DESK REVIEWS | 03.02. Long-term care system financing

DESK REVIEW | 03.02. Long-term care system financing

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.

Yes, there are private healthcare insurance companies that provide health-related LTC (ANS, 2016). In addition, private companies have started building residential villages for older people to live, to stay for a period of time or to spend a day. In these villages, older people receive social and healthcare assistance as required. However, such private services are expensive and only those who can afford it have access to it (an example of such a private programme can be seen here).

References:

ANS. (2016). ANS propõe novo modelo de assistência a idosos na saúde privada. Agência Brasil. https://agenciabrasil.ebc.com.br/geral/noticia/2016-05/ans-propoem-novo-modelo-na-assistencia-ao-idoso-na-saude-suplementar

To our knowledge, there are no specific private long-term care based insurance schemes in the country as of May 2020.

To date (February 2020), there has been no private long-term care insurance.

Access to private health insurance for older persons is limited (Maina, 2017) due to financial constraints. Although the proportion of people purchasing private long-term care insurance in Kenya is currently not documented, insurance companies provide inpatient and outpatient services depending on the ability to pay. For example, the Afya Imara Seniors insurance that provides health benefits for individuals between 65 and 80 years charge premium rates ranging between Kshs.57,755 to Kshs.113,565 per person for inpatient services and between Kshs.45,244 to Kshs.61,566 per person for outpatient services (UAP OldMutual, 2020). Further information on how private insurance markets are regulated in general (not specific to LTC) is provided in the overall health system under health system financing.

References:

Maina, L. (2017). How Kenya can ensure adequate health care for its older people. The Conversation, 25 January. https://theconversation.com/how-kenya-can-ensure-adequate-health-care-for-its-older-people-70163

UAP OldMutual. (2020). What you get with Afya Imara Seniors. https://www.uapoldmutual.com/h/health-insurance/solution/afya-imara-seniors

While some private insurance companies have tried to introduce long-term care insurance policies (importing mainly US insurance schemes), these have not been popular as the market is restricted only to those with the highest income levels and who already would be able to afford 24-hour care through, for example, live-in carers.

Around 22% of the population aged 60 and over in Brazil have a private healthcare insurance  (ANS, 2013). However, we do not know how many of these individuals have access to LTC in this group. Data from the Institute for Applied Economic Research (IPEA) showed that 64% of the long-term care homes were private in Brazil, but we do not know how much of the costs are paid for by the individuals/families or health insurances (Camarano, 2017).

References:

ANS. (2013). Caderno de informação da saúde suplementar. Beneficiários, operadoras e planos. https://bvsms.saude.gov.br/bvs/periodicos/caderno_informacao_suplementar_dez2013.pdf

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

Information specific to out-of-pocket expenditures on long-term care services is not available.

No data found (27 February 2020) on the proportion of population incurring out of pocket expenditures, or the amount. 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 might be covered by donations or out-of-pocket expenses (Kementerian Kesehatan RI Direktorat Jenderal Kesehatan Masyarakat, 2018).

References:

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

There is no data on the population that incurs out-of-pocket expenditure when purchasing long-term care services. Although the cost of residential homes is not included on the websites, only a few people can afford to pay for the high costs as indicated by the 2016 NGEC audit (National Gender and Equality Commission, 2016).

Studies on OOP spending in both public and private sector for the general population in 2005/2006, reveal that more than 50% of individuals spend their own resources in the public health sector (Barnes et al., 2010). While the percentage of households incurring OOP has been decreasing since 2003, 7.1% of households were still experiencing catastrophic health expenditures in 2018 (Salari et al., 2019). Measures such as Universal Health Coverage starting with four pilot counties may enhance access to care in the coming years.

References:

Barnes, J., O’Hanlon, B., Feeley, F., McKeon, K., Gitonga, N., & Decker, C. (2010). Private Health Sector Assessment in Kenya. 193(1). Washington, D.C. https://openknowledge.worldbank.org/bitstream/handle/10986/5932/552020PUB0Heal10Box349442B01PUBLIC1.pdf?sequence=1&isAllowed=y

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

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6). https://doi.org/10.1136/bmjgh-2019-001809

 

No data is available at national level regarding the purchase of long-term care services or the number of people incurring in catastrophic levels of out-of-pocket LTC expenditures within the private market (profit or non-profit). However, some information on unpaid care work and its value is available.

As part of Mexico’s National Accounts, the National Statistics Institute, INEGI generates different Satellite Accounts[1] in order to cover activities that are not part of the core economy but they are linked to it in a highly relevant way. To date, many countries have a parallel system of Satellite Accounts, being environmental accounts, tourism, unpaid household (domestic) work satellite accounts, and satellite accounts on non-profit institutions and voluntary work are some of the most widely estimated.

Mexico currently estimates satellite accounts for unpaid household work, for unpaid health and personal care, a tourism satellite account, among others (INEGI, 2018b). Unpaid health and personal care is estimated on a yearly basis and published as the National Satellite Health Accounts of the Health Sector (Cuenta Satelite del Sector Salud en Mexico, CSSSM), with data from the National Time Use Survey. Data for 2017 (base year 2013) reports that GDP of the health sector is 5.6% of the national GDP. Of this 5.6%, 1.4% represents unpaid health and personal care (performed within the household). Within the health sector GDP, 72.3% corresponds to the economic activities of the sector and 27.7% to unpaid health and personal care work.

In order to take into account the dimension of the role of unpaid personal and health unpaid work performed within the household, it is important to note that the monetary value of household’s contribution to personal health care of other household members (27.7%) represents more than half of what is generated by public sector establishments (39.5%). This is also larger than the contribution of primary care (ambulatory) medical services (17.0%) and is similar to the one generated by all hospital services (20.7%) (INEGI, 2018b).

Figures of unpaid work in health refer to care for people of all ages. However, changes in the population structure due to the aging process are visible. Since among the population reporting motor, cognitive or sensory limitations in the country, 26% of them refers to old age as being the cause of their limitations, it can be expected that a significant percentage of unpaid care is dedicated to care for the elderly.

Results from the 10/66 research group’s INDEP study (The Economic and Social Effects of Care Dependence in Later Life) show that significant health care costs for households with care additionally presented higher likelihood of catastrophic healthcare spending (Guerchet et al., 2018).

[1]According to the European Union, satellite accounts provide a framework linked to the central accounts and which enables attention to be focussed on a certain field or aspect of economic and social life in the context of national accounts; common examples are satellite accounts for the environment, or tourism, or unpaid household work (European system of national and regional accounts (ESA 2010).

References:

Guerchet, M. M., Guerra, M., Huang, Y., Lloyd-Sherlock, P., Sosa, A. L., Uwakwe, R., Acosta, I., Ezeah, P., Gallardo, S., Liu, Z., Mayston, R., de Oca, V. M., Wang, H., & Prince, M. J. (2018). A cohort study of the effects of older adult care dependence upon household economic functioning, in Peru, Mexico and China. PLoS ONE, 13(4). https://doi.org/10.1371/journal.pone.0195567

INEGI. (2018b). INEGI. Datos. https://www.inegi.org.mx/datos/

See Part 2 (specifically 2.02.08) about the role of remittances in health care.

Remittances in Kenya constituted 2.5% of GDP in 2015. They increased from US $934 million in 2011 to US $1.73 billion in 2016 and at an average of 14.3% in the past one decade (Misati et al., 2018). According to household surveys conducted in Burkina Faso, Kenya, Nigeria, Senegal, and Uganda in 2009 as part of the Africa Migration Project, households in Kenya devoted 7.3%, 5.8%, and 7.0% of outside Africa, intra-Africa, and intraregional remittances to health respectively. Regionally, food was the highest while health was the fifth highest in terms of remittances. Remittances may improve health outcomes through purchase of more food and access to health care, by increasing awareness on proper diet (Mohapatra & Ratha, 2011).  Even though there is no data showing the amount of remittances spent on LTC, it is assumed that the services provided through such remittances cover all life cohorts since some of the factors that motivate sending of remittances include (Jena, 2016):

  1. The need to assist parents in old age
  2. Financing younger siblings
  3. Inheritance motives
  4. Cultural norms and expectations
References:

Jena, F. (2016). The remittance behaviour of Kenyan sibling migrants. IZA Journal of Migration, 5(1), 11. https://doi.org/10.1186/s40176-016-0059-x

Misati, R. N., Kamau, A., & Nassir, H. (2018). Do migrant remittances matter for financial development in Kenya? (WPS/08/18). Financial Innovation. Springer. https://doi.org/10.1186/s40854-019-0142-4

Mohapatra, S., & Ratha, D. (2011). Remittance markets in Africa. The World Bank. The World Bank. Washington D.C. https://openknowledge.worldbank.org/bitstream/handle/10986/2292/613100PUB0mark158344B09780821384756.pdf?sequence=1&isAllowed=y

Similarly, as for health financing, while remittances play an important role in supporting families in many localities throughout the country and they are predominantly provided by the large number of Mexican migrants living in the U.S., the scarce information available shows that these are primarily spent on basic subsistence items such as food and clothing. One of the few studies available on this subject shows that, based on different data sources, the main uses of remittances sent by Mexicans are: buying clothes and groceries. Remittances are used much less frequently to purchase education, health services, settle debts, and for buying, renovating, or building homes (CONAPO & Fundación BBVA Bancomer, 2018).

References:

CONAPO, & Fundación BBVA Bancomer. (2018). Anuario de Migración y Remesas México 2018. https://www.migracionyremesas.org/docs/Anuario_Migracion_y_Remesas_2018.pdf

No information was found about this.

After enacting the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, and launching the Integrated Programme for Older Persons in 2015, old-age homes have begun to emerge as one of the key institutions for long-term care in India. This has intensified the need to establish a licensing and regulatory authority for old-age homes and similar institutions. Moreover, minimum standards and mechanisms for quality assurance must be put in place.

At present, the National Health Policy 2017 (MoHFW, 2017) addresses long-term care in the following manner: India needs to develop its own cost-effective and culturally appropriate approach to addressing the health care needs of older persons. It emphasises a community-centred approach where care is provided in synergy with family support, with a greater role for formal caregivers at the community level, with good continuity of care at secondary and tertiary levels. A closely related concern is the growing need for palliative care for life threatening illness and where people approach the end of life. Palliative approaches include measures to relieve pain and suffering and provide support to the patient and the family (UNESCAP, 2016). The Ayushman Bharat scheme proposes setting up 1,50,000 health and wellness centres, which in addition to primary healthcare will also provide care of older persons, and palliative healthcare services (MoHFW, 2019a).

References:

Ministry of Health and Family Welfare. (2017). National Health Policy-2017. Ministry of Health and Family Welfare, Government of India. Available from: https://www.nhp.gov.in/nhpfiles/national_health_policy_2017.pdf

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 from: https://ab-hwc.nhp.gov.in/download/document/340b49eb2c0937e7b79ad8c1d6b975ad.pdf

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

Indonesia is nearing the end of its National Medium-term Development Plan 2015-2019. Long-term care is expected to also be included in the consecutive long-term development plan. However, it is unclear whether this involves reforms to the organisation and financing of the long-term care system (UNESCAP, 2014, p.12).

References:

UNESCAP. (2014). Report of the Regional Expert Consultation on Long-term Care of Older Persons. https://www.unescap.org/sites/default/files/Report%20Reg-Consultation.pdf

 

As previously explained, there are currently two working groups collaborating towards the generation of a National Care System that could potentially lead to the creation of some LTC policies or strategies in the next years. In addition, in recent months (by August 2020) as ministries and federal institutions develop their six-years plans as required at the beginning of each presidential period[1], three institutions have included care-related objectives that may bring changes towards the generation of a National Care System[2], including long-term care.

The first institution to include actions toward supporting those in need of care and their carers was the National Institute for Women, one of the few institutions that has been working towards the generation of a National Care System in previous administrations. With the objective of increasing awareness about all individuals having care needs during the life course, of achieving a fairer distribution of unpaid domestic work and care between women and men, and of modifying intergenerational cultural norms towards gender equality, the 2020-2024 Program establishes the need to develop and implement a national care strategy in which co-responsibility between the State, the private sector, the community, and households prevails.

Specifically, its Priority Strategy 2.3 to increase awareness on the need to recognise, reduce, and redistribute household work and care among the family, the state, the community and the private sector, includes three main actions (2.3.1-2.3.3): a) to encourage actions between the state, families, communities and the private sector that allow positioning Care as a human right and the revaluation and redistribution of care work, as well as promoting equality between women and men; to collaborate with other ministries and public institutions in order to develop a National Care System; and to promote organisational culture actions within the Federal Public Administration that allow balancing work responsibilities with personal care needs.

Second, the Welfare Secretary (previously the Social Development Secretary), in its Welfare Sector Program 2019-2024 (DOF 26/06/2020) (Secretaría de Bienestar, 2020) includes the need to incorporate the Right to Care as part of All Human Rights in Mexico. Specifically, in its Priority Objective 1 to contribute towards guaranteeing a basic set of human rights in an effective and progressive way, starting with those most in need, the document states the urgent need for the National Government to develop and ensure the Right to Care as a social right, with the aim of decreasing discriminatory practices, development and wellbeing inequalities present within the current system of care characterised by the lack of public support to those in need of care and their carers. By establishing the need to include the Right to Care within Mexican legislation, the Program envisions access to care services as a right for all individuals who might need to be cared for during the life course but focusing on particular groups with care dependency such as older adults, people with disabilities and young children.

Within Priority Objective 1, Priority strategy 1.1 defines the need to work towards granting access to care services for girls and boys, for people with disabilities and older adults in order to improve their well-being. The strategy includes three main actions:

  1. implementing care services for girls and boys, people with disabilities and older adults;
  2. contributing to the coordination and implementation of a National Care System based on the care services of the sector;
  3. ensuring early childhood care service for children with and without disabilities, with a human-right and differentiated approach, for mothers, single fathers, or guardians who are looking for a job, studying or working.

The third program that includes strategies or actions that could support LTC, is the Health Sector Program 2020-2024 developed by the Secretary of Health. Priority Objective 2 aims to increase the efficiency, effectiveness, and quality of all processes within the National Health System to provide comprehensive public health and social care. This program also includes a main action to establish specific actions and strategies for the care of carers of people who are ill, and/or have disabilities or special needs, to prevent excessive burden to the carers.

In addition, Priority Objective 5, which aims at improving health protection by prioritising the prevention of health risks through timely and optimal treatment and control of diseases, includes the Priority Strategy 5.1 to improve coverage, equitable access, and quality in health services for the timely diagnosis and treatment of NCDs, and includes three main actions (5.1.8-5.1.10) related to LTC. These are: to efficiently and safely promote palliative care; to ensure quality of life and relief of patients with advanced disease and in terminal phase; to promote support for patients living with NCDs under a comprehensive and multidisciplinary approach that facilitates self-management and the acquisition of skills oriented towards their quality of life; and to establish protocols for the recognition and support of individuals who care for others who are ill, especially those who care for people with disabilities or special needs.

[1] Planning and budgeting within Mexico’s Public Administration is based on a National Planning System, which is structured under the guidelines of the Planning Law and with the active participation of public, social and private sectors. This system is reflected in a National Development Plan that, every six years, is presented to Congress by the President for its revision and approval where appropriate, usually within the first six months of each new administration. Once the National Development Plan is published, all Ministries and Decentralised Federal Institutes have to develop and publish their National Plans for the period. These plans define the priority objectives and main actions they will implement throughout the period and which must be aligned with the National Development Plan.

[2] The National Care System would include three main groups/care needs: early childhood care; older adults and people with disabilities and therefore would go beyond LTC for those with care dependency and their carers, by including nurseries, child care, extended hour schools, etc.

References:

Secretaría de Bienestar. (2020). Programa Sectorial derivado del Plan Nacional de Desarrollo 2019-2024. Programa Sectorial de Bienestar. https://www.gob.mx/bienestar/documentos/programa-sectorial-de-bienestar