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 is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

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, Pharoah D (eds.) and LTCcovid contributors. LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6

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.

Overview

Governance has been defined as the processes and systems by which an organisation or a society operates, encompassing leadership, planning, implementation, management and accountability.

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.

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.

International reports and sources

Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief. http://dx.doi.org/10.22617/BRF210448-2

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).

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: https://www.who.int/publications/i/item/9789241513388).

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: https://www.who.int/publications/i/item/9789241513388).

Last updated: January 6th, 2022


An important policy context for Long-Term Care (LTC) is the fact Australia is a federation.

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  (eg Victoria runs 178 nursing homes) and some home care is provided by local government (eg in Victoria).

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.

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 aged care sector, especially in light of COVID, and have recently issued their final report (Royal Commission, 2020).

References:

Royal Commission into Aged Care Quality and Safety (2020) Aged care and COVID-19: a special report. Commonwealth of Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf 

Last updated: January 17th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  


Governance of long-term care system in Austria is relatively fragmented, in that 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 long-term care 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).

References

Fink, M. (2018). ESPN Thematic Report on Challenges in long-term care. Austria 2018, Brussels, https://ec.europa.eu/social/BlobServlet?docId=19837&langId=en

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

Last updated: January 6th, 2022   Contributors: Cassandra Simmons  |  


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 (filesusr.com).

Last updated: January 6th, 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: https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html).

Last updated: January 6th, 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: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).  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: https://www.bcauditor.com/online/pubs/775/782#:~:text=The%20province’s%20six%20health%20authorities,responsible%20for%20health%20service%20delivery).

Last updated: January 6th, 2022


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, with municipalities taking a stronger role in prevention and health-oriented interventions.

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.

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

Last updated: January 6th, 2022


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: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: January 6th, 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  |  


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: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). 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: https://www.pflegebevollmaechtigter.de/amt-und-person.html).

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: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html; https://www.mdk.de/aktuelles-presse/meldungen/artikel/ab-oktober-persoenliche-pflegebegutachtungen-und-qualitaetspruefungen/).

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: https://www.mdk.de/mdk/mdk-gemeinschaft-gesundheitssystem/; https://link.springer.com/content/pdf/10.1007%2F978-3-662-56822-4.pdf).

 

Last updated: January 6th, 2022


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, the Long-Term Care (LTC) sector is a regional competence, with the central government only promoting guidelines for the system. In particular, the Ministry of Labour and Social Policy and the Ministry of Health are responsible for defining the national framework, producing general guidelines, and funding specific interventions to ensure regional equity. Further, at the central level, the National Social Insurance Agency (Istituto Nazionale Previdenza Sociale, INPS) is in charge of monetary contributions and cash allowances (above all, the companion allowance – CA – Indennità di Accompagnamento) that are paid directly to citizens. At the next level, the regions are the key actors because they regulate and fund in-kind services. Local health authorities (LHAs) and municipalities step into action when it comes to programming services and interventions that are delivered through care providers. The system is highly reliant on publicly funded services, which account, on average, for 85% of service providers’ revenues.

Coordination between different LTC responses is absent or left to local best practices and efforts at innovation. Citizens who access the LTC system can go through three different need evaluation systems (LHAs, municipalities, and INPS) to access the in-kind and cash services they are eligible for, without any kind of guidance or coordination between the different interventions.

Sources:

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: http://doi.org/10.31389/jltc.73

Last updated: January 6th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  


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: https://www.nuffieldtrust.org.uk/files/2018-06/learning-from-japan-final.pdf).

Last updated: January 6th, 2022


Public LTC expenditure in Lithuania represented 1.0% of Gross Domestic Product in 2016 (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

Last updated: January 6th, 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: https://www.who.int/publications/i/item/9789241513388).

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: https://www.who.int/publications/i/item/9789241513388).

Last updated: January 6th, 2022


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: January 6th, 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: https://www.who.int/publications/i/item/9789241513388).

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.

Sources:

Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief. http://dx.doi.org/10.22617/BRF210448-2

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: https://www.who.int/publications/i/item/9789241513388).

Last updated: January 6th, 2022


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: January 6th, 2022


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 (adb.org).

Last updated: January 6th, 2022


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: Sweden country report; https://www.sciencedirect.com/science/article/abs/pii/S2211883720300812). Although municipalities are responsible for care of older people, there are various care providers within the municipalities – these may be public or private (source: https://www.government.se/legal-documents/2020/10/dir.-202074/).

Last updated: January 6th, 2022


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.

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..

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 (see question 4.04 for more details).

Last updated: January 6th, 2022


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: https://academic-oup-com.gate3.library.lse.ac.uk/innovateage/article/4/1/igz044/5688188).

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: https://onlinelibrary-wiley-com.gate3.library.lse.ac.uk/doi/full/10.1111/1468-0009.12500#milq12500-bib-0016).

Last updated: January 6th, 2022


Contributors to the LTCcovid Living International Report, so far:

this list is regularly updated to reflect contributions to the report, if you’d like to contribute please email a.comas@lse.ac.uk

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Jorge 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, Stefania Ilinca, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, 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, 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.