LTCcovid Country Profiles

Responses to 1.04. Approach to care provision, including sector of ownership

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.

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. 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: Care, Dignity and Respect report).

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: myagedcare.gov), 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: Parliament of Australia).

Last updated: January 6th, 2022


While by law the federal states are responsible 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). The share of publicly- and privately-provided care providers varies immensely between the federal states and between the home and residential care sector.

In residential care, approximately 50% of care providers are public, 25% are non-profit, and the remaining 25% are for profit (Molinuevo & Anderson, 2017; Rodrigues & Nies, 2013). Approximately 900 nursing homes were in operation in 2017, providing 78,000 beds. Around 400 of these nursing homes were run publicly, with the remainder run by mostly non-profit (religious) organisations, such as Volkshilfe, Sameriterbund and Caritas.

In the home care sector, 91% of providers are non-profit, 8% are public and 1% are for-profit (Rodrigues & Nies, 2013). Mobile services are primarily provided by non-profit (often faith-based) organisations, while day centres (not connected to inpatient facilities) are mostly run by private providers (Grossmann & Schuster, 2017).

References

Grossmann, B. & Schuster, P.  (2017). Langzeitpflege In  Österreich:  Determinanter  Der  Staatlichen Kostenentwicklung. Studie Im Auftrag Des Fiskalrats. Wien: Fiskalrat. Retrieved from https://www.oesterreich.gv.at/themen/soziales/soziale_dienste/1/Seite.1210130.html

Molinuevo, D. & Anderson, R. (2017). Care homes for older Europeans: Public, for-profit and non-profit providers. Luxembourg: Publications Office of the European Union. Retrieved from Eurofound website https://www.eurofound.europa.eu/publications/report/2017/care-homes-for-older-europeans-public-for-profit-and-non-profit-providers

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

Rodrigues, R., &  Nies, H. (2013). Making Sense of Differences – The Mixed Economy of Funding and Delivering Long-term Care. In Leichsenring, K., Billings, J., & Nies, H. (eds), Long-term care in Europe: Improving policy and practice. Basingstoke: Palgrave Macmillan.

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


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.

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.

A recent paper situates the contemporary crisis of COVID-19 deaths in seniors’ care facilities within the restructuring and privatisation of this sector. Through an ethnographic comparison in a for-profit and non-profit facility, they explore what they identify as brutal and soft modes of privatisation within publicly subsidised long-term seniors’ care in Vancouver, British Columbia, and their influence on the material and relational conditions of work and care. Workers in both places are explicit that they deliver only bare-bones care to seniors with increasingly complex care needs, and they document the distinct forms and extent to which these precarious workers give gifts of their time, labour, and other resources to compensate for the gaps in care that result from state withdrawal and the extraction of profits within the sector. They nonetheless locate more humane and hopeful processes in the non-profit facility, where a history of cooperative relations between workers, management, and families suggest the possibility of re-valuing the essential work of care (Molinary and Pratt, 2021).

Sources:

https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf

https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2020/02/ABillionReasonsToCare.pdf

Molinari, N. and Pratt, G. (2021), Seniors’ Long-Term Care in Canada: A Continuum of Soft to Brutal Privatisation. Antipodehttps://doi.org/10.1111/anti.12711

Last updated: January 6th, 2022   Contributors: William Byrd  |  


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).

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: January 6th, 2022


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: January 6th, 2022


In 2020 there were 7,502 residential long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people.

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


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 providers 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%.

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.

Last updated: January 6th, 2022


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.

The table below classifies the Italian LTC system according to initiative and actor involved:

Typology Service/Intervention Actors involved
Cash transfer Companion Allowance (CA – Indennità di Accompagnamento) National Social Insurance Agency
Monetary vouchers to finance informal caregiving or care services Municipalities

Regions

Local Health Authorities

In-kind services Home care

Nursing homes

Day care

Informal caregiving

Local Health Authorities and Municipalities

Municipalities and regions; providers (public, private, or not for profit)

Relatives or migrant care workers

(source: https://journal.ilpnetwork.org/articles/10.31389/jltc.73/)

Informal care and migrant care workers, often with irregular contracts, play an important role in the organisation and provision of home care.

Sources:

European Commission (2016) Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee.

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  |  


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: January 6th, 2022


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: January 6th, 2022


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: CEQUA Poland Country Report).

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  


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: January 6th, 2022


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: January 6th, 2022


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: January 6th, 2022


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: January 6th, 2022


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: January 6th, 2022


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: January 6th, 2022


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: January 6th, 2022


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: ICF report). 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: CMA report). 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 organisations had either closed or handed back contracts in the last six months of 2020, creating enormous disruption and discontinuity for those receiving care. Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: CQC).

Last updated: January 6th, 2022


Care at home is either provided by the local authority, the health board (in the case of NHS Highland), by private firms or voluntary/not for profit firms. According to data collected by the Care Inspectorate, as of 31st March 2020, of the 1,046 registered care at home for adults’ services, 495 (47%) were run by voluntary or not for profit organisations, 406 (39%) by private firms, 136 (13%) by the local authority and in NHS Highland 9 (<1%) care at home services were provided by the health board.

Within the care home setting, ownership types are the same but unlike care at home, in Scotland most care homes are privately owned. Specifically, as of March 2020, 680 (63%) of care homes for adults were privately owed. The remainder were owned by voluntary or not for profit organisations (24%), local authorities (12%) and the Health Board (1%).

Last updated: January 6th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  


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.