DESK REVIEWS | 03.02.01.01. How is the public long-term care system financed?
DESK REVIEW | 03.02.01.01. How is the public long-term care system financed?
Although there has been an increase in the development of inter-sectoral policies that establish how and to whom health and social care services should be delivered/accessed in Brazil (e.g., integrated care for older people) (Brazilian Ministry of Health, 2018e), LTC is not a unified system in Brazil and the financing of such services is separate via health and social care ministries. As detailed in item VII: health-system financing, the three spheres of government in Brazil (federal, state, and municipal) are responsible for financing SUS, and a similar strategy is used within SUAS. Monetary resources allocated to each of these systems are directly transferred from the federal government to states, municipalities and the federal district, which results in decentralized and participatory management of public resources (laws 8742/93 and 8.080/90). Financing of such systems also occur via state and municipal taxation and each sphere of government manages their resources in line with some common shared responsibilities (Brasil, 1990, 1993).
In 2011, only six years after the implementation SUAS, the law 12.435/11 replaced the law 8.742/93 and established a system to regulate the organisation and provision of social assistance. This includes rules of social control, monitoring, evaluation, and management of SUAS, coordinated by the Ministry of Citizenship and in partnership with states, the Federal District and municipalities. This set of standards and rules introduced a new form of social assistance, breaking with a previous vision centred on charity and favour and establishing regular funding for social care (Brasil, 2011). In 2010, nearly R$11 billion was invested in assisting 1.62 million older people, which represented a growth percentage of 365% in the volume of funds invested and 177.7% in the total number of beneficiaries in relation to 2002 (Brasil, 2011).
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.
Brasil, no. 8080/90 (1990). http://www.planalto.gov.br/ccivil_03/leis/l8080.htm
Brasil, no. L8742 (1993). http://www.planalto.gov.br/ccivil_03/leis/l8742.htm
Brasil, no. L12435 (2011). http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/lei/l12435.htm
The central government of India has launched a programme to support health related issues of older people under the National Programme for Health Care of the Elderly (NPHCE). The central government of India initiated the NPHCE scheme with 75% financing of total budget from the centre and 25% from the state government for district level activities (MOHFW, 2016b). The NPHCE provides free, specialised health care services exclusively for the aging population through state level providers (MOHFW, 2016b). The Ministry of Social Justice and Empowerment has initiated programs like the Integrated Programme for Older Persons (IPOP) scheme, which funds long-term care services for the elderly.
The Ministry of Health & Family Welfare of the Government of India also has a National Program for Palliative Care. This scheme is centrally sponsored with most states carrying 40% of the cost, and the North-Eastern states and Union Territories carrying 10% of the cost (MOHFW, 2019b). The beneficiaries of this scheme are people with terminal cancer, AIDS etc. (MOHFW, 2019b).
According to a review by the International Labour Organisation (ILO), India spends only about 0.1% of its GDP on long-term care (Scheil-Adlung & Xenia, 2015).
Ministry of Health and Family Welfare. (2016b). National Programme for Health Care of the Elderly.
Ministry of Health and Family Welfare. (2019b). National Programme for Palliative care (NPPC): National Health Mission.
Scheil-Adlung, & Xenia. (2015). Long-term care protection for older persons : a review of coverage deficits in 46 countries. ILO Working Papers.
The Indonesian long-term care system is funded through a combination of national and local government funding. For instance, Law No. 36/2009 article 171-172 regulates that a minimum of 5% of national government’s budget and a minimum of 10% of local government’s budget have to be used for public health services prioritizing poor people, older people, and neglected children (Regulation No. 36/2009 on Health (UU No. 36/2009 Tentang Kesehatan), 2009). In addition, the Ministry of Home Affairs established Regulation No. 130/2018, which establishes that a minimum of 5 per cent of the local government’s budget has to be used to develop public facilities on Kelurahan (urban village) level (Ministry of Home Affairs Regulation No. 130/2018 on Development of Facilities and Infrastructure and Community Empowerment in Kelurahan Level (Permendagri No. 130/2018 Tentang Kegiatan Pembangunan Sarana Dan Prasarana Kelurahan Dan Pemberdayaan Masyarakat, 2018).
Besides the establishment of national law and the provision of funding to local government bodies, the Indonesian government has placed responsibility for the public long-term care system largely in the hands of local governments. At the national level, the national government’s budget (Anggaran Pendapatan Belanja Nasional (APBN)) is regulated by the central government and the National House of Representatives.
Local governments receive a budget (Anggaran Pendapatan Belanja Daerah (APBD)), funded out of taxes, provincial taxes (retributions), grants, and other legal resources. These resources are then used to fund, the city’s health departments, local laboratory facilities, emergency ambulance units, regional/local public hospitals, public health facilities, social, and welfare department, city’s social departments and other departments depending on the local governments’ policies. Puskesmas Santun Lansia, Posyandu Lansia, Panti Werdha, geriatric services in public hospitals and any other public long-term care services are funded out of this budget (Ministry of Health Regulation No. 61/2017 on Technical Guideline of Use of Special Non-Physical Health Fund Allocation for Budget Year 2018 (Permenkes No. 61/2017 Tentang Petunjuk Teknis Penggunaan Dana Alokasi Khusus Nonfisik Bidang Kesehatan Tahun Angga, 2017).
Some provinces and cities allocated additional proportions of their local government budget towards services for older peoples. The central government is supportive of these visionary developments. For example, the Mayor of Depok city in the province of Jawa Barat implemented an act, which aimed to increase of budget to further develop services available through Posyandu Lansia in each of the Kelurahan (Syarif, 2019).
However, while the integration of LTC into health care may have some policy benefits, Scheil-Adlung (2015) reports that allocations of funds for the provision of LTC fall short. The report states that public expenditure on LTC was 186.3 PPP$ per year and person aged 65 and older (Scheil-Adlung, 2015, p.34). Translated into GDP, this means that only 1.9% of GDP per capita was public expenditure on LTC for the population 65 and older (Scheil-Adlung, 2015, p.83).
Ministry of Health Regulation No. 61/2017 on Technical Guideline of Use of Special Non-physical Health Fund Allocation for Budget Year 2018 (Permenkes No. 61/2017 tentang Petunjuk Teknis Penggunaan Dana Alokasi Khusus Nonfisik Bidang Kesehatan tahun Angga, (2017) (testimony of Ministry of Health Republic of Indonesia).
Ministry of Home Affairs Regulation No. 130/2018 on Development of Facilities and Infrastructure and Community Empowerment in Kelurahan level (Permendagri No. 130/2018 tentang Kegiatan Pembangunan Sarana dan Prasarana Kelurahan dan Pemberdayaan Masyarakat, (2018) (testimony of Ministry of Home Affairs Republic of Indonesia).
Regulation No. 36/2009 on Health (UU No. 36/2009 tentang Kesehatan), (2009) (testimony of Republic of Indonesia).
Scheil-Adlung, X. (2015). Long-term care protection for older persons: A review of coverage deficits in 46 countries. Geneva: International Labour Organization. Available at: https://ideas.repec.org/p/ilo/ilowps/994886493402676.html
Syarif, M. (2019). Walikota Depok Usulkan Kelurahan Dapat Tambahan APBD Rp173,25 Miliar – Jelang Tahun Anggaran 2020. Neraca. http://www.neraca.co.id/article/112832/walikota-depok-usulkan-kelurahan-dapat-tambahan-apbd-rp17325-miliar-jelang-tahun-anggaran-2020
There is no specific funding allocated for long-term care services in Kenya. The overall financing details are discussed in part 2 under the overall health system financing. Families mainly provide long-term care support (Applebaum et al., 2013).
Applebaum, R., Bardo, A., & Robbins, E. (2013). International Approaches to Long-term Services and Supports. Generations: Journal of the American Society on Aging. 37:1. Pp. 59-65. https://www.researchgate.net/publication/273133611_International_Approaches_to_Long-term_Services_and_Supports
Mexico does not have a public long-term care system. The DIF and INAPAM are the only public institutions that have a total of ten residences for older adults and that are financed through federal budgets assigned to these institutions. Some of the state branches of these institutions are operated by public state-level budgets and will have some temporary services such as day centres, but the exact number is unknown.
The South African government funds public long-term care for older persons, for which the majority of care is through residential facilities (WHO, 2017). All registered facilities can apply for subsidies for individual residents, with eligibility restricted to the frail and destitute (South African Government, 2019).
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
WHO. (2017). Towards long-term care systems in sub_Saharan Africa: WHO series on long-term care. Available from: https://www.who.int/publications/i/item/9789241513388