LTCcovid Country Profiles

Responses to 1.02. Long-Term Care system governance

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science.

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.


About this question

This page contains the answers for question 1.04. Long-Term Care System Governance in the LTCcovid International Living Report on COVID-19 Long-Term Care. This report is updated and expanded over time, as experts on long-term care add new contributions.


Definition and goals

Governance has been defined as the processes and systems by which an organisation or a society operates, encompassing leadership, planning, implementation, management and accountability. Strong governance in Long-Term Care requires that the roles and responsibilities of the actors and institutions involved are clear, that there are structures and mechanisms for coordination and engagement with stakeholders (Allen et al. 2011; ADB Briefs).

National governance arrangements

Some countries have created specific agencies or ministries with responsibility for LTC to develop national policies and strategies to support the implementation of LTC laws and policies. This may be independent or based within a another ministry such as Ministry of Health (e.g. Singapore, Australia) or ministry of Labour and Social Policy (e.g. in Poland). In some countries several ministries are responsible for parts of LTC policies (e.g. Turkey). Whilst many strategies are developed at the national level, in some countries (e.g. Spain), they are developed from the subnational/municipal level and, in some cases, may be later pulled into a national policies. Moreover, LTC policies and strategies can be stand-alone or integrated into other policies. For example, in Japan, the policy framework for LTC is outlined in LTC insurance acts.


LTC governance often involves a wide range of stakeholders, including national and regional across multiple sectors (e.g. health, public health and social care, housing, transport etc). Coordination between different stakeholders at different levels is key to effective governance, although most LTC systems are poorly coordinated (see Section 1.06 for more details on care coordination). In fact the COVID-19 pandemic has shown that fragmented responsibilities for long-term care in most countries resulted in difficulties in the adoption and implementation of measures to mitigate the impacts of the pandemic.


Allen K et al. (2011) Governance and finance of long-term care across Europe. Overview report. Birmingham/Vienna: University of Birmingham/European Centre for Social Welfare Policy and Research (Interlinks report 4).


International reports and sources

Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief.

Allen K et al. (2011) Governance and finance of long-term care across Europe. Overview report. Birmingham/Vienna: University of Birmingham/European Centre for Social Welfare Policy and Research (Interlinks report 4).

European Commission (2021). Long-term care report. Trends, challenges and opportunities in an ageing society. Country profiles Publications Office of the EU (

The Executive Council of the African Union recently adopted a Common African Position on Long-Term Care Systems for Africa. Despite this progress, few regional or national frameworks exist to guide more specific action. Focused debate has been largely absent, reflecting the low policy and political priority accorded to long-term care, combined with a belief that the issue has little impact on economic development. With the exception of a few countries, little organized service capacity or national coordination exists. Rather, the provision of long-term care rests overwhelmingly with family members, which is fuelled by a belief among some that western models of organized long-term care pose a threat to African values (source:

The African Union has drafted several policy frameworks relevant to long-term care. These include the AU Policy Framework and Plan of Action on Ageing; the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Older Persons in Africa; and the Common African Position on Long-term Care Systems for Africa. At the national level, several countries including Ethiopia, Ghana, Kenya, Mauritius, Uganda, and the United Republic of Tanzania have adopted consistent overarching ageing policies or national legislation relevant to older people, such as the Older Persons Acts of South Africa and Zimbabwe. However, with few exceptions, national policies and legislation overlook significant aspects of sustainable systems of long-term care. In general, they do not provide a framework or roadmap for integrating long-term care across a range of settings and often do not examine the cultural norms and expectations inherent in substantial family involvement in long-term care provision. In addition, they do not specify mechanisms for preparing and supporting caregivers and rarely specify how to ensure a sustainable financing mechanism and workforce supply as the older population grows. Few of the frameworks address how to improve access and affordability for poor and marginalized groups (source:

Last updated: January 6th, 2022

Australia is a federation and LTC is primarily the responsibility of the federal (Commonwealth) government which sets LTC policy, provides funding, oversights quality standards etc. Within the states, while funded by the Commonwealth and having to comply with Commonwealth standards, there are some nursing homes run by state governments  (e.g. Victoria runs 178 nursing homes) and some home care is provided by local government (e.g. in Victoria).

There is central oversight from the Australian government, as it is responsible for regulating and funding the majority of aged care services. However, state and territorial governments also have jurisdiction over the provision of aged care, which increases the complexity of the system and leads to a division of power.

The Australian Department of Health is responsible for the development and implementation of aged care policy, including advising the Australian Government, funding, and administration. The Aged Care Quality and Safety Commission is responsible for aged care regulation. State and Territory Governments, along with the private sector, are responsible for the delivery and management of health care, including aged care.

The Australian government’s Department of Health created the Royal Commission into Aged Care Quality and Safety in 2018 to evaluate the current Aged Care sector and to provide recommendations for reform. A group of experts in this commission have identified several weaknesses of the sector and have issued their final report (Royal Commission, 2020).


Royal Commission into Aged Care Quality and Safety (2020) Aged care and COVID-19: a special report. Commonwealth of Australia. 

Last updated: February 15th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  

Governance of LTC system in Austria is relatively fragmented, in that the responsibility is divided amongst the federal government and the federal states in several ways. The federal government is in charge of the care allowance benefit, while the regional governments are responsible for the provision of care services (Fink, 2018). These responsibilities by the federal states include providing LTC services (i.e. in-kind benefits), planning the number of beds/spots for care, and regulating tariffs and subsidies. In terms of home care services, the federal states are responsible for regulating the framework conditions as it relates to funding, collective bargaining agreements for services and out-of-pocket payments by users.  Although the federal states are responsible by law for the provision of long-term care services for older adults in Austria, in practice, the responsibility for carrying out these services is shared with several entities, such as the municipalities, non-profit organisations and private operators (Rechnungshof Österreich, 2020).


Fink, M. (2018). ESPN Thematic Report on Challenges in long-term care. Austria 2018, Brussels,

Rechnungshof Österreich, 2020 Bericht des Rechnungshofes: Pflege in Österreich. Wien: RH Österreich

Last updated: February 2nd, 2022   Contributors: Cassandra Simmons  |  

LTC consists of a wide range of medical and social services and is subject to a number of social and healthcare regulations. LTC under social services are provided in the community and in specialized institutions. LTC services are also regulated by the Health Act and are provided by different types of specialized medical institutions (Salchev, 2017).


Salchev, P. (2017), Bulgaria: Emerging policy developments in long-term care. CEQUA country report.

Last updated: February 3rd, 2022

Provinces in Canada have jurisdiction over the health care sector but are governed under the Canada Health Act, which establishes “criteria and conditions related to insured health services and extended health care services that the provinces and territories must fulfil to receive the full federal cash contribution under the Canada Health Transfer”. LTC facilities are not included under the Canada Health Act and are solely under the jurisdiction of the 5 regional health authorities (source:

Last updated: February 11th, 2022

Five regional health authorities are accountable for all LTC including residential facilities and community care. However, public health authority owned facilities receive more support and oversight compared to privately owned facilities (source:  BC has five regional health authorities and a Provincial Health Services Authority (PHSA), is responsible for managing the quality, coordination, accessibility and cost of certain province-wide health care programs. Each health authority has oversight over their own publicly owned LTC facilities. However, there is lack of coordination between health and social care. Healthcare is monitored more by the national government although jurisdiction is under the provincial government, whereas social care is almost exclusively provided and monitored by regional health authorities within the province (source: Health Authority: Overview).

Last updated: February 11th, 2022

Since the 1990s, experts in the Czech Republic have been working to address supply issues in long-term care because it stands between the social and health departments (Holmerová, 2018). A large number of working groups were set up to try to resolve this issue ( Holmerová, 2015).

The last group dealing with long-term care operated in the years 2018–2021. It included representatives – ministers of both ministries – the Ministry of Labour and Social Affairs of the Czech Republic and the Ministry of Health of the Czech Republic. After less than a year, the group ceased operations. Ministries have continue to prepare their own proposals and solutions that have never been published. The COVID-19 pandemic has hindered proposals for solutions or changes (Horecky et al., 2021).

In practice, post-acute care (“follow-up”) and long-term care are not always well distinguished. The term “long-term care” appears only in the Law on Health Care and in the  Bulletin 12/2019, of the Ministry of Health of the Czech Republic published   Methodological Recommendation for Follow-up and Long-Term Health Care, in which it defined as follow-up care – care for patients in need of treatment and long-term care – care for patients whose health cannot be improved and would worsen without nursing care (MZCR, 2019).

Long-term care usually follows acute or follow-up care. Long-term care can be provided in the patient’s own home-home environment, in a social care facility (residential homes and homes with special regime), in a medical facility where long-term inpatient care is involved, or in the form of palliative care (MZCR, 2019).

Long-term care is not enshrined in legislation (with the one above mentioned exception). There is growing awareness that the long-term care system in the Czech Republic needs to be reformed. It is important that both health and social groups seek solutions, and they must find a system that is financially sustainable in the long-term and for all the payers involved, be it the state, local governments, health insurance companies, long-term care clients and their families.  The disparity between long-term care needs and the insufficient capacities, quality and satisfaction with care has been attributed to the existing public policy and administration (Horecky et al., 2021).

Proposals for reforms to improve the system include the introduction of four basic principles (Horecky et al., 2021):

  1. Long-term care must be accessible, individualised and able to respond flexibly to changes in the health and needs of each person.
  2. Long-term care must be efficient in the use of financial resources and personnel, and ensure that the recipient always receives the support and care they need, taking into account their abilities and skills.
  3. Long-term care must be sustainable in the long run with a vision of development and future demand for LTC.
  4. It is important to strengthen community services – whether field or outpatient, whose proper functioning and support for people with impaired self-sufficiency in the home environment can fundamentally affect the demand for more expensive inpatient care.

HOLMEROVÁ, I. (2018) Case management v pé?i o lidi žijící s demencí: koordinace pé?e zam??ená na ?lov?ka. Praha: Fakulta humanitních studií Univerzity Karlovy, 2018. ISBN 978-80-7571-031-4.

HOLMEROVÁ, I. (2014) Dlouhodobá pé?e: geriatrické aspekty a kvalita pé?e. Praha: Grada Publishing, [2014]. ISBN 978-80-247-5439-0.

Horecky J, Potucek M, Cabrnoch M and Kalvach Z (2021) REFORMA DLOUHODOBE? PE?C?E PRO C?ESKOU REPUBLIKU. Asociace poskytovatelu? socia?lni?ch sluz?eb C?R.

Ministerstva Zdravotnictví, MZCR (2019) Vestnik.



Last updated: February 6th, 2022   Contributors: Martina Paulíková  |  

Although national legislation sets a broad framework for service provision, municipalities maintain responsibilities for long-term care policies. These include establishing eligibility and entitlement criteria and the level and content of service delivery, regulating services’ delivery and organizing the public provision of services.

In 2007 the number of municipalities was reduced from 275 to 98, creating larger administrative units. This change was accompanied by municipalities also taking charge of the rehabilitation of people who are being discharged from hospital, and  taking a stronger role in prevention and health-oriented interventions (Rostgaard, 2020).

In 2015, the responsibility for regulating services and support for older people was transferred from the Ministry of Social Affairs and the Interior to the Ministry of Health. This transfer of responsibilities for regulation and oversight of care for older people was a clear move towards integrating central and strategic decision making for health and social services (WHO, 2019). During COVID-19, it meant that it was the Board of Health that oversaw the implementation of pandemic restrictions and measures. As a consequence of the heavy workload during the pandemic, the responsibility was again placed with the Ministry of Social Affairs, now called the Ministry of Social Affairs and Senior Citizens. It is now again the Board of Services which oversees and guides policy implementation.


Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at:

Last updated: May 24th, 2023

The Ministry of Social Affairs and Health oversees the planning and drafting of all social care policy; it also monitors its service standards through 1) the National Supervisory Authority for Welfare, Valvira, which grants licenses to private and public care program, and 2) six Regional State Administrative Agencies (AVIs), which ensure standardization of care across the country.

Local municipalities are self-governing administrative units and have a key role in public administration. They are responsible for arranging and supervising the social and health services in their own area.

LTC is a policy priority for Finland’s Ministry of Social Affairs and Health, especially in the context of a rapidly growing older population with increasingly formal/institutional care needs. Clarity of accountability, assessment and monitoring when determining LTC service plans is a legislative priority. Implementation of legislative priorities is however challenging; the promoted value of self-determination often conflicts with ensuring the quality care provision plans (Ylinen et al, 2021).


Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021.

Last updated: February 1st, 2022

France has a highly fragmented LTC system with operations at multiple levels at national, regional and municipal levels and significant regional variation. There is also limited coordination across actors, which all have different remits. Local authorities (departements) have the primary responsibility for social policies including those relating to age.

Regional Health Agencies (ARS) were created in 2009 trying to represent central government at regional level, which resulted in expansion of remit of regions to social care as well as health. Regional structures (ARS) have oversight of healthcare, and some social care which is designed to provide some level of integration across the two sectors.

Author 2: Alis Sopadzhiyan (LTC Covid profile pending)

Last updated: January 6th, 2022   Contributors: Camille Oung  |  

Decision making powers

In the German health system as well as in the long-term care system decision-making power is shared between the Federal and the State Governments (Blümel et al., 2020). Even more importantly, the state only sets a legal framework for health and social care delivery, while major governance decisions are left to self-regulated provider and payer organisations. For long-term care the main decision-making power rests with the long-term care insurance funds on the one hand and providers of residential or community care services on the other. By law, long-term care insurance funds have to guarantee the provision of services that meet the demand by the population. Municipalities and local authorities have no authority over what services are provided within their region. The legal framework for long-term care, including the different actors, their roles and the list of benefits, is laid out in the Social Code Book XI (Lückenbach et al., 2021).

A Commissioner for Care

The German Federal Government created the role of a ‘Commissioner for Care’ in 2014 . The role of this position is to advocate for the interests of people with care needs in the political arena and to ensure that the health- and care system are centred around them. This office is involved in all matters (legal, orders etc.) to do with care and nursing. (Die Bevollmächtigte der Bundesregierung für Pflege, n.d.) , but is not directly involved in system governance. Germany does not have a Government Chief Nurse. Since 2014 the representative for care held the position of a permanent secretary at the Department of Health, reporting directly to the Minister of Health with a dedicated team of staff. In 2022 the Government transferred the role to a Member of Parliament and scraped the dedicated staff.

The role of the medical service in providing control of provision and quality of services

The medical service (Medizinischer Dienst (MD)) ensures that services provided through health- and long-term care insurance are provided to people based on objective medical criteria and that all people with insurance coverage receive services based on the same conditions. It aims to ensure that people receive necessary services but also are protected from those that are unnecessary or potentially harmful. The MD evaluates quality of services on an annual basis. The Social bill ensures that members of the MD are independent.

Public reporting of provision and quality of care

The LTC insurance funds are required to publish the quality reporting of the MD. The report consists of 59 criteria in the areas ‘care and medical care’, ‘handling of residents living with dementia’, ‘support and everyday life’ as well as ‘living, food, housekeeping and hygiene’. In addition, people living in residential care setting and people receiving support in the community are being ask about their experience (Medizinischer Dienst, n.d.; Jacobs et al., 2018).


Blümel M., Spranger A., Achstetter K., Maresso A. & Busse R. (2020) ‘Germany: Health system review’. Health Systems in Transition. 22(6): pp.i–273 Available at: (Accessed 10 February 2022).

Bundesministerium für Gesundheit (2020) Pressemitteilung – Bundesrat stimmt Gesetzespaketen zur Unterstützung des Gesundheitswesens bei der Bewältigung der Corona-Epidemie zu. Available at: (Accessed: 31 January 2022)

Die Bevollmächtigte der Bundesregierung für Pflege (n.d.) Amt und Person. Available at: (Accessed: 31 January 2022)

Jacobs, K., Kuhlmey, A., Gre?, S., Klauber, J. & Schwinger, A. (2018) Pflege-Report 2018:  Qualität in der Pflege. Available at: (Accessed: 31 January 2022).

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. Available at: (Accessed 31 January 2022)

Medizinischer Dienst (2020) Pressemitteilung – Ab Oktober wieder persönliche Pflegebegutachtungen und Qualitätsprüfungen. Available at: (Accessed 31 January 2022).

Medizinischer Dienst (n.d.) Der Medizinische Dienst im Gesundheitssystem. Available at: (Accessed 31 January 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Accountability is an issue in LTC services in Israel, due to the private and insular nature of Israel’s predominant culture of at-home LTC services. The creation and implementation of a national care coordinator and a working group to streamline LTC enrolment and increase transparency were explicit components of the 2018 governmental reform. Results of the effectiveness of this rollout have been unclear, and undoubtedly interrupted by the COVID-19 pandemic.

Last updated: January 6th, 2022

As with the National Health System, LTC sector is a regional competence. The Ministry of Labour and Social Policy and the Ministry of Health are responsible for defining the national framework, the issue general guidelines, and fund specific interventions to secure regional equity. At the central level, the National Social Insurance Agency is in charge of monetary contributions and cash allowances which are paid directly to citizens. The regions are the key actors and they regulate and fund in-kind services. Local health authorities (LHAs) and municipalities are responsible for interventions that are delivered through care providers. The system is highly reliant on publicly funded services, which account for around 85% of service providers’ revenues.

Coordination between different LTC responses is poor or left to local best practices. There are different need assessment systems (LHAs, municipalities, and INPS) which individuals can go through to access the in-kind and cash services they are eligible for, there is no guidance or coordination between the different interventions (Notarnicola et al., 2021).


Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI:

Last updated: February 4th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Accountability for the system is clear: a national framework of revenue raising, eligibility & benefits sits alongside clear roles for municipalities as insurers for over 65s and market shapers with some powers to influence provision (Curry et al. 2018).

While the municipal governments are the administrators of the LTCI, LTCI is a nationally regulated system. The menu of services and pricing is set by the Ministry of Health, Labour and Welfare (MHLW) and hence is standardized across the country. Furthermore, the MHLW sets the rules over who can operate as service providers and imposes specific requirements on the provision of services such as minimum levels of accommodation, care worker/resident ratio, the number of medical and trained care staff, nutritionists and physical therapists. The MHLW also requires municipal and prefectural governments to update their long-term care service plans every three years (Estévez-Abe and Ide 2021a).


Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from:

Estévez-Abe, Margarita & Hiroo Ide (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

Last updated: January 20th, 2023

Public LTC expenditure in Lithuania represented 1.0% of Gross Domestic Product in 2016 (source: European Commission: The 2018 Ageing Report).

Last updated: February 10th, 2022

A national policy on the elderly (2001) has been adopted. There is a Protection of Elderly Persons Act 2005, which is aimed at protecting older people from all forms of neglect and abuse. Older people are afforded further rights and protections in the more general National Human Rights Action Plan (2012–2020). The Government of Mauritius oversees and funds many aspects of health and social care for older people. Day care centres offer recreational and educational programmes throughout the country. Those with demonstrated need receive free assistive devices and home health visits (source:

The Residential Care Homes Act 2003 was enacted in order to establish standards and codes of practice and to monitor the quality of care delivered in private homes. Regular inspections of both public and private homes help to ensure that residents receive adequate care (source:

Last updated: January 6th, 2022

The Ministry of Health, Welfare and Sport is responsible for health and all aspects of long-term care (LTC). This includes care homes, social care and nursing care. Since 2015, community care has been devolved to private insurers and municipalities. Regional care offices contract with (WLZ and ZVW) providers and have a responsibility to ensure that there are sufficient services to meet demand. These offices are run by one private care insurer who represents all care insurers active in the region. Municipalities are responsible to provide services under the WMO and have incentives to reduce costs (Bruquetas-Callejo and Böcker, 2021).


Bruquetas-Callejo, M., Böcker, A. (2021) Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future MC Covid 19 Working Paper 11/2021 

Last updated: February 5th, 2022

The Government of the Seychelles has recently unified health and social care in a Ministry of Health and Social Affairs. This new Ministry has an opportunity to strengthen long-term care governance and to develop plans to ensure the quality and financial sustainability of long-term care in years to come (source:

Last updated: January 6th, 2022

The Ministry of Health is responsible for governance over the entirety of the health and LTC systems, including setting policy direction, projection of national-level service demand, health and LTC financing, regulatory frameworks, standards, oversight, and coordination of related bodies. There is an Ageing planning Office with responsibility for setting policy direction and implementation for successful ageing across sectors.

In 2018 the Agency for Integrated Care (AIC) was created, within the Ministry of Health, with responsibility for coordinating the delivery of Long-Term Care, enhancing service development and building capacity across health and social care. The AIC is responsible for integrating and coordinating health and care services, case assessment framework and case finding, monitoring and evaluation, case management, referral services, strengthening primary care and community care services and quality of services.


Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief.

Asian Development Bank (2020) Singapore’s Long-Term Care system. Adapting to population aging. ADB.

Last updated: January 6th, 2022

South Africa’s Older Persons Act (2006), as well as more general legal and policy instruments, guides national action on long-term care. Coordination and implementation of national policy fall mainly to the Department of Social Development and to the Department of Health. The former administers old-age pensions and finances and oversees residential, community and home-based care, while the latter addresses older people’s health care needs. The Department of Human Settlements plays a lesser role, in that it regulates retirement villages. Overall coordination of long- term care across these Departments is lacking and clinical-level integration of health and social care is limited. Organized long-term care could be expanded to include a broader range of service approaches and settings (source:

Last updated: January 6th, 2022

As responsibility for administering social assistance has been assumed by all the autonomous communities, the governance of the System for Autonomy and Dependency Care (SAAD) falls into the hands of the bodies established within the framework of the different social service systems. This is dependent upon the structure of each of the autonomous communities. The responsibility of the management of SAAD (both the reception of the application, assessment of the applicant, and the recognition of the situation of dependency and the benefits that can be recognized to each person), corresponds to each autonomous community. The sole exceptions to this is the management of SAAD in the Autonomous Cities of Ceuta and Melilla, which is assumed by the General State Administration through the Institute for the Elderly and Social Services.

Delegating the provision of LTC services and benefits to the regions has entailed differences in the access to benefits in different regions. Even though social services are managed, regulated and promoted by the autonomous regions, there are some programmes promoted by the central state, for example  vacations programmes for older people which are partly subsidised by the state (Guillen et al. 2017)


Montserrat Guillen, Ramon Alemany, Manuela Alcañiz, Mercedes Ayuso, Catalina Bolancé, Helena Chuliá, Ana M. Pérez-Marín, and Miguel Santolino (2017). Country Report: Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network. Retrieved from European Network on LTC (CEQUA).


Last updated: July 4th, 2022   Contributors: Sara Ulla Díez  |  

The Constitution of Sri Lanka grants all citizens the right to health care, while legislation such as the Protection of the Rights of Elders Act and the Protection of the Rights of Elders (Amendment) Act focus more on elders’ rights and welfare. The National Elderly Health Policy of Sri Lanka was launched in February 2017, and the delivery plan mandated the redevelopment of underutilized inpatient health-care facilities into LTC facilities. The Ministry of Health, together with the established State Ministry of Primary Health Care, Epidemics and COVID
Disease Control, are responsible for policy and formulating LTC services for older persons (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (

Last updated: January 6th, 2022

A brief history

Prior to the 1950s, adult children were legally responsible for the care of their elderly parents. In the 1950s, 5% of GDP was allocated to care of the elderl, pensions were raised, and children were relieved of their duty of care. For the first time, government-funded institutional care and supported home care were offered to the elderly population in Sweden. In 1982, these provisions were codified into the Social Services Act, guaranteeing the right to claim public service support if needs cannot be met in another way (source: MJIL online).

Current governance

Care in Sweden is a social right: anyone with permanent residency in Sweden is eligible for care, eligibility for which is determined only by assessment of needs (Fukushima et al., 2010). Responsibility for the provision of health and social care is divided between national, regional, and local government. As per The Community Care Reform of 1992, housing and social care needs for older people are the responsibility of local government. The Swedish LTC system is therefore provided, managed and financed by the 290 municipalities, and health and medical care (including at-home palliative care) for older people falls under the responsibilities of the 21 counties and regions. Home care provided by municipalities includes (but is not limited to) help with activities of daily living (ADLs) and personal care, and the provision of meals-on-wheels and various housing adaptations. They provide at-home care and institutional care (including residential care facilities, nursing homes, and group homes for people with dementia (Johansson and Schön, 2017).

More recently, an ‘ageing in place’ policy, based on the philosophy that people should be able to live independently for as long as possible, has dominated the long-term care landscape in Sweden, which has led to the downsizing of institutional resources, and only the most dependent being able to access institutional care (source: European Commission).

In a climate of decreased per capita spending on care for elderly people in a rapidly ageing population, The Local Government Act (1992) allowed municipalities to outsource the provision of care services to private providers (source: This trend of increased marketization means that there is increased diversity and choice in provider for those in need of long-term care (source: European Commission). Although there has been a proliferation in the provision of care from the private sector, although financing for elder care through taxes still remains generous in Sweden compared to other nations (Meagher and Szebehely, 2010).


Fukushima, N., Adami, J., & Palme, M. (2010). European Network of Economic Policy Research Institutes Assessing Needs of Care in European Nations THE SWEDISH LONG-TERM CARE SYSTEM.

Johansson, L. and Schön P. (2017) Country report for Sweden. CEQUA LTC network.

Last updated: February 12th, 2022   Contributors: Daisy Pharoah  |  

The Department of Health and Social Care (DHSC) has overall policy responsibility for setting adult long-term care policy in England and the legal framework, and is accountable to Parliament and public for the performance of the system. The Ministry of Housing, Communities & Local Government oversees the distribution of funding to Local Authorities (LAs) and the financial framework within which local authorities operate.

The Care Act 2014 sets out the responsibilities of 152 LAs in the assessment of social care needs, commissioning and organisation of care, LAs also deliver some services directly, but this is increasingly rare (Source: The Care Act 2014).

The National Health Service (NHS) in England was established by the National Health Service Act of 1946. NHS England is an arm’s-length body of the DHSC and is responsible for arranging the provision of health services in England. The DHSC sets objectives for the NHS through an annual mandate. Since 2013, Clinical Commissioning Groups have been responsible for commissioning hospital and community care for their local populations. In relation to Long-Term Care, nursing and rehabilitation services are mostly provided through the NHS, or funded by the NHS and provided by social care providers for individuals who require nursing in a social care setting or that are considered to have primarily a health need (Source: NHS Continuing Healthcare).

The Care Quality Commission regulates care providers for quality, monitoring and inspecting services to ensure they meet quality and safety standards, and also provide oversight of the financial resilience of the largest and potentially most difficult-to-replace care providers. They publish their findings, including performance ratings.

Although there are initiatives at local and regional levels which aim to integrate health and long-term care services (with varying degrees of success), they remain two separate systems. The NHS White Paper published in February 2021 sets out legislative proposals to establish Integrated Care Systems (Source: Integration and innovation; see question 4.04 for more details).

Last updated: March 8th, 2022

The governance of LTC in the United States is complex and uncoordinated, primarily because of the state variations regarding fund allocation and aging populations. There is a shortage of an appropriate, nationwide system to address the health and social care needs of the population, whilst fragmented and under-resourced systems are common. Federal services tend to be scattered across agencies with minimal collaboration. Various LTC programs are often operating independently (De Biasi et al. 2020).

Federal level attempts at financing reform have either ended in failure or produced small changes to the financing arrangements. Demands for reforms have increased particularly in light of the pandemic (Dawson et al. 2021).


De Biasi, A. et al. Creating an Age-Friendly Public Health System (2020). Innovation in Aging, Volume 4, Issue 1,

Dawson, W. D., Boucher, N. A., Stone, R., & Van Houtven, C. H. (2021). COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now. The Milbank Quarterly, 99(2), 565–594.

Last updated: February 11th, 2022

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.