Care homes in Brazil are recognised by the National Health Surveillance Agency (ANVISA) as ‘living settings’ (Brasil, 2005). They have strong links to social assistance policies and come less under the ‘health-systems radar’. The offer of health services often varies according to the legal nature of the institutions, meaning that care homes do not need to have health professionals as part of the staff team by the law. Even though every care home should inform the municipal health surveillance of its operation and licensing, many institutions work in informality and clandestinely, particularly small not-for-profit and private institutions. In addition, care home workers’ profession is not secured by law, meaning that anyone could work in care homes, regardless of their preparedness to carry out that role.

Each profession involved within the LTC workforce has its own regulatory body, except for the ‘informal care workers’, as explained in the previous item. Such professional councils regulate, inspect, and establish the necessary basic training, staff/user ration, quality monitoring, etc. for the overall role of each profession within any area of care. With regards to care for older people, in specific, there is the Brazilian Society of Geriatrics and Gerontology (https://sbgg.org.br/) and the National Academy for Palliative Care (https://paliativo.org.br/) which provide specialist knowledge, training, and accreditation for those working in LTC. However, there is no national council or guidelines which are specific for the LTC workforce. Though not recognized as a profession, there are formal dedicated spaces to try and formalize, inform, and support informal care workers, such as the Association for Carers of Older People of the Metropolitan Area of Sao Paulo (ACIRMESP – https://www.acirmesp.org.br/).

The National Surveillance Agency – ANVISA regulates the minimum staff and infrastructure within care homes in Brazil, as described in the law RDC nº 283 published on 26 September 2005 (Brasil, 2005). For care workers, for example, this document states the staff/user ratio according to the older people’s level of care dependence:

Level I (low dependence): one care worker for 20 older adults per 8h/day.

Level II (medium dependence): one care worker for every10 older adults per shift.

Level III (high dependence): one care worker for every 6 older adults per shift.

This ANVISA document also details key quality monitoring and compliance variables (page 11), which can be used to fine or close down an institution for poor standards, for example (e.g., mortality rates, prevalence of dehydration and undernutrition, infection, pressure injuries, etc.) (Brasil, 2005). A single annual report detailing such variables are sent to ANVISA by the care home managers. ANVISA can make unannounced visits for inspection voluntarily or in case there is a formal complaint from anyone. However, ANVISA does not monitor the quality of the day-to-day care and interactions with older people (e.g., outside visits, person-centred care, eye contact, etc.). 

References:

Brasil. (2005). Legislação—Anvisa. http://antigo.anvisa.gov.br/legislacao/?inheritRedirect=true#/visualizar/27647

The LTC workforce is regulated by the Social Welfare Department in Hong Kong. Each profession belongs to its own professional body of registration as mentioned above. For all subsidised services, service operators must follow the Fund Service Agreement (FSA) in order to receive the Government subvention. For all residential care homes including subsidised and privately funded, they are regulated by the Licensing Scheme for Residential Care Homes for the Elderly under The Residential Care Homes (Elderly Persons) Ordinance (Cap 459) and The Residential Care Homes (Elderly Persons) Regulation (Cap 459A) (Social Welfare Department, 2020, January 8).

References:

Social Welfare Department. (2020, January 8). Licensing Scheme for Residential Care Homes for the Elderly. Retrieved from https://www.swd.gov.hk/en/index/site_pubsvc/page_lr/sub_rche/id_introd/

As part of the Ministry of Health and Family Welfare programmes, NPOP, the NPHCE provided operational guidelines, which support the provision of accessible, affordable, comprehensive and high quality long-term care to the elder population (MoHFW, 2011). However, there are no regulatory mechanisms in place for long-term care workers. 

References:

Ministry Of Health And Family Welfare. (2011). Operational Guidelines: National Programme For Health Care Of The Elderly (NPHCE). Available from: https://main.mohfw.gov.in/organisation/Departments-of-Health-and-Family-Welfare/national-programme-health-care-elderly-nphce

There is no regulatory body for care workers operating in Indonesia. Members of the public long-term care workforce, such as those working as volunteers for Puskesmas and Posyandu Lansia, are bound by the guidelines of their local healthcare provider. Similarly, members of the private long-term care workforce operate within the guidelines of the private sector (Pratono & Maharani, 2018). The BNP2TKI, however, operates a regulatory body for care workers working overseas (BNP2TKI, 2011).

References:

BNP2TKI. (2011). Sejarah Penempatan TKI Hingga BNP2TKI. http://www.bnp2tki.go.id/frame/9003/Sejarah-Penempatan-TKI-Hingga-BNP2TKI

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

In February 2004, the Jamaican Government piloted a bill to amend the 1934 Nursing Homes Registration Act, aimed at improving the quality of service provided to residents and working conditions of staff at privately owned Nursing Homeowners.

The Bill introduced requirements for the biennial registration of homes with the Ministry of Health. The registration process was also adjusted to rely on a compulsory inspection and certificate of inspection in order to qualify for registration or renewal of registration. However, according to the regulatory unit at the Ministry of Health, the rate of registration of private care homes is quite low, with less than 20% of all private care homes estimated to be registered (1^st Caregivers Symposium, 2019).

Penalty fees for non-registration were increased from $100 to $30,000JD (approx. $240.00 USD) and registration fees from 50 cents to $5,000JD for homes with a bed capacity of 25 beds or fewer. Registration fees for homes with a bed capacity of 25 beds or more was set at $10,000JD (approx. $80.00 USD) (JIS, 2004).

 References:

1^st Caregivers Symposium (11-12 June 2019). “Supporting your own mental health as a caregiver”. Hosted by the University of Technology, Jamaica.

Jamaica Information Service (JIS). (2004). Nursing Homes Improve Service as Stricter Guidelines. Available from: https://jis.gov.jm/nursing-homes-improve-service-as-stricter-guidelines/

There are 27 Professional bodies and Associations operating in Kenya and regulate the training and conduct of their members. Some have been established under Kenyan law, while others are loose associations representing members of the profession. For instance, the Kenya Hospices and Palliative Care Association (KEHPCA) is a national association formed to represent all palliative care service providers in Kenya (Kenya Hospices and Palliative Care Association (KEHPCA), 2019). The professional bodies that regulate the health professionals include the Medical Practitioners and Dentists Board for doctors, Nursing Council of Kenya for nurses and Clinical officer council for clinical officers. The Kenya National Qualifications Authority (KNQA) is mandate to set the standards for accreditation, Quality Assurance, assessment and examination, to guide all players operating in the Country (Kenya National Qualifications Authority (KNQA), 2019).

References:

Kenya Hospices and Palliative Care Association (KEHPCA). (2019). Hospices. https://kehpca.org

Kenya National Qualifications Authority (KNQA). (2019). Professional Bodies and Associations in Kenya.

As mentioned at the beginning of Part 3., Mexico does not have a mandatory national registry of long-term care institutions, mandatory standards of care, including human resources, and no professional care/caregiver bodies exist.

New Zealand law requires nurses, physiotherapists, and occupational therapists to be registered with a professional body or council in New Zealand before they can work in those roles in New Zealand.

The Ministry of Health administers the Health and Disability Services (Safety) Act 2001. This Act requires providers of health services to be certified against the relevant Standards. The relevant standards are the Health and Disability Services Standards (NZS8134:2008) (Ministry of Health n.d.) and consist of 4 overarching standards that provide the foundation for quality of services and set out the rights for consumers, and ensure all providers are clear about their obligations and responsibilities.

Staffing in aged care is guided by the NZ standard indicators for safe aged care and dementia care for consumers (SHNZ HB 8163:2005). However, these guidelines are from 2005, with a 2019 report by the NZ Nurses Organisation (NZNO) and E tū Union into aged care staffing “In safe hands? How poor staffing levels and rationed care are harming aged care residents and staff” outlining how they are no longer fit for purpose (New Zealand Nurses Association, Etū, n.d.). Critiques include:

• Residents entering care much later in life which often means their needs are more complex
• Adherence to the standards is voluntary
• Residential care homes allocating staff based on revenue
• The 1:5 staff to resident ratio in 2012 is now closer to 1:10 in many facilities despite the increased complexity of resident needs.

 References:

Ministry of Health. (n.d.). Services Standard. Available from: https://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/services-standards.

New Zealand Nurses Association, Etū. (n.d.). In safe hands? How poor staffing levels and rationed care are harming aged care residents and staff. New Zealand Nurses Association.

Nurses are regulated by the South African Nursing Council (SANC); however, the bulk of caregiving for persons living with dementia are believed to rest on an informal, unregulated caring system. Recommendations to the Older Persons’ Act amendment bill have called for the registration of all caregivers of older persons with the Department of Social Development, and to practice under the supervision of a registered nurse (SAHRC, 2017b). With regards to guidelines for LTC, the Department of Social Development (DSD) published Generic Norms and Standards for Social Welfare Services, that set out the following: (1) that together with the Department of Health (DOH), practitioners should be trained and understand the dynamics of ageing and disability when rendering services to older people; and that (2) the application of this understanding should be monitored through performance management (DSD, 2011).

References:

DSD. (2011). Generic Norms and Standards for Social Welfare Services: Towards improved social services.

SAHRC. (2017b). South African Human Rights Commission Older Persons Amendment Bill. Available from: https://www.sahrc.org.za/home/21/files/SAHRC%20Submission%20on%20Older%20Persons%20Bill-%20Dept%20Soc%20Dev-%2030.6.17.pdf