Responses to 1.04. Long-term care system governance


Public LTC expenditure in Lithuania represented 1.0% of Gross Domestic Product in 2016 (source:

Last updated: August 2nd, 2021

African Union

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: September 10th, 2021


There is central oversight from the Australian government, as they are 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 (source:

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 (sources:;

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 aged care sector, especially in light of COVID, and have recently issued their final report (source:

Last updated: August 3rd, 2021


LTC consists of a wide range of medical and social services and is understood as lying across the boundary between medical and social care 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 (source: CEQUA Bulgaria Country report (

Last updated: August 3rd, 2021

Canada (British Columbia)

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:’s%20six%20health%20authorities,responsible%20for%20health%20service%20delivery).


Last updated: August 3rd, 2021


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: August 3rd, 2021


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 represents a step towards integrating central and strategic decision making for health and social services. In 2016, a position of Minister for Senior Citizens was created within the Ministry of Health, transferring to it a portfolio that was previously under the control of the Minister for Health.

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. Healthcare agreements are political and administrative documents agreed on by each municipality and the corresponding administrative region at the beginning of each election cycle and are renewed every four years. The goal of these agreements is to provide a platform for negotiation between the main stakeholders and a framework for the practical collaboration of actors at different government levels. These agreements include six mandatory thematic areas: hospitalization and discharge processes, rehabilitation, devices and aids, disease prevention and health promotion, mental health and follow-up on adverse events and feedback mechanisms (source:


Last updated: August 3rd, 2021

England (UK)

The Department of Health and Social Care has overall policy responsibility for adult long-term care policy in England. The assessment of care needs, and the commissioning and organisation of care is the responsibility of 152 local authorities, a small minority of which also run and deliver some care services. Government financial support for local authorities, including their social care responsibilities, is channelled through the Ministry of Housing, Communities and Local Government. 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.

Last updated: August 3rd, 2021


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. However, local municipalities hold vast discretionary power: they are responsible for arranging and supervising the social and health services in their own area. They act as self-governing administrative units and form the majority of public administration in Finland. 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 (source:

Last updated: August 3rd, 2021


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. 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. Some level of integration has also been achieved through pathways and networks generally around gerontology and independence loss, as well as regional support networks and local information centres (source:

Last updated: August 3rd, 2021


The government has laid out the legal framework, providing an overview of the different actors, their roles and the list of benefits in the Social Code Book XI (source: The German Federal Government has a dedicated person responsible for care. This role was created in 2014 and the responsible person was appointed in 2018. 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. (source:

By law, 50% of residential care workers are required to be trained as skilled workers. This requirement, however, is not always met. From March to October 2020 quality controls were suspended during the pandemic to relieve the burden on domiciliary and residential care (source:;

The medical service of the health insurances (Medizinischer Dienst der Krankenversicherung (MDK)) 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 MDK evaluates quality of services on an annual basis. The Social bill ensures that members of the MDK are independent.

TheLTC insurances funds are required to publish the quality reporting of the MDK. 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 (source:;


Last updated: August 3rd, 2021


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: August 3rd, 2021


The current LTC governance structure is fragmented, e.g. at the central level, the responsibilities for LTC lies between the Ministry for Labour and Social Policy and the Ministry of Health. Moreover, Regions implement the dual ministerial policies by defining regional policies and network of services; local health authorities and municipalities manage services and interventions at the local and individual level (

Last updated: August 3rd, 2021


Accountability for the system is clear: national framework of revenue raising, eligibility & benefits sits alongside clear role for municipalities as insurers for over 65s and market shapers with some powers to influence provision (source:

Last updated: August 3rd, 2021


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: August 3rd, 2021


The Ministry of Health, Welfare and Sport is responsible for care homes, social care and nursing care (i.e. all aspects of LTC), as well as health. 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.

Last updated: August 3rd, 2021


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: August 3rd, 2021


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. The Aging planning Office is responsible for setting policy direction and implementation for successful aging across sectors; Agency for Integrated Care is responsible care integration for health and social care systems (source:

Last updated: August 3rd, 2021

South Africa

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: August 3rd, 2021


Generally speaking, LTC services are under regional administrations. 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 (source: CEQUA Spain Country report (

Last updated: August 3rd, 2021

Sri Lanka

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: September 6th, 2021


The Community Care Reform of 1992 was the major policy initiative which defined responsibilities and accountability in LTC for older people. Responsibility for health care and social services is divided between three levels of government. At the national level, parliament and the government set out policy aims and directives by means of legislation and economic steering measures. At the regional level, the county councils and regions are responsible for the provision of health and medical care. At the local level, the municipalities are legally obliged to meet the social care and housing needs of older people. The Swedish LTC system is therefore provided, managed and financed by the 290 municipalities and the 21 counties and regions.  Municipalities are responsible for home care, including help with activities of daily living (ADLs) and personal care; for providing home health care, day care, and short-and long term institutional care including nursing homes, residential care facilities and group homes for persons with dementia (source:; Although municipalities are responsible for care of older people, there are various care providers within the municipalities – these may be public or private (source:

Last updated: August 3rd, 2021

United States

The governance of LTC in the United States is complex and uncoordinated, primarily because of the variation by state 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. There has been a recent increase in attention given to the issue at the national level, despite this, fragmented and under-resourced systems remain in place. Federal services tend to be scattered across agencies with minimal collaboration. Various LTC programs are in nascent stages, operating independently (source:

Federal?level attempts at financing reform have either ended in failure or produced incremental changes to the financing arrangements. Demands for reform and reconsideration of the direct-care workforce have increased particularly in light of the pandemic (source:

Last updated: August 3rd, 2021