometimes also allowed. Some institutions offer a wide range of additional recreational services and amenities, such as cable television, internet, movies, access to a gym, climate and controlled ventilation or beauty salons.
According to the DENUE, there are 603 private institutions identified as nursing homes and private homes for the care of the elderly. However, there is no additional information to identify if these are private lucrative or non-profit organisations and as a result, the precise number of private for-profit institutions in the country is unknown. Great diversity was found in the total number of private institutions registered in each state of the country (INEGI, n.d.-b).
Private Community Care
There is an increasing market of private day centers and incipient services for care aides at home. However, since no regulatory framework or agency establish care standards, monitor, or evaluate the services which are in place, little information on their number and how they operate is known. There are some at-home personal assistance (not qualified medical care) services provided by private for profit companies. The range of services usually cover from basic personal company services (inside and outside the home), support with activities of daily living such as feeding (but not cooking), bathing, basic nursing activities and physical therapy or rehabilitation. While these services are being offered in Mexico’s largest cities, the costs are very high and only accessible to a very small percentage of those who can benefit from them (López-Ortega & Aranco, 2019). On the other hand, the lack of regulation and standards to overlook these services generates a wide variety with respect to the quality of services provided (including the training and skills of hired personnel), from highly standardised and monitored U.S. franchises operating in Mexico, to agencies/individuals that gather a group of “carers” and act as placement services. While the former use highly professional advertising campaigns, services with the latter are usually known from word of mouth.
Services provided in day centers are usually focused on independent and highly functional individuals. These are mostly social and recreational centers which aim at maintaining the independence and participation of the elderly, mainly providing occupational therapies, crafts, health promotion and information, training in information and communication technologies (ICTs), physical activation, and, in some occasions, general medical and dentist consultations. That is, they focus primarily on functional people and, for the most part, do not consider dependency care as care strategy or model them (López-Ortega & Gutiérrez-Robledo, 2015). Except for around 15 day-centers for people with dementia in the country, no other day care services are in place for older adults (or any other age groups) with disabilities or care dependent.
Finally, while it is common practice for domestic workers (by the day and live-in), to provide care on a needs-basis (infants, young children, older adults, people with disabilities), no information is publicly available on how many and how much of their time is dedicated to care for each of these population groups.
 The objective of CAAS was to collect information on the conditions and services offered by public, social and private establishments that house vulnerable populations, along with their characteristics and those of the people who work in these centres (INEGI 2015). It focuses on all types of social assistance institutions, such as care homes and residences for the elderly, but also others as rehabilitation (drug & alcohol) centres, homes for orphans, etc.
INEGI. (2015a). Censo de Alojamientos de Asistencia Social. https://www.inegi.org.mx/programas/caas/2015/
INEGI. (n.d.-b). Directorio Estadístico Nacional de Unidades Económicas. DENUE. Retrieved March 16, 2020, from https://www.inegi.org.mx/app/mapa/denue/
López-Ortega, M., & Aranco N. (2019). Envejecimiento y atención a la dependencia en México. Nota técnica del BID. https://publications.iadb.org/publications/spanish/document/Envejecimiento_y_atención_a_la_dependencia_en_México_es.pdf
López-Ortega, M., & Gutiérrez-Robledo, L. M. (2015). Percepciones y valores en torno a los cuidados de las personas adultas mayores. In L. Gutiérrez Robledo & L. Giraldo (Eds.), Realidades y expectativas frente a la nueva vejez. Encuesta Nacional de Envejecimiento. (pp. 113–133). Instituto de Investigaciones Jurídicas, Universidad Nacional Autónoma de México.