DESK REVIEWS | 03.02.01. If the country has a public long-term care system, please answer:

DESK REVIEW | 03.02.01. If the country has a public long-term care system, please answer:

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).

References:

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).

References:

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).

References:

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).

References:

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 Ministry of Planning (“Ministério do Planejamento”, in Portuguese) (International Budget Partnership, 2018), in partnership with each relevant ministry (in this case, Ministry of Health and Ministry of Citizenship).

References:

International Budget Partnership. (2018). Defining and managing budget programs in the Health Sector: The Brazilian Experience.

 

As described above, both central government and local government are responsible for allocating available funds for LTC system. The national government develops targets and provides a budget. The institutions involved are the Ministry of Health, the Ministry of Social Affairs, the Ministry of Home Affairs and both the National and Regional Houses of Representatives. The local governments, on the other hand, are responsible for managing funds, implementation, and operation of services. In addition, local government, within their budget, can decide to allocate more funding towards long-term care.

Similar to other departments in health, there is little information on how finances for LTC services should be distributed. However, the level of provision from the ministry of health should be within the ceilings provided by the sector working groups (Republic of Kenya, 2018a).

References:

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

Budget for the few public care homes by INAPAM and DIF comes directly from the total budget of these institutions and has to be planned internally by each institution. However, the overall budget of these institutions has to be approved by the Finance Ministry, thus, adjustments may have to be made.

There are several laws informing the planning of allocation and expenditure of public resources for the entire health (SUS) and social care (SUAS) systems which, together, finance the LTC services provided to older people in Brazil (Brasil, 2011). SUS has several participatory forums at federal, state, and municipality levels, which help inform the healthcare strategy nationally. These occur at different points in time along the year and are secured by different laws. As Brazil does not have a unified LTC system, and it is unclear which services are classified as being LTC, it is difficult to estimate how and how much of the total amount is allocated to LTC specifically every month/year. Further, for the financing of public/philanthropic LTC institutions, in addition to the budget coming from the public system financed mostly through taxation, the budget may come from the older person/family funds, older people’s pensions, philanthropy, donations, and others, all of which are varied (Freire et al., 2012; Watanabe, 2018). In the private LTC institutions, the main source of financing is through individual payment (e.g. pension, family funding) (Freire et al., 2012).

References:

Brasil, no. L12435 (2011). http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/lei/l12435.htm

Freire, F. de S., Mendonça, L. H. de, & Costa, A. de J. B. (2012). Sustentabilidade econômica das instituições de longa permanência para idosos. Saúde em Debate, 36(95), 533–543. https://doi.org/10.1590/S0103-11042012000400005

Watanabe, H. (2018). Instituições de Longa Permanência conveniadas com o MDS.

The allocation of funds is decided through the annual financial statement, commonly known as the Union Budget. The Union budget is announced in Parliament by the minister of finance. Both the finance bill and the appropriation bill are passed by the Lok Sabha before the annual announcement. In 2019–2020, the health budget was increased to support the requirements of the rural health mission and to initiate the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana health scheme (AB-PMJAY).

For other programmes, such as the National Programme for Palliative care, declared in 2012, a model Personal Independence Payment (PIP) framework with operational and financial guidelines has been designed. Based on a model PIP (Project Implementation Plans), the states/UTs may prepare their proposals related to palliative care and seek financial support from the National Health Mission. Palliative Care is part of the ‘Mission Flexipool’ under the National Health Mission (NHM) and no separate budget has been allocated for the implementation of the programme (MoHFW, 2019b). However, large gaps in the implementation of this programme have been reported with only about 2% of the proposed budget being sanctioned to a small number of states (Rajagopal, 2017).

References:

Ministry of Health and Family Welfare. (2019b). National Programme for Palliative care (NPPC): National Health Mission.

Rajagopal Vallath Nandini, M., Mathews Rajashree, L. K., & Watson, M. (2017). An Indian Primer of Palliative Care For medical students and doctors. Available from https://palliumindia.org/wp-content/uploads/2020/04/Chapter-1-Principles-of-Palliative-Care.pdf

Local governments receive an allocated budget (effective for one year) on an annual basis. Local governments submit their financial plan to the Regional House of Representatives six months before the beginning of the new financial year for approval. The process is monitored by the Ministry of Home Affairs (Proses Penyusunan APBD, 2016).

References:

Proses Penyusunan APBD. (2016). Media Riset, Diklat, Dan Konsultan Lembaga Kajian Nasional Kementerian Dalam Negeri. http://diklat.org/proses-penyusunan-apbd/

The process of allocation in all sectors including LTC is determined by the ministry of health based on cost-effective and efficient programmes (Ministry of Health, 2016b).

References:

Ministry of Health. (2016b). National and county health budget analysis FY 2016/17. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/6138-6239_FINALNationalandCountyHealthBudgetAnalysis.pdf

As previously mentioned, while DIF and INAPAM define the budget annually allocated to the few institutions they have, their overall budget has to be approved by the Ministry of Finance.

The budget to be spent on social assistance, which includes LTC, follows a “transference system” and the priorities are set by the federal government, states, and municipalities in an independent way (Brazilian Ministry of Citizenship, n.d.). Decisions are based on strategic/economic/epidemiological figures and on active participation from the population in the decision-making processes (e.g., municipal and state health forums; local management collegiate; national older people’s council). The processes of planning and allocating resources are transparent, decentralized and regularly evaluated by CONASS, which ensures that the data are available for consultation online (Brasil, 2019).

References:

Brasil. (2019). Conselho Nacional de Secretários de Saúde – CONASS. https://www.conass.org.br/

Brazilian Ministry of Citizenship. (n.d.). Módulo II: o Financiamento do SUAS. Retrieved July 17, 2019, from http://aplicacoes.mds.gov.br/sagi/dicivip_datain/ckfinder/userfiles/pdf/aulas_or%C3%A7amento_mds_modulo_II.pdf

It is a calculative process between the Ministry of Finance and the ministries to which the budget is allocated to decide on the funding. The budget process guides the respective ministries and departments to prepare revised budget estimates.

As previously explained, we understand that priorities for funding are set autonomously by the local governments and monitored by the central government through the Ministry of Home Affairs and with guidance from other ministries involved.

Ministry of health decides using its own criteria or formula how funding should be distributed while prioritizing allocations towards the achievement of “Big Four Plan (Otieno, 2016).

References:

Otieno, M. (2016). Resource allocation to health sector at the county level and implications for equity, a case study of Baringo county. University of Nairobi. http://erepository.uonbi.ac.ke/handle/11295/98703

 

 

As with any other public administration agency, as mentioned above. Just as DIF and INAPAM define the budget to be annually allocated to the few LTC institutions they have, they define their priorities for funding.

The National Fund for Social Assistance (Fundo Nacional de Assistência Social) transfers budget to states and municipalities according to the Pluriannual Plan, the Law of Budgetary Guidelines, and the Annual Budget Law. It is considered a decentralized system in which each level of government can manage how the money will be spent (Brazilian Ministry of Citizenship, n.d.). The social care budget allocated to assist older people has changed over the years (in R$ millions) within each of the country’s regions. This federal allocation considers the number of older people locally, the increase in the value of minimum salary/basic pension, poverty levels, among other variables (Brasil, 2011).

References:

Brazilian Ministry of Citizenship. (n.d.). Módulo II: o Financiamento do SUAS. Retrieved July 17, 2019, from http://aplicacoes.mds.gov.br/sagi/dicivip_datain/ckfinder/userfiles/pdf/aulas_or%C3%A7amento_mds_modulo_II.pdf

Brasil. (2011). Caderno SUAS: Financiamento da Assistência Social no Brasil. https://www.mds.gov.br/webarquivos/publicacao/assistencia_social/Cadernos/Suas_Financiamento_V.pdf

 

At the administrative level, the Ministry of Social Justice and Empowerment works in close collaboration with the state governments. The budgets are generally dispersed to the states through the respective national schemes, which are responsible of providing the health care services to older persons.

The Financial Management Groups (FMG) of the program management support units, working under the National Health Mission, help the state and district levels maintain accounts, release funds, and create expenditure reports along with utilisation certificates and conduct audits (Verma & Khanna, 2013). The funds are allocated to each state/union territory through the State Health Society (SHS), which enables the various activities of the programmes to be carried out (Verma & Khanna, 2013). The SHS further disperses the funds to CHCs, PHCs and Sub-centres via the District Health Society (DHS), covering the state and district levels (Verma & Khanna, 2013).

References:

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

There is no funding specifically for long-term care services. However, the amount allocated within the health sector in counties is distributed within programs in an efficient way while prioritizing cost-effective and efficient programmes (Ministry of Health, 2016b). Programs that are directed towards achieving the “Big Four Plan”  agenda, reflect on the actual financial requirement and are in full compliance with government priorities are given priority in terms of funding (Republic of Kenya, 2018a).

References:

Ministry of Health. (2016b). National and county health budget analysis FY 2016/17. Nairobi, Kenya. http://www.healthpolicyplus.com/ns/pubs/6138-6239_FINALNationalandCountyHealthBudgetAnalysis.pdf

Republic of Kenya. (2018a). Guidelines for the preparation of the medium-term budget for the period 2019/20 -2021/22. Nairobi, Kenya.

No. The central/federal offices of these institutions decide how budgets are allocated and dispersed, given that the exact budget they requested, is granted by the Ministry of Finance.

Using the budget allocated by the Federal government, states and municipalities then decide how to prioritise or to create program areas that require investment. We have no detailed information on the details of how this budget is spent locally.

The funding is allocated to state federals and to the respective programmes and schemes initiated as part of the budgets.

No repository listing all program areas related to long-term care in Indonesia was found. However, a specific program called ASLUT (Program Asistensi Sosial Penduduk Lanjut Usia Terlantar) is available for neglected or poor elderly individuals. The criteria for eligibility are:

  1. aged 60 years and above
  2. having physical ailments that forbid performing daily activities
  3. not having a source of income
  4. being neglected and in poverty
  5. not being a recipient of the Keluarga Harapan Program.

The budget for the ASLUT program is derived from the social assistance funds of the Ministry of Social Affairs. ASLUT program is managed by the Directorate of Elderly’ Social Rehabilitation, the Director General of Social Rehabilitation, and the Ministry of Social Affairs. In 2017, the budget allocation for beneficiaries of the ASLUT program was at IDR 60 billion. This budget is fully allocated as a grant of Rp. 200,000 per person per month to 30,000 ASLUT beneficiaries (TNP2K, 2018, p.132).

References:

Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia. https://www.developmentpathways.co.uk/wp-content/uploads/2018/11/44293181123-SP-ReportFinal-ENG-web.pdf

There is no funding specifically for long-term care services.

There are no long-term care programs in the federal or local public administrations and, therefore, no budgets are allocated and dispersed for this.

Yes. SUS provides the health-related LTC, such as visits from community health teams, domiciliary care, and provision of treatment, which are all financed by the municipality budget of primary/secondary healthcare (Brazilian Ministry of Health, 2019l).

References:

Brazilian Ministry of Health. (2019l). Sobre a Assistência Farmacêutica.

The NPHCE and other elder care related schemes are covered by the country’s main health financing mechanisms. Ayushman Bharat (MoHFW, 2019a) proposes to transform the primary healthcare system in the country through the establishment of Health and Wellness Centres (HWCs). The HWCs are envisioned to provide primary healthcare services, with an addition of care for older persons and palliative healthcare services (Keshri and Gupta, 2019).

References:

Keshri, V., & Gupta, S. (2019). Ayushman bharat and road to universal health coverage in India. Journal of Mahatma Gandhi Institute of Medical Sciences, 24(2), 65. https://doi.org/10.4103/jmgims.jmgims_44_19

Ministry of Health and Family Welfare. (2019a). Ayushman Bharat Health and Wellness Centres: Accelerating towards health for all April 2018 – September 2019. Government of India. Available

The main health financing insurance in Indonesia is regulated through the national independent social insurance institution (Badan Penyelenggara Jaminan Sosial (BPJS)). In the health sector BPJS or BPJS-Kesehatan covers the health care costs of all members, irrespective of their age. However, the LTC guideline for Puskesmas explained that most components of LTC services are still not covered under the national health insurance or other insurances, and therefore they might be covered by donations or out-of-pocket expenses (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018).

As LTC services are aimed towards increasing quality of life by assisting with daily activities, there is a link with services provided by BPJS-Kesehatan, specifically BPJS-Prolanis, which aim to increase quality of life of members with chronic illnesses, such as diabetes and hypertension. This scheme provides services such as screening, reminders to visit healthcare facilities and home visit as well as public activities and projects for people previously identified to be eligible to be part of ‘Prolanis Clubs’ (BPJS Kesehatan, 2014). These services do have LTC components in them, however, are not classified as LTC services or geriatric services.

References:

BPJS Kesehatan. (2014). Panduan Praktis PROLANIS (Program Pengelolaan Penyakit Kronis)/PROLANIS Guideline. In BPJS Kesehatan.

Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat. (2018). Pedoman untuk Puskesmas dalam Perawatan Jangka Panjang bagi Lanjut Usia. Kementerian Kesehatan RI.

The lump sum amount under health covers long-term care services. Also, the older persons cash transfer targeting those aged 65 and above has supported 833,129 households (i.e. one person per household regardless of the number of people who have attained the age of 60 in the household) (Kenya Institute for Public Policy Research and Analysis (KIPPRA), 2019).

References:

Kenya Institute for Public Policy Research and Analysis (KIPPRA). (2019). Social Protection Budget Brief (No. 67/2018-2019). Nairobi, Kenya. https://repository.kippra.or.ke/bitstream/handle/123456789/2278/social-protection-budget-brief-pb67.pdf?sequence=1&isAllowed=y

 

As previously mentioned, there are only two strategies in the country that cover some long-term care services, one at the Mexican Institute of Social Security, IMSS (one of the main social security institutions in Mexico) and one from Mexico City’s Health Secretariat. Both provide domiciliary services for people with functional disabilities.