Knowledge Brief Health, Nutrition and Population Global Practice AGING AND HEALTH: POLICY CONSIDERATIONS FOR LONG-TERM CARE Meriem Boudjadja, Sameera Altuwaijri, and Seemeen Saadat for the Healthy Longevity Team July 2024 KEY MESSAGES: • Providing care for older parents or parents-in-law significantly reduces the probability of employment and annual earnings, particularly among women and intensive caregivers, which remains the most prevalent form of long-term care (LTC) for older adults. • Addressing the growing care needs of older adults requires increasing coordination, integration, and capacity building within the health and long-term care systems. Engaging the private sector can help bridge the gap between supply and demand of LTC. • Governments play a crucial role in providing and regulating LTC services, especially in low- and middle- income countries (LMICs) where progress has been slow and uneven. • Many countries have taken steps towards implementing LTC services, but more is needed to improve access, affordability, and quality of services. A person-centered approach with multiple options supports greater access to LTC services. Introduction Concurrently, there is growing recognition that family- All over the world, people are living longer, and the based informal care for older adults alone – traditionally the proportion of older adults in growing rapidly. Population mainstay of old age support, often performed by women in projections indicate that the share of people aged 65 years the household – is no longer sufficient to meet the growing or older will surge worldwide from 9 percent in 2019 to 16 demand for LTC services for rapidly aging populations percent in 2050, with the cohort of the “oldest old”, across LMICs (Feng 2019). Yet, in most countries, LTC has individuals aged 80 years and above, expected to reach an yet to receive sufficient priority on the national policy estimated 4.4 percent of the global population by 2050 agenda (Scheil-Adlung 2015). (UNWPP 2019). Notably, the aging process is accelerating at a more rapid pace in low- and middle-income countries The Healthy Longevity Initiative (HLI) is a multi-year, multi- (LMICs) than in high-income countries (HICs). disciplinary analytical study to advance technical and operational knowledge to promote healthy longevity and This significant demographic shift is accompanied with support maintenance of human capital during adulthood rising rates of people with functional dependency1, age- through addressing key challenges for older populations. related disabilities, and an increasing burden of non- This brief is based on three HLI background papers on the communicable diseases (NCDs). These trends highlight demand and supply of long-term care in LMICs, the health the escalating need for long-term care services (LTC). and long-term care needs of aging populations, and the Page 1 HNPGP Knowledge Brief • relationship between familial caregiving and the labor For example, in China, national and local governments supply of women and men aged 40 to 59 years (Araújo and encourage public-private partnership LTC service delivery Garcia 2024; Gatti et al. 2024; Glinskaya et al. 2024). models, whereby the government contracts with a qualified private-sector company to deliver the desired services or operate a government-built facility. In other countries, Study Findings policy efforts and private sector initiatives have put an emphasis on fostering home and community based LTC AVAILABILITY OF LTC SERVICES services such as community homes or day centers to meet older people’s needs and preference for such services. LTC encompasses “a range of healthcare and social care Moreover, some models such as China’s ‘Happiness services and assistance, for people who, as a result of Homes’ allow older adults to maintain independent lives mental and/or physical frailty and/or disability and/or old while helping each other and offer alternatives to age, over an extended period of time depend on help with institutional or family based care. daily living activities, and/or need some permanent nursing care” (European Commission 2021). As such, LTC covers In contrast to health care services, for which increases in both medical care and non-medical services. projections of demand due to aging are more uncertain, the rise in long-term care expenditures is assured with the Where available, the range of LTC services provided can increasing share of older individuals in the population vary, contingent upon a beneficiary's level of dependency (Rechel et al. 2009). In most LMICs and Europe, family and/or difficulties with activities of daily living (ADLs); and members continue to be primary caregivers (Villalobos can cover long-term residential care, home care, daycare Dintrans 2020). Yet, as populations age, there is a need for centers, tele-assistance services, and support for informal alternate models of LTC provision that reduce this reliance, caregivers (table 1). allowing younger family members to pursue labor market opportunities while ensuring that care is accessible, Table 1. Long-term care services, by type affordable, and of good quality. Residential Services are provided in institutions and include care housing, meals, help with daily activities, and basic health care services. These services ACCESSABILITY OF LTC SERVICES usually focus on individuals with severe degrees of dependency. Affordability of care is a significant barrier to access of LTC services across countries, especially for low and middle Home care Services provided in the house of the dependent income countries (Table 2). As publicly financed LTC is services person. Usually includes a personal assistant limited particularly in LMICs, formal care is primarily paid who helps with daily activities, but can also include a wider array of services, such as meal for by older persons and their families out-of-pocket. There delivery or help with household chores. These is generally limited availability of and access to formal services are suitable for individuals with all levels home care, community-based services, and institutional of dependency. services. Day Services offered at facilities for a number of centers hours a day but not including accommodation. Table 2. Reasons for not accessing healthcare (age These focus on preventive activities and 60+, %), by country income category promoting healthy aging, so their target HIC UMIC LMIC LIC population is autonomous individuals or people with only mild levels of dependency. Could not afford visit 15.7 30.9 60.9 60.2 Tele- Information technology-based services that No transport 12.1 19.3 20.7 29.1 assistance monitor and assist the dependent person Could not afford transport 8.7 12.9 28.1 33.0 services remotely (emergency hotlines, fall detectors, and others). They usually focus on autonomous Inadequate health 11.2 10.5 14.1 16.7 individuals or individuals with mild levels of equipment dependency. Inadequate provider skill 19.0 8.3 7.8 13.1 Services Support services for unpaid caregivers, which Previously treated badly 23.8 8.7 7.9 8.3 for may include training, counseling, respite Did not know where to go 12.2 9.7 9.8 7.8 caregivers services, and special work leave. Was not sick enough 21.5 31.8 27.3 25.8 Source: Adapted from Cafagna et al. (2019) Tried but denied healthcare 20.0 16.2 8.3 8.5 While LTC services are more common in HICs, a variety of Other 43.8 22.5 23.5 13.9 LTC provision and delivery models are emerging in LMICs. Source: WHO 2015, based on World Health Surveys 2002-2004. Page 2 HNPGP Knowledge Brief • Many countries have taken steps to provide coverage for disease-related care.2 These unpaid care responsibilities health and long-term care for older individuals through shouldered by women have significant repercussions on insurance or free services aimed at specific groups. their mental and physical well-being, as well as their ability However, due to limited public financing for LTC in most to generate income. The consequences that care LMICs, eligibility is very narrowly defined. Moreover, responsibilities have for family members’ health, wellbeing, evidence shows even when people have coverage, older and labor market participation are well documented. More individuals experience barriers to care due to factors such than 48 percent of caregivers in rural China were forced to as indirect costs (e.g., transport), poor quality of services, give up or reduce paid working time to fulfill their caregiver lack of timely care and poor provider attitudes (Table 2). responsibilities (Mayston et al. 2014). Implementing integrated, community based LTC models HLI work on gendered care responsibilities in Colombia, can address these challenges and contribute to reduced Egypt, Indonesia, and Poland shows that women taking health care costs in the form of fewer hospital admissions care of parents are less likely to participate in the labor and re-admissions, fewer emergency entries, and shorter market and that, when they do, they work for a smaller hospital stays (Costa-Font et al. 2018; Holland et al. 2014). number of hours, albeit with nuances (e.g., in Poland and Colombia, both women and men who provide care are less RELIANCE ON FAMILY CAREGIVERS likely to be employed). Overall, LTC is associated with a 5.7 percentage point gender employment gap and a 31.5 Traditionally, caregiving has predominantly been assumed percent gender earnings gap to women’s disadvantage by families, particularly women, without remuneration for (Table 3). Moreover, families make tradeoffs between the their contributions. Cultural norms and deeply ingrained opportunity cost of parental care and employment, with filial values toward older individuals often impede the women’s level of education and the presence of younger advancement of alternative public and private support children in the household influencing familial caregiving systems for elder care. decisions (Gatti et al. 2024). Worldwide, unpaid care work constitutes roughly 3 percent Acknowledging that most caregiving responsibilities are of economic output, with the majority being provided by borne by the family, even in countries where long-term care family members, typically women, and a significant portion systems provide accessible and high-quality services, of this caregiving is dedicated to non-communicable Table 3. Gender difference in the effect on employment of providing long-term care to parents, four-country pooled sample Employed Wage Employment Casual/Self Weekly Hours Log Earnings Employment Worked (USD) (2) (3) (4) (5) (1) Parental Care -0.087*** -0.087*** 0.000 -2.076** -0.476*** (0.015) (0.012) (0.014) (0.888) (0.131) Male 0.317*** 0.150*** 0.167*** 7.030*** 0.676*** (0.003) (0.004) (0.004) (0.161) (0.027) Parental Care * Male 0.057** 0.082*** -0.024 -1.324 0.315** (0.025) (0.026) (0.025) (1.332) (0.155) Observations 66244 66244 66244 46192 26825 Dep. Var Mean 0.700 0.340 0.359 43.498 7.173 Share of Parent Carer 0.021 0.021 0.021 0.018 0.022 Source: Gatti et al. 2024 Notes: (1) Sample includes all individuals aged 40-59 in Poland, Egypt, Indonesia, and Colombia. Log earnings indicate log annual earnings (in USD) conditional on being employed. (2) Robust standard errors in parentheses. *, **, *** indicate statistical significance at 10%, 5%, and 1%, respectively. Each regression includes individual and household-level characteristics: individual age, age-squared, country fixed effect, highest educational level, number of children aged 0-6, 7-12, and 13-18 in the household, and marital status. Page 3 HNPGP Knowledge Brief • many nations have made provisions to support unpaid differences (e.g., rural vs. urban), and socioeconomic caregivers, ranging from the delivery of cash benefits to inequalities (World Bank 2021). flexible working conditions, training, or counseling services. • Invest in enhancing the efficiency of healthcare A long-term care system that supports informal caregivers systems, with a focus on prevention and primary care, by providing training, respite care, labor flexibility, without compromising the quality of care. counseling, or cash transfers might help to mitigate the negative effects that care responsibilities can have on • Take steps to address data limitations related to aging caregivers’ physical and emotional health and ensure the and health necessary for designing effective policies. quality of care (WHO 2015). A person-centered and integrated approach to care is As care demands increase in aging societies, so will care paramount to achieving the shift in paradigm necessary to responsibilities, especially for women. When unpaid, such tackle the challenges of aging societies. demands further limit women’s labor market participation or impose a double work burden, when women are responsible for both paid and domestic labor (World Bank 2015). However, this also presents an opportunity to References expand formal LTC services and employment for This brief is excepted from the following HLI studies: caregivers. Araújo, N.A., and G.M. Garcia. 2024. "Health and long-term care needs in a context of rapid population aging." in Unlocking the Power of Healthy Longevity: Compendium of Research for the Policy Recommendations Healthy Longevity Initiative. Washington D.C.: World Bank. • To reduce the gap in LTC demand and supply in Gatti, R., D. Halim, A. Hardiman, and S. Sun. 2024. “Gendered Responsibilities, Elderly Care, and Labor Supply: Evidence from LMICs, public policies should support a mix of meaningful Four Middle-Income Countries”. Unlocking the Power of Healthy and affordable options – including private formal, semi- Longevity: Compendium of Research for the Healthy Longevity formal, and informal familial care - to allow families choices Initiative. Washington, D.C.: World Bank. and to contain cost of care. Glinskaya, E., X. Hou, Z. Feng, M. Angrisani, G. Suarez, et al. • Engage the private sector in developing LTC services, 2024. "Demand for and supply of long-term care for older persons in low- and middle-income countries." in Unlocking the Power of markets, and delivery systems in LMICs; and consider Healthy Longevity: Compendium of Research for the Healthy public-private partnership models of service delivery. Longevity Initiative. Washington, D.C.: World Bank. • Strengthen government stewardship for clear guidance on rules of engagement and quality assurance as well as For a fuller discussion and complete set of references, please see the regulatory capacity to enforce them. the above studies. • Take steps towards establishing a systematic approach to public LTC financing in LMICs, with guiding End Notes principles of equity, fiscal sustainability, and efficiency. 1 The loss of functional capacity is measured through difficulties and/or • Consider multipronged strategies to build and the need of assistance in performing a set of activities of daily living, classified as basic activities of daily living (ADL) or instrumental activities strengthen the LTC workforce (recruitment, training, of daily living (IADL). The former are basic activities necessary for survival retention with clear career paths) and enhance their and self-care, like eating, dressing, using the toilet, or bathing. The latter working conditions to improve the quality of care and to are more complex activities that involve some degree of cognitive function and interaction with the external world, such as cooking, shopping, using narrow gender gaps in labor participation, financial public transport, managing personal finances, and taking care o f one’s autonomy, and care responsibilities. own health (WHO 2015, 2004). 2 See the Lancet Commission on Women’s Health. Available at: • Support informal caregivers through a combination of https://www.thelancet.com/commissions/women-health-2015 . financial support and in-kind services such as respite care and labor policies, to allow the participation of caregivers in the formal labor market. This HNP Knowledge Brief presents key findings of research conducted • Future policy responses should also consider key as part of the Healthy Longevity Initiative – a World Bank initiative in distributional issues that come with population aging, collaboration with the University of Toronto, PAHO and others, and with financial support from the Access Accelerated Trust Fund. including gender gaps, intergenerational disparities, spatial The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4