INTERNATIONAL REPORTS

Responses to 1.06. Approach to care provision, including sector of ownership


Australia

In 2018-2019, there were over 3,000 providers of aged care services. 873 of these were residential services, 928 were home care providers, and 1,458 were Commonwealth Home Support Programme providers (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

The majority of aged care providers are not-for-profits owned by community, charity, or religious organizations. The remaining are privately owned organizations, which are run as a commercial business. There is also a small group of government owned providers. Australia has seen a trend of aged care providers consolidating to just a few large-scale operators – in 2018-2019, 10 providers operated 39% of all aged care services (source: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf).

The CHSP is an “entry-level” programme designed to help people remain independent and safe at home, with home support services and respite care, transport, nursing care.  The HCP programme is aimed at people requiring more support to stay at home and offers coordinated packages of care from an approved home care provider, there are four levels of HCP, according to the levels of care needs. Residential care is subsidized by the government and provided by approved providers. Flexible care aims to offer more innovative care approaches, for example to support recovery following hospitalisations, to serve rural and remote communities and to support Indigenous Australians in ways that are culturally appropriate. There is a single entry point for government-funded care (source: https://www.myagedcare.gov.au), people assessed as eligible for subsidized care can select approved providers who have availability. Approved providers may be not-for-profit, for-profit or public (source: https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp2021/Quick_Guides/AgedCare2021).

Last updated: August 4th, 2021


Canada (British Columbia)

Publicly subsidized services are provided by regional health authorities who deliver them through health authority owned or contracted private/not-for-profit facilities. For-profit, private facilities are often regarded as inferior to publicly owned/health authority owned facilities in terms of care, access to equipment, and government support (source: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

In 2020, 33% of publicly funded LTC beds are operated directly by health authorities. The remaining 18,000 beds are delivered by for-profit companies (35%) and not-for-profit societies (32%) who have been contracted by one of the five regional health authorities in B.C (source: https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf).

Last updated: August 4th, 2021


Denmark

Since 2003, free choice of provider was introduced, banning public monopolies in service provision.  Municipal councils have been required by law to ensure private offers in each municipality, based on contracts with accredited companies. In 2017, Denmark had 320 private for-profit home care agencies. (sources: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019; https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Municipalities typically use competition with fixed prices for tendering home care and competition takes place on quality by, for example, ensuring continuity of workforce. Municipalities are obliged to contract with any private-for-profit provider that meets the requirements on quality standards and the price. Public and for-profit providers co-exist and the latter are not permitted to refuse to provide care for any individual. Recent legislation allows private home care providers to compete on price in the privately-paid for sector and, although municipalities are no longer obliged to contract with all bidders who meet minimum tender specifications, they must contract with at least two such providers (source: Commissioning long-term care services – Policy Press Scholarship (universitypressscholarship.com).

Last updated: September 16th, 2021


England (UK)

Care is provided by approximately 9,000 home care providers and over 15,000 care home providers. Around 78% of all adult care services are privately owned and run (source: https://www.skillsforcare.org.uk/Documents/About/sfcd/Economic-value-of-the-adult-social-care-sector-England.pdf). The Care Act 2014 places a duty on local authorities to ensure that there is diversity and quality in the market of care providers. However, due to the downward pressure on fees stemming from cuts to local authority budgets, many providers find that the fees paid by local authorities fall short of covering the full costs of providing care. People who fund their own care are being charged on average 41% more than local authority funded residents because of this shortfall (source: https://assets.publishing.service.gov.uk/media/5a1fdf30e5274a750b82533a/care-homes-market-study-final-report.pdf). It is increasingly common for care providers to go out of business, struggle to stay in business or hand back contracts to local authorities. A survey in 2019 found that some 75% of councils reported that these organisations had either closed or handed back contracts in the last six months of 2020, creating enormous disruption and discontinuity for those receiving care (source: https://www.adass.org.uk/media/7295/adass-budget-survey-report-2019_final.pdf). Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: https://www.cqc.org.uk/guidance-providers/market-oversight-corporate-providers/market-oversight-adult-social-care).

Last updated: August 4th, 2021


Finland

Municipalities determine whether they provide services themselves, work with other municipalities, purchase services from for- or non-profit actors, or set up cash benefit informal care systems (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 4th, 2021


Germany

Over the past three decades, Germany has seen an overall increase in home care and residential care providers. However, the increase in beneficiaries has been even steeper, leading to a higher number of beneficiaries per provider. Both homecare and residential care recorded a change in the market structure from private non-profit to private for-profit providers. The change is however more pronounced in home care than in residential care (source: Germany_draft.pdf (who.int).

Between 1999 and 2019, the share of private care provider in residential care increased from 35% to almost 43%, while the share of third sector organisations declined from 57% to 53% and that of public institutions from 8.5% to 4.5% (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=875&p_ansnr=13711351&p_version=8&D.000=1&D.374=3&D.983=2).

Among domiciliary care providers, the share of private providers increased from 51% to 67%, while the proportion of third sector decreased from 47% to 32% and that of public providers from 19% to 1% between 1999 and 2019 (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=876&p_ansnr=98223306&p_version=2&D.000=1&D.374=2&D.983=1).

Last updated: August 4th, 2021


Italy

The actors directly involved in the organisation of LTC services are municipalities, local health authorities and the National Institute of Social Security (INPS), but other players are involved in planning and funding these services – i.e. the central state, regions and provinces. Additionally, in Italy individual households play an important role in the organisation and provision of long-term care (source: update_joint-report_it_en.pdf (europa.eu).

Last updated: August 4th, 2021


Japan

There is a mixed market of provision in most parts of the market (except nursing care, where market entry is restricted to medical and non-profit providers). The 2000 LTC insurance reforms sought to create a competitive and mixed market of provision, especially for home care and has largely succeeded. Providers are paid according to a national fee schedule although municipalities have some freedoms to adjust it to suit local needs (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan).

Last updated: August 4th, 2021


Mauritius

LTC is typically viewed as a family responsibility, although this is being challenged as society undergoes change. The government acknowledges that family caregivers require support and allocates a monthly allowance to caregivers of older people experiencing significant declines in capacity. Some efforts have been made to provide practical training to family caregivers. A number of residential facilities also exist. Currently, approximately 25 charitable homes are operated by nongovernmental organizations and funded by the government. Nursing and medical care is provided on site. Access to these homes is first-come, first-served and based on means testing. Overall, the demand for admission into these homes far outweighs their bed capacity. The number of private retirement homes, for those who can afford them, has increased in recent years (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021


Poland

LTC services in Poland are provided by both private and public providers. The former includes unpaid carers and a grey zone (including immigrant carers) as well as non-for profit and for-profit residential care providers. Non-governmental organizations are active in the provision of care for older people – in supporting hospitals, care, and nursing facilities (source: Poland Country (filesusr.com).

Last updated: August 4th, 2021


Seychelles

The right to health care and social protection for all citizens is enshrined in the Seychelles’ Constitution of 1993. A number of government-funded long-term care services are available, including both home care and residential services. Long-term care provision remains mainly in the public sector, with some involvement of civil society and limited participation of the private sector. The country’s home care scheme was established in 1987. This programme makes it possible for people to remain at home rather than using residential or institution-based care. Caregivers are chosen by the beneficiary, usually a family member of the older person (source: https://www.who.int/publications/i/item/9789241513388).

Public residential facilities take the form of regional homes for older people and one 136-bed long- term care nursing facility. The regional homes usually consist of ten single-occupancy independent living units. Residents do not pay rent but are responsible for living costs. The country’s sole long-term nursing facility is in high demand: the waiting list is long (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021


Singapore

LTC in the community is mostly provided informally by family and surrogate carers. Formal community services (e.g. day care) and residential care are largely provided through Voluntary Welfare Organisations or Social Service Agencies. In 2019, Singapore had 7,600 day care places, 10,300 home care places, 1,986 community hospital beds and 16,059 nursing home beds. Of the available nursing home beds, 75% were supplied through the Social Service Agencies and the government and 25% through private providers (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: August 4th, 2021


South Africa

Traditionally, long-term care has been seen as a family responsibility yet few schemes are in place to support family caregivers. Private retirement villages cater mainly to older people with financial means. Publicly funded long-term care is available to only a small fraction of the older population. The majority of this type of care is provided in residential facilities which tend to be clustered in urban settings. Applicants are subject to a comprehensive assessment of their current living situation, family support, financial means and care needs. Only those who meet the criteria are eligible for admission. Individual care homes usually have their own admission policies and procedures, in addition to the formal criteria for obtaining public financial support. Availability of beds is another hurdle: most facilities have waiting lists for admission (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021


Spain

Due to limits in public spending on LTC, a number of public services are provided by private entities, both for and non-profit. In the care home sector. Although marketization has led to an increase in the available places, this has been at the expense of the quality of services, and public administrations have difficulties in terms of inspecting and evaluating services. Additionally, migrant workers, often without an official contract, provide a share of home care in Spain (source: LTCcovid-Spain-country-report-28-May-1.pdf).

Last updated: August 4th, 2021


Sri Lanka

State and NGO operated day-care centers. The NSE supports 662 day-care centers around the country.  HelpAge Sri Lanka and other NGOs have also supported day-care centers. There may be other day-care centers and Elders’ Clubs operated by small NGOs and village-level
committees.

Sri Lanka has two main types of residential facilities: those primarily designed to provide housing for older people who lack shelter, and those that aim to provide LTC support and nursing care. Most facilities fall into the first category and are known as “elders’ homes” or “eldercare homes.” Even if the primary aim is to provide shelter, some residents have or develop needs for LTC support over time. Sri Lanka currently has around 255 eldercare homes serving approximately 7,100 elder residents, two owned by the central government and three by provincial councils. The private sector operates around 20 homes; others are not-for-profit and funded by private donations and some government funding. Not-for-profit eldercare homes are usually operated by faith-based organizations and NGOs. Homes for elders registered under the Department of Social Services increased from 68 in 1987 to 162 in 2003. Five public eldercare homes house 7% of all elder residents, and 220 private (i.e., not for-profit) eldercare homes house 85% of all elder residents.

The 2017 survey of eldercare provider institutions, it was estimated that there were about 25 home nursing care service providers, although the exact number is not known due to gaps in the implementation and monitoring of the formal registration system of such providers and regulation of the industry. These home nursing care services provide 24-hour nursing care to about 900 older clients. The services are usually expensive and not affordable for lower-income families (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (adb.org).

Last updated: September 6th, 2021


sub-Saharan Africa

Within sub-Saharan Africa, national efforts to develop long-term care systems exist only in Mauritius, Seychelles, and South Africa. The expansion of organized long-term care has been organic and uneven in terms of geographical spread, populations served, and services offered. Most organized care is clustered in urban metropolitan settings. Two major service models appear to dominate: charitable care for the most destitute older people (usually operated with few resources by faith-based, civil society or public welfare bodies) and private for-profit services, mostly in the form of residential homes for those who are able to pay. There appear to be few, if any, organized services for the majority of older people who fall between these extremes of the spectrum (source: https://www.who.int/publications/i/item/9789241513388).

Because organized systems of long-term care are generally lacking, families constitute the major source of care for older people who are no longer able to live independently. However, evidence also reveals that a substantial group of older people receive no family care whatsoever. The majority of family care is provided by female relatives, ranging in age from children to older adults, although some studies document significant involvement of men in caregiving. Some further evidence points to a role played by unorganized and unregulated domestic workers in long-term care provision. Care is provided either in older people’s homes or in the home of caregiving relatives (source: https://www.who.int/publications/i/item/9789241513388).

Many researchers and some policy-makers in sub-Saharan Africa have concluded that it is no longer feasible to rely on kin as the mainstay of long-term care provision, given a perceived weakening of extended family support systems. Key factors assumed to underly this shift include increased rural to urban migration and labour force participation, especially among young women; increasingly monetized economies; the impact of the HIV/AIDS epidemic (increased deaths among younger adults); and loosening norms and structures for extended family solidarity. Although perhaps intuitive, it is important to note that presumed declines in family care provision have not yet been studied formally and considerable debate continues about the ways in which social trends are shaping the experiences of families and later life in sub-Saharan Africa (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: August 4th, 2021


Sweden

Municipalities and county councils can decide on how to organise the provision of LTC, including collaboration with different providers. Institutional and home care may be provided either by a municipality or a private provider (which can include private companies but also trusts and cooperatives). However, even when care is provided by the private sector, municipalities and country councils still have the exclusive responsibility for ensuring financing, provision and ensuring an adequate level of quality. In 2018 around 24 % of homecare was delivered by private providers (source: https://ec.europa.eu/info/sites/info/files/file_import/joint-report_se_en_2.pdf;  https://sweden.se/society/elderly-care-in-sweden/).

Last updated: August 4th, 2021