A new social risk to be managed by the State?
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1 LONG-TERM CARE FOR BRAZILIAN ELDERS: A new social risk to be managed by the State? Ana Amélia Camarano IPEA June, 2013
2 MOTIVATIONS A NEW DEMOGRAPHIC PARADIGM: THE PROLIFERATION OF FAMILIES WITH A SINGLE CHILD. AN INCREASING LIFE EXPECTANCY. A REDUCTION IN THE TOTAL POPULATION AND IN THE LABOUR FORCE. AN OVER-AGED AGE STRUCTURE AND, A NEW EPIDEMIOLOGIC PROFILE. SUMMARIZING, IT IS EXPECTED THAT THE NUMBER OF ELDERS WHO DEMAND LONG-TERM CARE WILL RISE AND THE OFFER OF FAMILY CAREGIVERS WILL DECREASE.
3 ADDRESSED QUESTIONS WILL BRAZILIAN FAMILIES BE ABLE TO KEEP THEIR ROLE AS THE MAIN CAREGIVERS FOR THEIR FRAIL ELDERS? OR SHOULD THE BRAZILIAN GOVERNMENT TAKE OVER THIS RESPONSIBILITY? THIS IS NOT A PARTICULAR BRAZILIAN QUESTION.
4 METHODOLOGICAL POINTS ELDERLY POPULATION: THOSE AGED 60 AND PLUS, AS ESTABLISHED BY THE ELDER S BILL OF RIGHTS. NOT ALL THE ELDERLY POPULATION CAN BE CONSIDERED AS CARE-DEMANDING. LACK OF AUTONOMY TO DEAL WITH THE ACTIVITIES OF DAILY LIFE (USING THE TOILET, BATHING, AND EATING BY ONESELF) IS THE MAIN DETERMINANT OF THE NEED FOR LONG- TERM CARE.
5 FRAIL ELDERS THE PROPORTION OF FRAIL ELDERS INCREASES WITH AGE AND IS HIGHER IN WOMEN COMPARED TO MEN. THIS PROPORTION DECLINED BETWEEN 1998 AND 2003 AND INCREASED BETWEEN 2003 AND ALTOGETHER, THIS BENEFITED WOMEN MORE THAN MEN. NEVERTHELESS IN 2008, 3.2 MILLION PERSONS WERE FOUND IN THIS CONDITION, 2.0 MILLION (63.0%) BEING FEMALES. ABOUT 100,000 LIVED IN INSTITUTIONS.
6 LONG-TERM CARE: What does it mean? THERE IS NOT A CLEAR DEFINITION OF LTC. IN GENERAL LONG-TERM CARE PROVIDES CUSTODIAL AND NON- SKILLED CARE, SUCH AS ASSISTANCE WITH ACTIVITIES OF DAILY LIFE. POPULATION AGEING INCREASINGLY REQUIRES INCLUSION OF SOME LEVEL OF HEALTH CARE IN LONG-TERM CARE PROGRAMS. OECD RECOMENDS TO INCLUDE REHABILITATION, MEDICAL SERVICES, SHELTERING/RESIDENCE AND OTHER SERVICES AS TRANSPORTATION, FEEDING, AND HELP FOR THE ACTIVIES OF THE DAILY LIFE. THEY CAN BE PROVIDED AT HOME, IN THE COMMUNITY, IN ASSISTED LIVING, IN RESIDENTIAL INSTITUIONS OR NURSING HOMES. IN GENERAL, LONG-TERM CARE IS PART OF THE HEALTH SYSTEM OR OF THE SOCIAL ASSISTANCE SYSTEM. THE BOUNDARIES OF THE TWO SYSTEMS ARE NOT VERY CLEAR.
7 INFORMAL CARE INFORMAL CARE PREDOMINATES ALL OVER THE WORLD FOR ANY POPULATION GROUP, SPECIALLY FOR CHILDREN AND ELDERS. REASONS: THERE IS A CONSENSUS, AMONG EXPERTS, THAT IT IS BETTER FOR THE FRAIL ELDER TO BE TAKEN CARE OF BY FAMILIES. FORMAL CARE IS VERY EXPENSIVE. NEVERTHELESS THE FAMILY IS AN IDEALIZED INSTITUTION. IT IS A LOCUS OF POWER STRUGGLE BETWEEN GENDERS AND BETWEEN GENERATIONS AND IT IS EXPERIENCING DRAMATIC CHANGES.
8 CARE: MATTER OF GENDER THROUGHOUT HISTORY, SOCIAL AND FAMILY NORMS ESTABLISH THAT THE CARE FUNCTION IS A FEMALE RESPONSIBILITY. THE CARE FUNCTION WAS UNDERSTOOD AS PART OF HER ROLE AS SPOUSE AND HOUSEWIFE. CARE ACTIVITIES ARE PERFORMED BY WOMEN, EITHER IN THE FAMILY, OR SALARIED WORK IN RESIDENTIAL INSTITUTIONS, NURSING HOMES, HOSPITALS ETC.
9 FORMAL CARE FORMAL CARE MAY BE OFFERED BY GOVERNMENTS OR PRIVATE SECTORS. HOMECARE: FAMILY CARE MAY BE COMPLEMENTED WITH FORMAL HOME CARE OR BY MEANS OF SOME SUPPORT TO FAMILY MEMBERS. COMMUNITY SERVICES: DAY CENTERS AND DAY HOSPITALS. INSTITUTIONAL CARE INVOLVES FULL ATTENTION TO THE ELDERLY IN NURSING HOMES OR RESIDENTIAL INSTITUTIONS.
10 INSTITUTIONAL CARE INITIALLY THEY WERE DIRECTED TO THE POOR POPULATION WHO NEEDED SHELTER. ABOUT 1% OF THE BRAZILIAN ELDERS LIVE IN INSTITUTIONS. THE LARGE MAJORITY OF THE BRAZILIAN INSTITUTIONS ARE CHARITIES (65.2%), 28.2% ARE FOR-PRIVATES AND ONLY 6.6% ARE PUBLIC. THE SOCIETY OF SÃO VICENTE DE PAULA (A RELIGIOUS CHARITY) HAS ABOUT 700 INSTITUTIONS. THERE ARE 218 PUBLIC INSTITUTIONS. THERE IS SOME EVIDENCE FOR BRAZIL THAT A LARGELY PRIVATE SECTOR IS EMERGING TO MEET THE NEED OF LTC.
11 WHO TAKES CARE FOR BRAZILIAN FRAIL ELDERS? THE BRAZILIAN GOVERNMENT HAS MADE MUCH PROGRESS IN ENSURING A MINIMAL INCOME FOR THE ELDERLY, BUT THE CARE FOR OLDER PEOPLE DOES NOT HAVE MUCH IMPORTANCE IN THE SET OF POLICIES AIMED TO THEM. THE BRAZILIAN LEGISLATION ESTABLISHES THAT THE FAMILY IS THE MAIN CAREGIVER FOR THE OLD FRAGILE POPULATION. THIS MAY BE DUE TO THEIR HIGH COSTS, THE IMPORTANCE GIVEN TO THE ACTIVE AND HEALTHY AGEING, AND THE FAMILY RESPONSIBILITY.
12 WHO TAKES CARE FOR BRAZILIAN FRAIL ELDERS? FAMILY CARE IS TAKING PLACE WITH LITTLE SUPPORT FROM THE STATE. THE FEW GOVERNMENTAL ACTIONS ARE FOCUSED ON SHELTERING POOR ELDERS AND IN REGULATING FOR-PROFIT INSTITUTIONS. GENDER MATTER THE MAIN POTENTIAL SOURCE OF SUPPORT OF THE BRAZILIAN AGED MALES IS THE SPOUSE. IN 2008, 76.9%, LIVED WITH THEIR SPOUSES, WITH OR WITHOUT CHILDREN. THE MAIN SOURCE OF SUPPORT FOR FEMALES ARE THEIR CHILDREN: ABOUT 46.0% OF THE FRAIL FEMALES LIVED WITH CHILDREN, WHETHER OR NOT IN THE PRESENCE OF SPOUSES. SUPPORT FROM SPOUSE AND/OR CHILDREN HAVE DECREASED BETWEEN 1998 AND 2008 FOR MALES AND FEMALES.
13 WHO ARE THE FAMILY CAREGIVERS? POTENTIAL CAREGIVERS: FEMALES AGED YEARS WHO REPORTED NOT EXPERIENCING ANY DIFFICULTIES TO CARRY OUT THE DAILY LIFE ACTIVITIES. THEY ARE SPOUSES, DAUGHTERS OR OTHER RELATIVES AND WHO DO NOT PARTICIPATE OF THE LABOUR MARKET.
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15 FAMILY INTERGENERATIONAL SUPPORT ANOTHER IMPORTANT AND NECESSARY RESOURCE FOR ELDER CARE IS INCOME. 84.9% OF FRAIL MALES AND 80.5% OF FEMALES RECEIVED SOME SOCIAL SECURITY BENEFIT. ALSO, THE YOUNGER GENERATIONS ARE EXPERIENCING SEVERAL DIFFICULTIES IN THEIR TRANSITION TO ADULTHOOD, ESPECIALLY IN THE LABOUR MARKET AND IN LEAVING PARENTAL HOMES. FOR INSTANCE, IN 42.2% OF THE HOUSEHOLDS COMPOSED BY FRAIL ELDERS, ONE MAY FIND ADULT CHILDREN LIVING THERE. AMONG THESE CHILDREN, 45.2% HAD NO INCOME. THEY PROBABLY COUNT ON PARENTAL INCOME FOR THEIR LIVING AND PROVIDE SOME HELP.
16 FAMILY INTERGENERATIONAL SUPPORT 28.8% OF THE FEMALE AND 14.3% OF THE MALES ELDERS LIVED IN THE HOUSEHOLDS OF THEIR CHILDREN OR OTHER RELATIVES. THEIR CONTRIBUTION TO FAMILY BUDGET WAS ABOUT A THIRD OF THIS. THEY LIVE WITH THEIR CHILDREN LOOKING FOR HELP BUT HELP AS WELL. WE ARE SPEAKING OF A TWO-WAY INTERGENERATION TRANSFER SYSTEM INTERMEDIATED BY PUBLIC POLICIES.
17 WHAT CAN WE THINK ABOUT THE FUTURE DEMAND FOR LONG-TERM CARE? EVEN IF THE PROPORTION OF FRAIL OLD PEOPLE DECREASES AS A RESULT OF VARIOUS IMPROVEMENTS, ONE MAY EXPECT AN INCREASE IN THE DEMAND OF LTC AS A RESULT OF THE AGEING OF THE ELDERLY POPULATION.
18 PROJECTIONS: FOUR SCENARIOS 1. ALL CONSTANT: PROPORTION OF FRAIL ELDERS AND OF THE CAREGIVERS REDUCTION IN THE PROPORTION OF FRAIL ELDERS AND THAT OF CAREGIVERS KEPT CONSTANT: 50% OF THE VARIATION OBSERVED IN THE UK IN 10 YEARS. 3. REDUCTION IN THE PROPORTION OF CAREGIVERS UNTIL 2020 TAKING INTO ACCOUNT THE ANNUAL VARIATION OBSERVED BETWEEN 1998 AND 2008 AND THAT OF FRAIL ELDERS KEPT CONSTANT. 4. REDUCTION IN BOTH PROPORTIONS.
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21 WHAT CAN ONE THINK? BRAZILIAN CARE POLICIES SHOULD BE A RIGHT AND NOT BE AN ACT OF CHRISTIAN CHARITY. THIS POINTS TO A NEW DIVISION OF RESPONSABILITIES AMONG FAMILIES, THE STATE AND THE PRIVATE MARKET. IT MEANS THE EXISTENCE OF A FORMAL SYSTEM OF SUPPORT INCORPORATING FAMILY AND COMMUNITY. THE CREATION OF A NETWORK FORMED BY DAY CARE CENTRES, DAY HOSPITALS, LEISURE CENTRES, HOME SERVICES, INSTITUTIONS OF RESIDENCE, NURSING HOMES AND ETC. EACH ONE OF THESE FORMS MEETS DIFFERENTIATED NEEDS.
22 HELP TO FAMILIES ALTHOUGH THE PROVISION OF CARE BY THE FAMILIES WILL CONTINUE TO DECREASE, THEY WILL HAVE TO CONTINUE TO PLAY SOME ROLE. NEVERTHELESS, FAMILY CARE SHOULD NOT BE TAKEN FOR GRANTED. IT IS IMPORTANT TO ACKNOWLEDGE THE IMPORTANCE OF FAMILY CAREGIVERS, SUPPORTING THEM AND COMPENSATING FOR THEIR PERFORMANCE (LLOYD- SHERLOCK, 2004). TO HELP FAMILIES IS BENEFICIAL FOR CARE GIVERS, CARE RECIPIENTS AND PUBLIC FINANCES. GOVERNMENTS CAN SUPPORT FAMILY CARE GIVERS THROUGH CASH BENEFITS, SUPPORT GROUPS, LEAVES, INCLUSION IN THE SOCIAL SECURITY SYSTEM, RESPITE PROGRAMS, TRAINING, AMONG OTHER MEASURES.
23 OTHER POLICIES INCOME: TO GUARANTEE THE ACCESS TO SOCIAL SECURITY BENEFITS TO THE BRAZILIAN ELDERS. TO STIMULATE THE DEVELOPMENT OF NEW ASSISTIVE DEVICES SUCH AS ROBOTS, SMART HOUSES, TELE-ALARM AND OTHERS. GENDER MATTER: PUBLIC POLICIES SHOULD DEFINE THE CARE ACTIVITY NEUTRALLY AS REGARD TO THE GENDER OF THE CAREGIVER (WHO, 2002). CARE FOR WHO CARES: PUBLIC AND PRIVATE HEALTH CARE MAKE A CAREFUL MONITORING OF THEIR HEALTH CONDITIONS IN ORDER TO REDUCE THE DEGREE OF DEPENDENCE AND TO PROMOTE THEIR QUALITY OF LIFE.
24 FUNDING??? SOME COUNTRIES INCORPORATED THIS NEW RISK INTO THEIR SOCIAL SECURITY SYSTEMS (OBLIGATOR INSURANCE) AND OTHERS FUNDED IT WITH GENERAL TAXES. ONE CANNOT CONCEIVE AN OBLIGATOR INSURANCE FOR THE BRAZILIAN WORKERS AS ABOUT 45% OF THE LABOR FORCE IS NOT IN THE FORMAL LABOR MARKET.
25 CONCLUDING WHAT IS REQUIRED IS A COMPLEX ARRAY OF ACTIONS: INCOME, HEALTH, HOUSING AND CARE. THIS MAY BE ACCOMPLISHED BY EXTENDING THE SYSTEM OF SOCIAL SECURITY TO ADD A NEW PILLAR, THE FOURTH ONE (PASINATO AND KORNIS, 2009). THE MAIN POINT IS TO CONSIDER LTC AS A POLICY BY ITSELF WITH A SEPARATE FUND ALTHOUGH IS INTERTWINED WITH OTHER AREAS OF PUBLIC POLICIES. IN A COUTRY AS BRAZIL, WHERE MANY SOCIAL NEEDS ARE NOT MEET, THE DECISION MUST BE A POLITICAL DECISION.
26 Mercy!
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