Abstract

Aim: The aim of this paper is to identify and assess gaps and deficits in coverage in long-term care (LTC) systems across the globe. This analysis covers a representative group of low, middle and high-income countries in Africa (Algeria, Ghana, Nigeria, South Africa), America (Argentina, Brazil, Chile, Colombia, Mexico), Asia (Australia, China, India, Japan, South Korea, Thailand) and Europe (Germany, Poland, Russian Federation, Turkey, United Kingdom). In the context of the analysis, the national legal background and eligibility for LTC services as well as the affordability of LTC services have been assessed for the respective countries. This analysis helps bridging a gap in literature, as research on LTC system is devoted mostly to high-income countries. Little is known about LTC systems of low and middle income countries.

Results: With regard to legislation and entitlement for LTC services in the sample countries, we found that almost two out of three older citizens live in a country where families rather than governments have the legal duty to provide LTC services for older family members who cannot cover their needs on their own. While in several Asian countries the nuclear family is held responsible, in many African countries a more widely defined family is obligated. Among the sample countries, only a quarter of older citizens can refer to legal rights to LTC services provided or financially supported by the government. As we expected, a legal right to public LTC services is mainly present in high-income countries, while governments of middle-income countries have in general not yet established legal rights to public LTC services. But even in countries with a legal right to public LTC services, this right can be contrasted by a severe lack of capacities to provide the corresponding services.

With regard to affordability of LTC services in the sample countries, we found that information on affordability is only limited and piecemeal, even in high-income countries. We used the presence and levels of out-of-pocket (OOP) payments as well as the share of OOP payments in total LTC expenditure as a proxy for affordability. Among the sample countries, the levels of OOP payments for LTC services are high in African and American countries. The levels of OOP payments vary substantially in the Asian countries. While they are low to moderate in Australia, Japan and South Korea, they are high in India and Thailand. Japan is the country with the lowest OOP payments relative to total LTC expenditures. Even in the European high-income countries, OOP payments are an important source of funding for LTC services. In Germany and the United Kingdom, for example, OOP payments amount to approx. 25% and 30% of total LTC expenditures, respectively.