Long term-care protection for older persons
29
For others, the need to provide informal care requires the decision to leave the formal labour market and forego related income. As a result, informal care giving has the
potential to aggravate existing gender gaps.
Further, it is most likely that informal care giving results in a divide of those who can afford to stay at home and provide care to their relatives and those who cannot and whose
relatives might be challenged by severe gaps regarding needed services. Often the type of care provided by informal family care givers is very demanding,
particularly if care is needed not only for activities of daily living such as dressing and eating, but for persons with mental disorders. In most countries, the majority of persons
aged 65+ challenged by mental disorders are living at home and require very challenging support from informal care workers. This does not only have an adverse impact on the
informal care workers, but due to the lack of professionalism also on those persons in urgent need of specialized LTC services: The related lack of quality in LTC services might
increase the level of dependence of older persons in need.
When assessing the high numbers of informal LTC workers, it is important to keep in mind that in the majority of the countries in all regions, no professional care is publicly
financed and thus informal care is the only form of care available andor affordable. In other countries, the only alternative to informal care might be institutional care that is often
of very poor quality and has a negative reputation.
Thus, from both viewpoints – the informal family care workers and the persons in
need of care – it is important to clearly set in legislation or regulation boundaries between
tasks and responsibilities of formal and informal LTC workers and to develop successive chains of formal and informal care. Further it is important to define quality standards for
formal and informal LTC workers and to limit work burdens that can be shouldered by formal and informal LTC workers.
3.2.4. The availability of the LTC infrastructure is deplorable
Access to needed LTC services is also hampered by absent infrastructure, in both developed and developing countries, particularly in rural areas. This concerns mostly the
availability of services in settings that are person-centred and culturally responsive. Further, we find a large gap in infrastructure that is allowing for older persons to stay at
home, to receive quality care in institutions and to live in enabling community environments including retirement communities such as in Florida or Spain.
Unfortunately, globally all forms of LTC infrastructure are extremely scarce. The low availability of care institutions is particularly deplorable as institutional care remains a
crucial backbone of LTC for those who cannot be cared for at home despite the fact that institutional care is often avoided as many LTC users and their families prefer home-based
care.
Table 5 illustrates the significant shortages of infrastructure for institutional and home-based care that exist in all regions:
Globally, publicly supported home care is even more restricted than institutional care. Where LTC infrastructure is available, it is rather in urban than in rural areas for
example in Brazil, Colombia and China.
Extreme shortages of LTC capacities are observed in African countries, where capacities are close to non-existent, with only some very limited capacities in South
Africa. The situation in Africa is worsened by the largely insufficient health
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protection coverage for older persons, particularly given the severe lack of trained professionals in geriatric care, such as in Nigeria Okoye, 2013.
Very limited availability of LTC infrastructure exists in most countries of Asia and Latin America and in some European countries with the exception of high-income
countries.
In Asia, particularly India faces most severe shortages and public services are only scarcely available. Further, in some countries of Asia there is no clear distinction between
retirement homes for the poor and institutional care: For example in China no distinction is made between retired persons needing housing and those needing care Wong and Leung,
2012. As a result the quality of services is inadequate in terms of infrastructure, staffing and other resources.
Among the Latin American sample countries, Argentina has the most developed infrastructure. The state, regions or private organizations provide services nationwide.
Still, supply is rather scarce and only 2 per cent of the elderly population have the possibility to live in nursing homes, residential homes, or adapted housing Jauregui et al.,
2011. In Brazil, the respective proportion is below 1 per cent and LTC institutions are relatively small, accommodating only 23.3 people on average. Moreover, the Brazilian
institutions are concentrated in urban areas and in the North-east part of the country e.g. 34.3 per cent of the overall capacity is situated in São Paolo Gragnolati et al., 2011.
Similarly, in Colombia LTC institutions exist almost exclusively in metropolitan areas and are mainly supported by religious institutions Gómez et al., 2009. In Mexico, a very
limited amount of institutional services is available across the country, while home-based care is concentrated only in some communities:
No availability of nationwide services exist in countries that have legally established family responsibilities even if eligibility rules foresee LTC provisions in the absence
of family members.
Nationwide services both in terms of institutional care and home-based care are only available in countries that provide universal coverage for LTC.
As a result, most of those who have no legal LTC coverage, also suffer from a lack of access to both institutional and home based care.
Table 5. Gaps in availability of quality services due to shortages in infrastructure,
selected countries, 2015
Country Institutional care
Home-based care Africa
Algeria Very limited nationwide services
– No nationwide services – No services in communities
Ghana No nationwide services
No nationwide services
Nigeria
– No nationwide services – Very limited capacities in communities
– No nationwide services – No services in communities
South Africa
– No nationwide services – Very limited capacities, concentrated in two
regions Gauteng and Western Cape – No nationwide services
– No services in communities
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Country Institutional care
Home-based care Americas
Argentina Limited nationwide services
Limited nationwide services
Brazil
– No nationwide services – Very limited capacities, mainly concentrated
in urban areas and in the North-East – In some communities only
– No nationwide services – Very limited capacities in communities
Chile Very limited nationwide services
Very limited nationwide services
Colombia
– No nationwide services – Very limited capacities, concentrated in urban
areas – No nationwide services
– No services in communities
Mexico Very limited nationwide services
– No nationwide services – Very limited capacities in communities
Asia and the Pacific Australia
Nationwide services Nationwide services
China Very limited nationwide services
In some communities only – No nationwide services
– Very limited services, concentrated in urban areas
India No nationwide services
No nationwide services
Japan Nationwide services
Nationwide services
South Korea Nationwide services lower availability in rural
and “fishery” regions Nationwide services lower availability in rural
and “fishery” regions
Thailand
– No nationwide services – Limited capacities mainly private ones,
concentrated in the capital city Bangkok and some other cities
– No nationwide services – Very limited services, concentrated in a few
areas pilot areas
Europe Germany
Nationwide services Nationwide services
Poland Nationwide services
Nationwide services
Russian Federation Limited nationwide services Very limited nationwide services
Turkey
– No nationwide services – Very limited capacities, concentrated
in big cities in some communities only
– No nationwide services – Very limited services, concentrated in
municipalities such as İstanbul, Ankara, Kocaeli, Trabzon
United Kingdom Nationwide services
Nationwide services
Source: ILO based on legislation and literature review.
In conclusion, in addition to the tight eligibility rules, limited scope of benefits, and absence of a sufficient LTC workforce, access to needed LTC is significantly hampered by
the large absence of infrastructure for institutional and home-based care.
3.3. The LTC financing crisis: Insufficient public funding results in intolerable high private
expenditure, access gaps and inequalities
The choice of financing mechanisms for social protection including LTC defines the overall amount of funds available and creates different distributional effects. If LTC funds
derive from taxes, governments often use progressive income taxes or sometimes revenues
