Improve the quality of health and social care services for the elderly

01/04/2024 07:10 AM

Policymakers, health care systems, and families are all facing the question of how to provide high-quality long-term care and how to finance that care growing senior population. According to the World Health Organization, “Long-term care includes a broad range of personal, social, and medical services and support that ensure people with, or at risk of, a significant loss of intrinsic capacity (due to mental or physical illness and disability) can maintain a level of functional ability consistent with their basic rights and human dignity.” (WHO, 2022)

Population ageing is unfolding at a faster rate in much of the Americas than elsewhere. In Latin America and the Caribbean, by 2050, the proportion of people aged 65 or older will more than double, and will be larger than the number of children under age 15 (PAHO, 2021a). In addition, rather than stabilize at around 1.75 children per women on average as experts had predicted, the fertility rate has dropped rapidly and further. In some countries it has already reached “ultra-low” levels (around 1.3 children per woman) seen in only a handful of countries outside the region (Constance, 2024).  A similar picture emerges in North America. In Canada, the population aged 65 and older is expected to grow by 68 per cent over the next twenty years, and has more than tripled in the last 40 years (CIHI, 2017). In the United States, by 2060, nearly one quarter of the population will be aged 65 or older, and the number of those aged 85 and older will triple (Vespa, 2018).

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Simultaneously, the “disease burden by age” is on the rise. Despite significant advancements in health care, life expectancy has outpaced healthy life expectancy, resulting in an average ten-year gap between the two. Notably, in countries that have made substantial strides in improving life expectancy, this gap is even more pronounced. The increasing prevalence of disability among older individuals has raised the demand for LTC (PAHO, 2021b, as cited in ISSA, 2021a). Eight in ten people aged 65 and over have LTC needs, underscoring the critical need for such services. As the Americas undergo an epidemiological transition, chronic conditions and, by extension, care dependency are rising (IDB, 2019; Villabos Dintrans et. al, 2021).

Defining long-term care

According to the World Health Organization, “Long-term care includes a broad range of personal, social, and medical services and support that ensure people with, or at risk of, a significant loss of intrinsic capacity (due to mental or physical illness and disability) can maintain a level of functional ability consistent with their basic rights and human dignity.” (WHO, 2022)

More than 8 million older people in Latin America depend on long-term care (LTC), accounting for 12% of people aged ≥ 60 years and almost 27% of those aged ≥ 80. It is crucial to develop sustainable strategies for providing LTC in the area, including institutional care. This special report aims to characterize institutional LTC in four countries (Brazil, Chile, Costa Rica and Mexico), using available information systems, and to identify the strategies adopted to support institutional care in these countries. This narrative review used nationwide, open-access, public data sources to gather demographic estimates and information about institutional LTC coverage and the availability of open-access data for the proportion of people with LTC needs, the number of LTC facilities and the number of residents living in them. These countries have a larger share of older people than the average in Latin America but fewer LTC facilities than required by the demand. National surveys lack standardization in defining disability, LTC and dependency on care. Information about institutional care is mainly fragmented and does not regularly include LTC facilities, their residents and workers. Data are crucial to inform evidence-based decisions to favor prioritization and to support advances in promoting policies around institutional LTC in Latin America.

The need for LTC can emerge suddenly or develop gradually. The need can often arise from an acute health issue that leads to chronic consequences, such as a heart attack, stroke or hip fracture. Alternatively, it can develop gradually due to progressive and chronic conditions, such as dementia or frailty (WHO, 2021). LTC may be required continuously or intermittently over an extended period and should meet its primary objective to “enable older people, who experience significant declines in capacity, to receive the care and support that allow them to live a life consistent with their basic rights, fundamental freedoms and human dignity,” (ibid.).

In practical terms, LTC should comprehensively address the health care, personal care, and social needs of individuals, including support with activities of daily living (ADL) such as bathing, dressing, mobility, eating, and toileting (Addati et. al., 2022).

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Furthermore, LTC encompasses a diverse spectrum of services, including preventive measures and end-of-life support, provided within both the health and social care sectors (WHO, 2021). The complex and interconnected nature of LTC poses a significant challenge for social security systems. However, by effectively leveraging existing resources in health and social care along an integrated continuum, social security systems can effectively evolve and enhance the LTC system (ibid.).

Long-term care systems in the Americas

Currently, health care systems in the region often place a stronger emphasis on addressing specific diseases rather than considering the loss of functional ability. This prioritization has led to the incomplete integration of LTC into primary health care (WHO, 2021), with implications for both care recipients and the sustainability of the health care system.  As long as LTC services remain separate from the broader health care framework, there is a risk of inefficient use of health care resources, resulting in high health care expenditures (PAHO, 2021b, ISSA, 2021a; Lloyd-Sherlock, et. al, 2022).

Throughout history, particularly in Latin America and the Caribbean, the predominant approach to addressing LTC needs has been through care provided by the family and the community. Though formal LTC provision remains largely sporadic, fragmented and lacking a structured regulatory framework in much of the region, changing demographics have pushed several countries to expand the offer of institutional care services. While the delivery of LTC services in the region mainly operates at the municipal and local levels, in collaboration with private organizations and local governments, there is a growing sense of urgency for systemic reforms (Panadeiros and Pessino, 2018; IDB, 2022).

Notably, Costa Rica recently enacted Law 10192, establishing the National System of Care and Support for Adults and Seniors in a Situation of Dependency (Sistema Nacional de Cuidados y Apoyos para Personas Adultas y Personas Adultas Mayores en Situación de Dependencia - Sinca), effective from June 14, 2022. Similarly, Chile has ambitious plans to implement the National Care System (Sistema Nacional de Cuidados - SNC) (Gobierno de Chile, 2022). Argentina has also proposed a bill to establish the Comprehensive Care Policy System of Argentina (Sistema Integral de Políticas de Cuidados de Argentina) (Casa Rosada Presidencia, 2022). Both Chile and Argentina place a significant emphasis on addressing caregiving requirements by centring their efforts on the well-being of care workers, who are predominantly women (Manzanas del Cuidado, n.d.).

Although assistive care needs are a significant component of LTC needs, countries are also focusing on preventive care and promoting healthy and active ageing, in addition to enhancing palliative and end-of-life care. Argentina, for instance, has initiated a comprehensive palliative care programme at the national level, incorporating interdisciplinary care, therapeutic interventions, and medical support, as outlined in Law 27.678 and respective Decree 311/2023 (Ministerio de Salud (Argentina), 2023, 2022). Uruguay has passed legislation guaranteeing universal access to palliative care, previously only available in half of the country’s provinces (Parlamento del Uruguay, 2023). Chile has also enacted such a law that ensures universal coverage (Law 21.375), implemented in March 2022 (Ministerio de Salud (Chile), 2022). Additionally, countries like Brazil and Ecuador have established regulatory frameworks for active and healthy ageing initiatives through specific programmes. Colombia, on the other hand, has incorporated such initiatives within its broader national policies (Inter-American Commission on Human Rights, 2022).

Long Term Care

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Both private and public health, plus social providers have been instrumental in this transformation (PAHO, 2021b, as cited in ISSA 2021a). While only a handful of these countries have established a formalized LTC system, several have taken steps to create institutions and programmes, primarily oriented towards the ageing population, to better address the growing LTC needs. In addition, measures towards establishing a shared vision and adopting a multidisciplinary approach, while acknowledging the role of various service providers are aimed at a more sustainable delivery of LTC services.

In North America, there has been a significant drive towards the concept of “ageing in place,” with a strong preference for home care over institutional care. In Canada and the United States (USA), a striking 78 and 77 per cent of people surveyed expressed a strong preference for home-based care, underscoring the need for investments in home adjustments and assistive technologies (March of Dimes Canada, 2021; AARP, 2022). In practice, LTC services are already delivered in Canada and the USA through existing health systems (OECD, 2023). These services encompass a broad range of health care benefits, including home visits by primary health care teams, community-based health care, the provision of assistive products, and the utilization of telemedicine (WHO, 2021; ISSA, 2021b). Disease prevention, chronic care, and palliative care services are typically provided in hospitals or assisted living facilities, while social care and support activities, such as those responding to declines in intrinsic capacity, are often administered within the home or local community. For situations with specific requirements, such as dementia care and rehabilitation, both home and institutional settings can be suitable. Furthermore, financial support is extended through cash benefits that subsidize services and goods, such as assistive devices. These benefits may be distributed directly to service providers or beneficiaries (Tessier, De Wulf and Momose, 2022).

Service providers may include a range of entities, encompassing public, private for-profit organizations, as well as not-for-profit entities such as mutual benefit societies, cooperatives, and associations operating within the health and social care sectors. In addition to unpaid carers, formalized care workers play a crucial role and may include home-health aides, registered nurses, community health care workers, social workers, physicians, physiotherapists, occupational therapists, and others.

The effective functioning of the LTC systems in the region hinges on the coordination and collaboration between multiple stakeholders, including various ministries, civil society organizations, the public and private sectors, and service users themselves. According to the Pan American Health Organization (PAHO, 2021b), this comprehensive approach to coordination is essential for optimizing LTC services.

Regarding the criteria for eligibility, most countries in the region evaluate the level of dependency and incorporate age-related requirements into their LTC assessment. While a preference exists for evaluating eligibility based on functional dependence rather than age, practical financial constraints often require the imposition of age-related restrictions (IDB, 2022; Matus-Lopez and Francisco Terra, 2021). Furthermore, recognizing the profound impact of ageing on LTC needs, it is essential to address LTC within the broader context of ageing, beginning with the establishment of effective health coverage tailored to the needs of older persons.

This article presents an overview of the LTC systems across the Americas by examining the diverse approaches taken by five countries to provide integrated health and social care services to meet LTC needs. It offers a description of the health and social care services accessible to the ageing population in Argentina, Canada, Chile, Costa Rica, and Uruguay.


Health coverage

In Argentina, both pensioners and persons of retirement age who do not receive a pension are eligible for health coverage. Access to free medical services is offered at public hospitals and primary health care institutions. For those who have accumulated entitlements under social insurance, the basic medical benefit package provided includes services such as palliative and rehabilitative care (Argentina - Decreto 492/95, 1995). During hospitalization and for those with chronic conditions, pharmaceutical products are supplied free of charge (ISSA, 2019a).

Argentina also has a federal telehealth programme prioritizing care for vulnerable populations, including adults aged 65 and over (Ministerio de Salud (Argentina), n.d.a, n.d.b).

In addition, persons with disabilities who lack health insurance or who are beneficiaries of non-contributory pension schemes are entitled to a subsidy for equipment to facilitate mobility, personal care, and communication (Agencia Nacional de Discapacidad, 2023).

Long-term care services

The National Secretariat for Childhood, Adolescence and Family – National Directorate of Social Policies (Secretaría Nacional de Niñez, Adolescencia y Familia – Dirección Nacional de Políticas Sociales – SENAF-DINAPAM) plays a pivotal role in the development of long-stay residences and day centres by offering training and financial support for equipment.  Service providers for these facilities are typically public centres, endorsed by provincial authorities and non-governmental organizations (NGOs). Qualifying conditions and services vary depending on location and provider, but these typically target low-income adults over 60 with varying degrees of dependency. Presently, eight long-stay residences are financially sustained through a combination of subsidies, donations, and revenue generated from service fees (Ministerio de Desarrollo Social (Argentina), 2023). Other residences and day centres operate at the municipal level (Ministerio de Salud (Argentina), 2023). The provision of teleassistance services is rather sporadic and predominantly organized at the municipal level, facilitated by not-for-profit organizations and local governments (PAHO and IDB, 2023).

The Programme for Comprehensive Medical Care (Programa de Atención Médica Integral - PAMI) takes an integrative approach to health and social care services, operating in both private and public settings. It provides subsidies to affiliated retirees and pensioners, enabling them to access home care services that help with activities of daily living. Eligibility for these benefits is determined based on the level of dependency, age, and socioeconomic status. The institution conducts a thorough medical assessment and evaluation (PAMI, 2023). Additionally, some municipalities provide free home care services to older residents experiencing extreme poverty (Ciudad de Buenos Aires, 2023).

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Health coverage

According to the Canada Health Act of 1985, health coverage is available to all legal residents of the country. Beyond a mandatory level of services, provinces and territories have the flexibility to provide "additional benefits" under their respective health insurance plans, which are funded and administered according to their own terms and conditions. These supplementary benefits, whether partially or fully covered, often target specific population groups, such as seniors. For instance, in Ontario, palliative care services are delivered by primary health care providers and local hospitals across various care settings. Provided at all stages of illness (beyond assessment and symptom management), this type of care is extended to include personal support and homemaking services, as well as physiotherapy, among other services (Government of Ontario, 2023a). The Assistive Device Program allocates funding for personalized assistive products, which may include mobility aids, hearing devices, communication aids, respiratory equipment, and diabetic supplies, designed for individuals with long-term physical disabilities. The programme covers 75 per cent of the total cost for these products, underscoring the commitment to enhancing the quality of life for those in need (Government of Ontario, 2023b).

Long-term care services

Excluded from the public insurance under the Canada Health Act, long-term facilities-based care is managed at the provincial level. With facility-based LTC, medical and personal care services are subsidized, while expenses related to accommodation and related services, such as food and laundry, are typically charged to the patient on their means-tested financial contributions. In addition to an income test, there may be a dependency-level needs assessment (Government of Nova Scotia, 2021). Services range from assistance with ADL to the provision of specialized services like physiotherapy. Some publicly subsidized day or community centres are provided free of charge, although health authorities may charge a nominal daily fee, which is subject to a maximum limit of 10 Canadian dollars (CAD) per day, though exemptions may apply in cases of serious financial hardship (Government of British Columbia, 2023).

Similarly, home and community care services in Canada are primarily administered by provinces, territories, and municipalities. The federal government provides funding through transfer payments for health and social services. Care delivery may be managed directly by the health authority or entrusted to a third party. For patients with assessed care needs, these services are subsidized, and patient co-payments are determined based on their income levels. Additionally, individuals may receive public funding to purchase their own personal care, home support, and respite care (Alberta Health Services, 2017). Regarding teleassistance, certain provinces and local governments have introduced initiatives to leverage technology to provide remote assistance (Gouvernement du Québec, 2023). These efforts reflect the commitment to enhancing accessibility and support for individuals care services.


Health coverage

In Chile, legally resident pensioners, those without a source of income, and beneficiaries of social assistance are eligible individuals for medical coverage. Provided by public or private institutions, benefits include periodic examination, hospitalization, rehabilitative and palliative care (Ministerio de Salud (Chile), 2023a). Additional benefits include chronic disease management, procedures such as hip replacements, and the provision of technical aids. Through the telehealth programme, private and public providers also treat conditions affecting older persons (Ministerio de Salud (Chile), 2018). For adults aged 65 and older, there are opportunities to receive subsidies for assistive devices, such as wheelchairs and crutches (Ministerio de Salud (Chile), 2010). These measures underscore the commitment to providing a comprehensive range of healthcare services tailored to the specific needs of older adults in Chile.

Long-term care services

Residential care in Chile operates through a co-financing model involving both the central and local governments, with not-for-profit organizations responsible for providing the care (PAHO and IDB, 2023). The National Service for the Elderly (Servicio Nacional del Adulto Mayor – SENAMA) delegates the operation of long-stay residences to municipalities or not-for-profit entities (SENAMA, 2023). Additionally, the Regional Ministerial Secretariat of Health (Secretaria Regional Ministerial de Salud – SEREMI) must grant authorization for the operation of these residences (Ministerio de Desarrollo Social y Familia, 2023). The residences specialize in providing care to individuals aged over 60 with physical or cognitive dependency who require assistance performing ADL. Beneficiaries should belong to the bottom 60 per cent of households income (Ministerio de Salud (Chile), 2023b). Community or day centres are predominantly managed at the municipal level. SENAMA provides an operations guide, but funding is primarily allocated by municipalities and not-for-profit organizations. Specialized community support centres are also available for individuals over 60 who have mild to moderate dementia (Ministerio de Salud (Chile). 2023b). Some municipalities offer day centres free of charge, often contracting private companies to provide the services (PAHO and IDB, 2023).

There are two home care programmes, one for adults with severe dependency and another at the municipal level designed for adults with moderate dependency. The local health service administers the benefits, with the Ministry of Health (Ministerio de Salud) and Health Superintendency (Superintendencia de Salud) monitoring the programme (Ministerio de Salud (Chile). 2023b). Various other programmes are also directed towards older individuals, including a food delivery initiative offered by the Ministry of Health, among several others facilitated by SENAMA. Teleassistance programmes are relatively scarce and either provided by private entities or municipalities, though some municipalities may offer these services free of charge (PAHO and IDB, 2023).

Costa Rica

Health coverage

In Costa Rica, resident pensioners are covered under the mandatory social insurance system. The Costa Rican Social Insurance Fund (Caja Costarricense de Seguro Social – CCSS) offers a comprehensive range of medical services, including general and specialist care, hospitalization, medication, auditory aids, and various medical appliances, at a reduced cost. Similarly, residents in need, particularly those with limited financial resources, receive identical benefits through social assistance programmes (ISSA, 2019b).

To ensure the well-being of older adults, the country has established community networks that conduct comprehensive health assessments. Volunteers within these networks focus on various aspects, including geriatric health, integrated community care, and home-based interventions (Presidencia de la República de Costa Rica , 2022). In addition, Costa Rica’s telehealth programme includes a specialized branch dedicated to palliative care (Presidencia de la República de Costa Rica , 2016). As well as health care services, the National Council of People with Disabilities (Consejo Nacional de Personas con Discapacidad – CONAPDIS) provides a cash benefit that covers the expenses associated with assistive devices or personal aids. This support is available to individuals without age restrictions, but beneficiaries must have a certified disability, and it is specifically aimed at those with low incomes (Viceministerio de Desarrollo Humano e Inclusión Social, 2022).

Long-term care services

In the country, LTC services are primarily delivered by private organizations, operating under the authority of the Ministry of Health and their respective municipalities. Certain organizations can qualify for state subsidies if they meet the criteria for recognition as “Social Welfare Organizations” (Organizaciones de Bienestar Social – OBS), which provide services to low-income adults (CONAPAM, 2023). Additionally, NGOs have the flexibility to create programmes that incorporate shared payment systems (Costa Rica – Ley No. 10192, 2022).

The National Council of the Elderly (Consejo Nacional de la Persona Adulta Mayor – CONAPAM) plays a key role in providing home care support services to legal residents of Costa Rica who are aged 65 and over (Viceministerio de Desarrollo Humano e Inclusión Social, 2022). The care network for older persons comprises individuals, families, organized community groups, NGOs, and government agencies. These entities collaborate in offering high-quality care to older persons, often seeking government aid to fund home care, day centres, and residences. Home care support services include both basic home care and specialized care. In addition, a temporary subsidy is available to facilitate the relocation of older persons with dependency to certified institutions (Viceministerio de Desarrollo Humano e Inclusión Social, 2022). Both the CCSS and private providers offer teleassistance services, underscoring the commitment to offering a wide range of support options for older adults (ISSA, 2021a).


Health coverage

Within the framework of national health insurance, legally resident pensioners and individuals receiving old-age benefits through social assistance enjoy comprehensive coverage in Uruguay. The provision of medical services is mainly supplied by mutual health institutions, which offer a broad range of health care services, including medical assistance, surgical procedures, pharmaceutical products, as well as grants for essential items such as eyeglasses, prostheses, wheelchairs, and more. Approved service providers include both public clinics and hospitals managed by the state health services administration, as well as private health care providers. Importantly, public hospitals and clinics do not require any cost-sharing from patients, ensuring access to care without financial barriers (Ministerio de Desarrollo Social (Uruguay), 2021).

For older adults, primary health care includes the management of chronic diseases (Presidencia de Uruguay, 2021). Basic services include therapeutic interventions but also palliative care (Uruguay – Decreto N° 465/008, 2008) (Uruguay – Decreto N° 289/009, 2009). Additionally, this essential benefit package includes medication for dementia and rehabilitation (Ministerio de Salud Pública, 2018). Lastly, both public and private providers offer universal telemedicine services (Law No. 19869, 02/04/2020). This underscores the effort to provide accessible health care services through remote means, supporting the convenience and well-being of the older adult population (Uruguay - Ley No. 19869, 2020).

Long-term care services

Day centres are available at no cost for low-income adults aged 60 and over (Ministerio de Desarrollo Social (Uruguay), 2022; Aranco and Sorio, 2019, as seen in IDB, 2022). These centres receive both technical and financial support from the Social Insurance Bank (Banco de Previsión Social – BPS). In addition, the Ministry of Public Health (Ministerio de Salud Pública) operates a day centre within the Geriatric Center Hospital, and several municipal authorities, NGOs, religious communities, and cooperatives also operate day centres (Sistema de Cuidados, 2020a; Aranco and Sorio, 2019, as seen in IDB, 2022). To further enhance the quality of services provided, a territorial monitoring commission collaborates at the inter-institutional level with the Comprehensive National Care System (Sistema Nacional Integral de Cuidados – SNIC). This coordination is crucial in ensuring the effectiveness and efficiency of these day centres.

The national care system provides financial assistance through subsidies for in-kind benefits and offers direct payments to service providers. Two primary programmes are offered: a personal assistant programme designed for individuals with severe dependency and a teleassistance programme tailored for those with mild or moderate dependency. To qualify for the personal assistant programme, individuals with LTC needs must either be younger than 29 or older than 80, reside within the national territory, and have accumulated at least 10 years of residency. The benefit amount is determined by the individual's income and covers a maximum of 80 hours of service per month. The teleassistance benefit is also income-based and limits eligibility to persons aged 70 or older with mild or moderate dependency. The maximum benefit covers the cost of the monthly teleassistance service, whilst the device and installation are provided to the beneficiary at no cost. Beneficiaries are granted the flexibility to choose a private teleassistance provider and a personal assistant from the national care system registrar. (Sistema de Cuidados, 2020a; Ministerio de Salud Pública, 2023)

Within the national care system, certified long-stay residences, which are typically managed by not-for-profit or community organizations, may apply for loans (IDB, 2019; Ministerio de Salud Pública, 2022). Outside the national care system, the BPS offers a range of residential services. Additionally, various fragmented services are available for low-income older adults with disabilities (Matus-Lopez and Terra, 2021; Sistema de Cuidados, 2020b). The BPS takes comprehensive measures to support vulnerable pensioners, including the provision of housing solutions for those with severe dependency (Social Insurance Bank, 2021). The BPS offers a rehabilitation cash benefit for invalid pensioners, aimed at enhancing their well-being and quality of life (Social Insurance Bank, 2023).

Final remarks

Despite regional heterogeneity, the countries presented here provide valuable insights into the health care  and social service strategies used to meet evolving LTC needs in the Americas. Notably, several countries have established programmes to address health-related challenges, such as the Assistive Device Program in Canada-Ontario and coverage of chronic diseases and palliative care in Argentina and Uruguay. In addition, organizational developments to manage care services and stay residences are being made in Chile through the National Service for the Elderly (Servicio Nacional del Adulto Mayor) and in Costa Rica through the National Council of the Elderly (Consejo Nacional de la Persona Adulta Mayor). However, the current challenge lies in the effective integration of LTC into primary health care, ensuring seamless coordination without overburdening existing health care systems. This system integration strives to mitigate the risks of excessive fragmentation, while also distributing responsibilities and financing across various service providers, ultimately fostering a more sustainable LTC system.

Though it is not the focus of this article, the importance of equipping a workforce with adequate training, decent remuneration, and good working conditions should not be overlooked. Argentina, for instance, has developed specific training programmes to aid home carers assisting those with cognitive decline, Alzheimer’s disease, and dementia (Ministerio de Desarrollo Social (Argentina), 2023). Similarly, Uruguay’s national care system requires that personal assistants complete certification through the Ministry of Education (Ministerio de Educación) training course, becoming registered with the BPS, and gaining authorization from the NCS Secretariat.

Addressing the enduring and multifaceted challenges posed by LTC calls for countries to establish common definitions and categorize LTC requirements effectively. It involves strengthening LTC policies at both national and regional levels and fostering international coordination to exchange experiences and approaches (PAHO, 2021b, as seen in ISSA, 2021a). In turn, through a project producing guidelines, technical reports and articles, the ISSA supports its members in addressing challenges to administer sustainable LTC systems with a high-quality workforce, ensuring quality care, and enhancing inter-institutional coordination to create more robust LTC systems.