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Spring 2013 • Vol. 37
.No. 1 | 59
GENERATIONS – Journal of the American Society on Aging
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
info@asaging.org
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Most of us go through our day-to-day tasks,
from taking a shower, to getting dressed,
to making breakfast, without a second thought
about the effort required to accomplish them.
However, for older adults who may experience
significant disability from injury or disease, these
daily activities present challenges that may re-
quire ongoing assistance from family members,
friends, or a formal care service provider. Long-
term services and supports enable those who
need continual help because of physical, cogni-
tive, or developmental disabilities to accomplish
the necessary tasks of daily living.
The definition, measurement, and prevalence
of disability vary across the globe. For example,
in Kenya and Bangladesh, estimates report that
less than 1 percent of the population experiences
a disability, compared to 20 percent for New
Zealand and Australia and 19 percent in the
United States and Canada (Mont, 2007). Disabil-
ity rates vary so dramatically between countries
for a number of reasons—from age distribution,
life expectancy, and socioeconomic status, to
healthcare availability. However, the most
significant explanations for these variations
appear to be derived from issues surrounding
measurement and data collection.
Although good data for comparing disability
rates across nations are lacking, virtually every
nation has older adults with some disability who
need assistance with basic tasks of daily living.
The U.S. Census Bureau estimated that
worldwide, the number of people older
than age 80—those most likely to need
long-term services—will increase by
233 percent between 2008 and 2040
(Kinsella and He, 2009). This article
will focus on how countries are responding to
the new and growing challenges of assisting older
people with long-term services and supports.
Defining Long-Term-Care
Services and Supports
It is important to have a common understand-
ing of what is meant by long-term care (LTC).
As noted, individuals who require long-term
services and supports primarily need ongoing
assistance with the basic tasks of daily living.
In some instances, individuals may have acute
medical needs as well, but it is the personal and
instrumental tasks of life—such as dressing,
bathing, walking, housekeeping, meal prepara-
By Robert Applebaum, Anthony Bardo, and Emily Robbins
International Approaches to
Long-term Services and Supports
When dividing governmental levels of
support into five groupings, the United
States falls in the middle of the pack.
Between 2008 and 2040, the number of
people worldwide who may need long-term
services will increase by 233 percent.
GENERATIONS – Journal of the American Society on Aging Pages 59–65
60 | Spring 2013 • Vol. 37
.No. 1
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
info@asaging.org
. For information about ASA’s publications
visit
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tion, and laundry—that define someone’s daily
level of care needs. Long-term services can be
provided in a range of environments, from an
individual’s home to the home of a friend or
relative, an adult day facility, a foster home, an
assisted living community, or a nursing home.
The type and amount of assistance needed are
affected by one’s environment, available tech-
nology, geographic area, and needed level of
care. A person’s circumstances can exacerbate
or mitigate challenges of accomplishing the tasks
of everyday living, but the need to provide
ongoing long-term services and supports is
universal across nations.
Typologies of Long-Term-Care
Services and Supports
To date there is no formal systematic method
to categorize and compare LTC systems cross-
nationally. Kraus and colleagues (2010) catego-
rized twenty-one of the European Union LTC
systems using two distinct clustering strategies.
One approach focused on LTC system charac-
teristics, while the other focused on system use
and financing. The first approach examined the
availability of such components as cash benefits,
and whether or not individuals had a choice of
provider. The second approach focused on areas
such as public expenditures on LTC as a share
of gross domestic product, the share of private
expenditures, and the proportion of the older
population that used formal care.
An analysis by the Organisation for Econ-
omic Co-operation and Development (OECD)
expanded upon the Kraus typology (Colombo et
al., 2011). Their classification was based on the
funding structure (universal, means-tested, or
mixed) and care provided by each LTC system.
Universal systems provide publicly funded nur-
sing and personal care to all eligible individu-
Table 1. Typology to Classify a Country’s Long-Term Care Services and Supports System
Group 1 Group 2 Group 3 Group 4 Group 5
Public insurance
funding available
for long-term
care-services
Mixture of public
insurance and
means-tested
funding available
All funding for
long-term services
is means-tested
Funds are means-
tested but quite
limited in availability
No public funds
are available
for long-term
care-services
HCBS (home- and
community-based
services) widely
available
HCBS widely
available
HCBS commonly
available
HCBS are of limited
availability
HCBS not available
Institutional care
widely available
Institutional care
widely available
Institutional care
widely available
Institutional care
somewhat available
Institutional care
rarely available
Housing with
services widely
available
Housing with
services widely
available
Housing with
services available
Housing with
services is of
limited availability
Housing with
services not
available
Cash payments often
available for
long-term services
Cash payments
generally available
Cash payments
available on a
limited basis
Cash payments
not available
Cash payments
not available
Informal care is
one component of
the system
Informal care is an
important part of
the system
Informal care is a
critical element
of the system
Very heavy reliance
on informal care
Exclusive reliance
on informal care
Examples:
Germany, Japan,
Korea, the
Netherlands
Examples:
Australia, France,
Ireland, Spain,
Switzerland
Examples:
Estonia, Italy, Poland,
Romania, United
States
Examples: Argentina,
Brazil, China, Egypt,
India, Mexico, South
Africa, Thailand
Examples:
Bangladesh, Ghana,
Kenya, Nepal
Source: Robert Applebaum, 2012.
Our World Growi ng Older: A Look at Global Aging
Pages 59–65
Spring 2013 • Vol. 37
.No. 1 | 61
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
info@asaging.org
. For information about ASA’s publications
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.
als (defined by level of disability) regardless of
income or assets. Under a means-tested financ-
ing structure, income and-or asset tests are used
to determine eligibility for publicly funded LTC
services and supports.
Building on previous work (Colom-
bo et al., 2011; Kraus et al., 2010), we
offer a five-category typology to classify
approaches to LTC services and sup-
ports. As noted, one can consider a range of
criteria when assessing and comparing LTC
systems. In addition to the previously identified
factors of funding and definition of disability,
we also include the supply of LTC services and
people’s access to them. In our view, it is critical
to combine the issues of financial and functional
disability requirements with the supply, balance,
and array of long-term services available. Thus
our classification approach draws heavily on
the OECD financial categories (Colombo et al.,
2011)—universal versus means-tested or mixed—
and some of the system classification factors
used by Kraus and colleagues (2010), such as
the availability of services and the amount of
out-of-pocket expenditures by individuals. We
then combined these factors with additional
delivery system indicators, such as the availabil-
ity of residential care and the balance of formal
and informal LTC services. Table 1 (on page 60)
describes the categories we established, and
selected examples of countries that have been
classified in each group.
Group 1: Universal Coverage
Nations in Group 1 have developed publicly
funded systems that provide universal LTC
coverage for older individuals. Using a range
of funding sources—including payroll tax, per-
sonal income tax, and general revenues (national,
regional, and-or municipal)—these countries
have in common a long-term benefit covering
both in-home and institutional services for their
older populations; they have developed system-
atic approaches to identifying and determining
levels of long-term disability, and have estab-
lished an array of service options. Their LTC
systems typically include a supportive service
option linked to housing and self-directed and
cash options for recipients. Although informal
caregivers are involved both as unpaid and
(sometimes) paid caregivers, the overall long-
term services and supports system of the nations
in this category is designed to balance the help
from informal and formal providers. Examples
of countries in this group include Germany,
Japan, Korea, and the Netherlands.
Germany
In 1995, Germany established a universal,
non-means−tested, contribution-based system
for funding LTC (Pflegeversicherung). The
system is funded through employee payroll
contributions with matching employer contri-
butions. Pensioners pay the entire contribution
out of pocket. Since 2008, the contribution rate
for individuals has been fixed at 1.95 percent;
for those ages 23 and older without children,
there is an additional 0.25 percent contribution
charge. The German LTC insurance fund
provides for homecare (family members or
non-professional private caregivers), home-help
service (professional staff or ambulatory help),
and institutional care (Heinicke and Thomsen,
2010). Benefits are received either in kind or in
cash. The benefit amount is based on the level of
care category under which the beneficiary falls,
which is determined via an examination by a
medical review board (Medizinischer Dienst der
Krankenversicherung) designated by the insur-
ance fund.
Based on the assessment of the review board,
individuals are placed into one of three levels of
care, ranging from the lowest to the highest level
of assistance required. Although there is no age
criterion for eligibility, nearly 80 percent of
Children who come of age in China ‘have the
duty to support and assist their parents.’
GENERATIONS – Journal of the American Society on Aging Pages 59–65
62 | Spring 2013 • Vol. 37
.No. 1
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
info@asaging.org
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visit
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.
beneficiaries are ages 65 and older (Rothgang,
2010). In general, the system favors community-
based care, and individuals using institutional-
ized care pay a significant co-pay to cover the
cost of services that lie outside the scope of the
LTC insurance fund.
Group 2: Mixed Funding
Nations included in Group 2 have systems that
rely on a mixture of public insurance and means-
tested funding strategies, using a range of
financing approaches. For example, some
countries provide a universal benefit for some
long-term services, such as nursing home care,
but not for others, like assisted living or in-home
services. The nations in Group 2 typically have a
wide array of institutional, community-based
services, and specialized housing and supportive
services. These countries generally have self-
directed services available, and informal care is
an important part of the system. Examples of
countries in this group are Australia, Canada,
France, Ireland, Spain, and Switzerland.
France
France’s LTC system (Allocation Personnalisée
d’Autonomie, or APA) includes a mix of universal
and means-tested funding for a wide array of
home- and community-based services and
institutional care. The APA is overseen by the
federal government, which is the main funding
source, but divides further fiscal and organiza-
tion responsibilities among regional or local
departments (Colombo et al., 2011).
Eligibility for APA assistance is nationally
based and requires that beneficiaries be age 60
or older and meet a high level of dependency
for ADLs (activities of daily living) and IADLs
(instrumental activities of daily living). Depen-
dency assessments, carried out by an assessment
team (medical doctor, nurse, and social worker),
define a care package (Kraus et al., 2010). Every
disabled person ages 60 and older is eligible
for benefits, but compensation is based upon
income. Low-income individuals would pay little
or nothing, but individuals with higher incomes
could be required to contribute as much as 90
percent of their LTC costs out-of-pocket. In
the case of community-based services, benefici-
aries are prohibited from hiring their spouse or
partner, but may engage only accredited and
approved providers to provide care (Colombo et
al., 2011). For institutional care, the APA covers
only personal and nursing costs and requires
users or their families to pay for board and
lodging themselves (approximately US$2,000
per month). The average out-of-pocket expense
is about 20 percent of income for home- and
community-based services, and 35 percent for
institutional care (Colombo et al., 2011).
Group 3: No Public Insurance
Countries in Group 3 offer a wide array of
long-term services, including supportive hous-
ing, institutional care, and home- and communi-
ty-based services. Under this model, no public
insurance is available to fund LTC. Typically
a range of services is available to low-income
people meeting a high disability and low-income
threshold. Under the approach used in these
countries, all LTC is means-tested, and public
financing begins after the consumer has deplet-
ed his or her resources. Self-directed care is
available on a limited basis for some services for
some populations. Informal care is an integral
part of this system, with an expectation that
family members will provide primary assistance
prior to using governmental services. Examples
of Group 3 countries include Estonia, Italy,
Poland, Romania, and the United States.
The United States
The United States has an extensive array of
formal services available to the approximately
6 million older adults with disabilities, including
more than 16,000 nursing homes that serve more
than 1.5 million individuals. The Medicaid pro-
gram of health services for low-income people
pays for more than 60 percent of all public LTC
services in the United States. It has very strict
Our World Growi ng Older: A Look at Global Aging
Pages 59–65
Spring 2013 • Vol. 37
.No. 1 | 63
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
info@asaging.org
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visit
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income and asset criteria, and requires the
participant to have severe disability. Approxi-
mately two-thirds of all nursing home residents
are supported by the income-tested Medicaid
program, even though when residing in the
community, fewer than 8 percent of these in-
dividuals were eligible for the program (Stone,
2011). This is because the high cost of nursing
home care (on average more than $7,000 per
month) results in individuals “spending down”
to Medicaid eligibility after their private re-
sources have been exhausted.
Other sources of revenue for LTC include
out-of-pocket payments by individuals (22 per-
cent), private LTC insurance (9 percent), the
U.S. Department of Veterans Affairs (3 percent),
philanthropic organizations (3 percent), and
state-funded programs (3 percent). Medicare
provides a 100 percent nursing home rehabilita-
tion benefit for twenty days following a three-
day or longer stay in the hospital, and eighty
additional days with a significant co-pay. A
sizable private homecare market, estimated to
be similar in scope to the publicly supported
services, also exists for individuals who do not
meet the strict Medicaid eligibility criteria for
income and severity of disability.
Private-pay individuals—and in some states
publicly funded participants—can self-direct
their services, determining both the nature of
assistance received and who will provide the
necessary assistance. As a large country with a
well-developed services system, the United
States spends more than $225 billion annually
on LTC. The majority of the nursing homes,
assisted living facilities, and homecare agencies
are proprietary in nature, and the U.S. delivery
system is consistent with the market values
of the nation.
Group 4: Few Public Funds,
Private Providers Developing
Nations in Group 4 have very limited public
funds to support individuals in need of LTC,
but they have begun to see the development of
some private service providers, particularly in
the nursing home and in-home areas. In Group 4
countries—including Argentina, Brazil, China,
Egypt, India, Mexico, South Africa, and Thai-
land—older people who need such care must
rely on family and friends for the majority of
assistance received.
China
Although it was not until the 1990s that institu-
tional care became available in China, by 2006
the country had more than 39,500 institutions
with about 1.5 million beds (Zhang, 2011;
Flaherty et al., 2007). Coincidentally, this is the
same number of beds available in the United
States to serve 100 million fewer older people.
Formal community services now are being
developed across China, with estimates identi-
fying more than 900,000 community service
centers (Chu and Chi, 2008). A study of commu-
nity service centers in Shanghai found that these
government-funded entities provided such ser-
vices as LTC, shopping, home maintenance,
counseling, and meals (Wu et al., 2005). How-
ever, the overwhelming majority of Chinese
elders with severe disability receive assistance in
their own homes, either from family caregivers
or through a live-in maid system, termed bao mu
(Hua and Di, 2002). The Chinese constitution
states that “children who come of age have the
duty to support and assist their parents” (Chu
and Chi, 2008). Although family care is the
dominant mode of LTC, China’s recent demo-
graphic changes, in combination with the
one-child policy, will present considerable
future challenges.
Group 5: Few Services, No Funding
Nations falling into Group 5 have a very limited
array of formal services available. For the most
part, nursing homes do not exist in these coun-
tries, and very few in-home services are avail-
able. Generally, public funding for support
services for older adults with severe disability
does not exist. Families provide the majority of
GENERATIONS – Journal of the American Society on Aging Pages 59–65
64 | Spring 2013 • Vol. 37
.No. 1
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
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long-term services and supports, and the nation
expects they will continue to be responsible for
such care. Representative countries included in
this category are Bangladesh, Ghana, Kenya,
and Nepal.
Nepal
Long-term care in Nepal is provided by family
members, not governmental or non-governmen-
tal agencies. Institutional care is practically
non-existent, with fewer than a handful of old
age homes in the entire country. Nepal has a
small number of old age homes called Bridd-
hashram. Pashupati Briddhashram is one of
the oldest old age homes and is funded by the
Government of Nepal. Although Nepal’s elders
constitute less than 4 percent of the population,
the country still has more than 1 million adults
ages 65 and older. With no formal community-
based services and an institutional capacity
of fewer than 1,000 beds in the country, older
people with disability rely exclusively on family
and friends for long-term assistance.
Because of a weak economy, the country has
not been able to develop even a basic infrastruc-
ture for old-age pensions, and the development
of long-term services does not seem to be a high
priority. A recent study of Nepali political officials
found that the majority of respondents were una-
ware of problems associated with LTC, and they
did not believe that LTC was an important role
for the government (Basnyat, 2010).
Nations Must Collaborate to Build
Better Long-Term Care
Countries have adopted a variety of fiscal and
care system responses to the growing num-
ber of older adults who need assistance with
activities of daily living. Based on the type of
care provided and the financing structure,
and in an effort to more clearly articulate the
different approaches to long-term services and
supports, we created a typology of LTC sys-
tems, ranging from most to least comprehen-
sive. For countries in Group 1, like Germany,
care is widely available and publicly supported
and funded. Group 2 countries, like France,
have a mix of public funding and means-tested
financing, and informal care is an important
part of the system. In Group 3 countries, like
the United States and Estonia,
eligibility for public funding is
means-tested, while individu-
als with resources are expect-
ed to be financially responsible
for their own LTC. In Group 4 countries, like
China, funding for care is means-tested and
available only on a very limited basis, so Chi-
nese elders rely heavily on informal family
care. Finally, for countries like Nepal in Group
5, no public funds are available for care, few
formal care providers exist, and older adults
must rely almost exclusively on informal care
and support networks.
All nations must take steps to mitigate the
challenges of an aging population by creating
sustainable financing systems, finding better
ways to support informal caregivers, sharing
ideas for best-care practices, and focusing efforts
on prevention. No matter the country, ensur-
ing good long-term services for individuals is a
growing challenge, and nations will need to learn
from each other to meet future needs.
Robert Applebaum, a member of the Generations
Editorial Advisory Board, is a professor of sociology
and gerontology and the director of the Ohio Long-
Term Care Research Project, Scripps Gerontology
Center, Miami University, in Oxford, Ohio. Anthony
Bardo is a doctoral student in the Department of
Sociology and Gerontology, Miami University. Emily
Robbins is a researcher at the University of Frankfurt
in Frankfurt, Germany.
In some countries, no public funds are available
for care and few formal care providers exist.
Our World Growi ng Older: A Look at Global Aging
Pages 59–65
Spring 2013 • Vol. 37
.No. 1 | 65
Copyright © 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson
St., Suite 1450, San Francisco, CA 94105-2938; e-mail:
info@asaging.org
. For information about ASA’s publications
visit
www.asaging.org/publications
. For information about ASA membership visit
www.asaging.org/join
.
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Authors’ Note
A longer version of this article
appears in Global Aging: Compara-
tive Perspective on Aging and the
Life Course, S. R. Kunkel, J. S.
Brown, and F. J. Whittington, eds.
(Springer, forthcoming in 2013).
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
