Providing and financing of long-term
care in Croatia and Latvia
Johannes KoettlWorld Bank
Sofia, December 9, 2010
Long-term care in Croatia
1. Demographic trends in Croatia
2. The current LTC system in Croatiaa)Institutional LTC servicesb)Non-institutional LTC servicesc)Financing of LTC services
3. Future policy directions
A shrinking and aging population
Source: UN Population Division
1990 2005 2020 2035 20500.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Population projection for Croatia, by age group (millions, 1990-2050)
80+ 65-79 15-64 0-14
Year
Popu
latio
n in
mill
ions
A common demographic picture
Demographic trend in Croatia mirrors that of most other European countries: an aging population with fewer younger people and a increasing dependency rate.
In the next 40 years:15-64 year old population will shrink 30 percent65+ year old population will grow by 41 percent80+ year old population will double
The old-age dependency ratio has increased from 17 percent in 1990 to nearly 26 percent in 2008.
Strong expansion of severely dependent population over the next
10 years and beyond
Already high burden, but inverse dependency ratios will decrease
further
Institutional LTC services in Croatia
LTC care is provided by the social and the health sector
LTC in the hospital sector: estimated 300,000 severely dependent people, but less that 50,000 receive benefits
Gap in coverage filled by informal care, but maybe also by hospitals?
Institutional capacity is growing, especially in the local government/private/NGO sector. Homes for elderly are the fastest growing type of institutional care
facilities. In 2007, 70 percent of beneficiaries were accommodated in non-
state institutions. There are significant differences in the funding sources, capacities
and staff -patient ratios between state and non-state institutions.
Non-institutional LTC services in Croatia
Social Welfare Homes also provide home- and community-based services. In 2007, an additional 22 percent of beneficiaries were serviced this way.
Health visitor services financed by national health insurance.
Pensioners associations provide home assistance but there are few data on these services.
Foster care for elderly is a unique program in Croatia.
Informal care is provided by spouses, friends and neighbors but there are few reliable data on this.
Recent pilot programs
Pilot programs by Ministry of Family, War Veterans and Intergenerational Solidarity (MoFVIS) were the first efforts to provide continuous provision of non-institutional care to the elderly. Day care and home-services were provided by teams
of five, including a nurse. An important outcome of one project was the
employment of disadvantaged groups, particularly middle-aged women with low to medium education.
Pilot programs were successful but now must be integrated into the national LTC system.
LTC benefits in CroatiaPotential beneficiaries must demonstrate a high
degree of disability, lack of family support and lack of income.
Only a few informal caregivers receive cash benefits through the nursing and home care allowance system.
LTC financing in Croatia
Payment for LTC services depends on the type of service.
To receive services in a state owned institution, the patient must use personal resources. Once those are exhausted, the patient must sell their property (if it’s not used by family members). If this does not suffice, the MoHSW covers the difference.
Funding sources for LTC homes
Structure of funding by type of ownership of homes for elderly and infirm persons, by no of funded beneficiaries
75%66%
46%
6% 26%
13%
7%
5%
21%
12%20%
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
county (N=10 337) private (N=3277) NGO/religious (N=554)
state+beneficiary
state
other sources
beneficiary
Source: Ministry of Health and Social Welfare (May 2008)
LTC expenditures in Croatia
Currently there is no system for collecting and tracking data LTC expenditures.
Projections based on demographic change predict spending on health and LTC for the elderly will grow to nearly 10 percent of GDP by 2050.
Croatia: future policy directions
1. Urgently re-think financing of LTC services. Regulations for private LTC insurance products
2. Improve coordination of the LTC system to better integrate health and social care components and reduce duplication across sectors (MoFVIS pilots).
3. Avoid focus on institutional care. Recent expansion in LTC services biased towards institutional care (especially private sector).
4. Build on past efforts to expand community-based services, like MoFVIS pilots and foster care
Long-term care in Latvia
1. Demographic trends in Latvia
2. The current LTC system in Latvia
3. Future policy directions
A shrinking and aging population
Source: Eurostat
Strong expansion of 75+ population now and during 2020s
Strong expansion of severely dependent population over the next
10 years and after 2025
Already high burden, but inverse dependency ratios will decrease
further
Current LTC system in Latvia
Health sector Mentally ill More than 25 percent of people with dementia stay in hospital for
over 1 year
Social sector Social services and social rehabilitation institutions Informal care providers receive training and psychological support Decentralized structure
Central government: disabled, mentally ill (orphans, other social cases)
Local government: frail elderly and financial support for informal care givers
Wide variation of extent and quality of LTC for the elderly among municipalities
Rural areas strongly disadvantaged
Current LTC system in Latvia
Little involvement of private sector 114 institutions in 2007: 78 municipal, 27 state-owned,
only 9 private
Trend towards more home-based services for elderly:
1995 2000 2005 2007
Home-care
Beneficiaries 869 5,019 6,113 7,553
Institutions
Beneficiaries 4,722 4,424 5,261 5,723
No. of institutions 48 61 75 82
Current LTC system in Latvia
Entitlements Joint needs assessment by specialized social
worker and the patients GPTakes into account medical and social needs as
well as family situation and financial situationChanges in status lead to updated assessment Best practice of care coordination
Latvia: future policy directions
1. Urgently re-think financing of LTC services. Regulations for private LTC insurance products
2. Improve coordination of the LTC system to better integrate health and social care components and reduce duplication across sectors (MoFVIS pilots).
3. Avoid focus on institutional care. Recent expansion in LTC services biased towards institutional care (especially private sector).
4. Build on past efforts to expand community-based services, like MoFVIS pilots and foster care
Current LTC system in Latvia
Public expenditures on LTC (LAT)
But: strong decrease (on central government level) during crisis in 2009
2007 2008
Total 59,080,647 72,273,275as share of GDP 0.40% 0.44%Central government 35,046,165 41,039,228
as share of GDP 0.24% 0.25%
Local government 24,034,482 31,234,047
as share of GDP 0.16 % 0.19%
Latvia: future policy directions
1. Urgently re-think financing of LTC services. Regulations for private LTC insurance products
2. From health to social services: Relative low spending on social services, probably too much LTC in hospitals (high ALOS); resist converting small hospitals into LTC institutions; expand rehabilitation (very low expenditures right now)
3. Care coordination: build on current system; improve on hospital discharge management
4. Improve incentives to involve private sector and charities/NGOs: payment reforms
5. Cash benefits: could help to spur private sector response and support informal care