Abstract

Latin America is beginning to implement long-term care public policies. But only a few studies look at the situation of the countries in the region. This study aims to examine long-term care public programs in Costa Rica and to estimate the country’s demand for formal care. For this purpose, we have revised its National Health Accounts, conducted five interviews with representatives of governmental institutions, reviewed the scientific literature and official reports, and analyzed the data drawn from a national care survey. The results show the existence of fragmented, poverty-focused programs that were not designed for long-term care needs. The estimated percentage of older adults in the region that currently require help to perform activities of daily living is 13.4%. The informal care work is intensive, mostly provided by a family member, and unpaid.

Keywords:
Costa Rica; Long-term Care; Dependency; Latin America; Middle-income Countries

Introduction

In developed countries, long-term care (LTC) services were first introduced during the second part of the 20^th century and, most of them, reformed during the last decade (Becker; Reinhard, 2018BECKER, U.; REINHARD, H. J. Long-Term Care in Europe: A Juridical Approach. Cham: Springer, 2018. DOI: 10.1007/978-3-319-70081-6
https://doi.org/10.1007/978-3-319-70081-... ; Leichsenring et al., 2013LEICHSENRING, K.; BILLINGS, J.; NIES, H. Long-Term Care in Europe: Improving Policy and Practice. London: Palgrave Macmillan, 2013.; Ohwa; Chen, 2012OHWA, M.; CHEN L-M. Balancing Long-term Care in Japan. Journal of Gerontological Social Work, Pennsylvania, v. 55, n. 7, p. 659-672, 2012. DOI: 10.1080/01634372.2012.670869
https://doi.org/10.1080/01634372.2012.67... ). Until a few years ago, the discussion was almost nonexistent in Latin America (Lloyd-Sherlock, 2014LLOYD-SHERLOCK, P. Beyond Neglect: Long-term Care Research in Low- and Middle-Income Countries. International Journal of Gerontology, Taipei, v. 8, n. 2, p. 66-69, 2014. DOI: 10.1016/j.ijge.2013.05.005
https://doi.org/10.1016/j.ijge.2013.05.0... ). However, this is changing, and some studies are being published, both for the region as a whole (Bloeck; Galiani; Ibarrarán, 2019BLOECK, M. C.; GALIANI, S.; IBARRARÁN, P. Long-Term Care in Latin America and the Caribbean: Theory and Policy Considerations. Economía, Baltimore, v. 20, n. 1, p. 1-32, 2019. DOI: 10.1353/eco.2019.0006
https://doi.org/10.1353/eco.2019.0006... ; Matus-Lopez, 2015MATUS-LOPEZ, M. Thinking about long-term care policies for Latin America. Salud Colectiva, Buenos Aires, v. 11, n. 4, p. 485-496, 2015. DOI: 10.18294/sc.2015.785
https://doi.org/10.18294/sc.2015.785... ; Matus-Lopez; Rodríguez-Modroño, 2014MATUS-LOPEZ, M.; RODRÍGUEZ-MODROÑO, P. Presiones de oferta y demanda sobre políticas formales de cuidados en Latinoamérica. Reforma y Democracia, Caracas, v. 60, p. 103-130, 2014.), and for specific countries (Lima-Costa ., 2016LIMA-COSTA, M. F. et al. Socioeconomic inequalities in activities of daily living limitations and in the provision of informal and formal care for noninstitutionalized older Brazilians: National Health Survey, 2013. International Journal for Equity in Health, London, v. 15, p. 137-145, 2016. DOI: 10.1186/s12939-016-0429-2
https://doi.org/10.1186/s12939-016-0429-... ; Matus-Lopez, 2021aMATUS-LOPEZ, M. The Long-Term Care System in Uruguay. Bremen: CRC 1242, 2021a. (Social Policy Country Briefs; 6). Disponível em: <Disponível em: https://www.socialpolicydynamics.de/f/1a437c54e0.pdf >. Acesso em: 10 jun. 2021.
https://www.socialpolicydynamics.de/f/1a... ; Matus-Lopez; Cid, 2015MATUS-LOPEZ, M.; CID, C. Building Long-Term Care Policies in Latin America: New Programs in Chile. Journal of the American Medical Directors Association, Washington, DC, v. 16, n. 10, p. 900.e7-10, 2015. DOI: 10.1016/j.jamda.2015.07.018
https://doi.org/10.1016/j.jamda.2015.07.... , ²⁰¹⁶MATUS-LOPEZ, M.; CID, C. New Long-Term Care Policies in Latin America: The National System of Care in Uruguay. Journal of the American Medical Directors Association, Washington, DC, v. 17, n. 7, p. 663-665, 2016. DOI: 10.1016/j.jamda.2016.04.001
https://doi.org/10.1016/j.jamda.2016.04.... ; Monteverde et al., 2016MONTEVERDE, M. et al. Envejecimiento poblacional y magnitud de la dependencia en Argentina y México: perspectiva comparada con España. Revista Latinoamericana de Población, Morelos, v. 18, n. 10, p.135-154, 2016. DOI: 10.31406/relap2016.v10.i1.n18.6
https://doi.org/10.31406/relap2016.v10.i... ).

In 2015, Uruguay was the first country in the region to create a national LTC system. Unfortunately, the development of the program is slow due to the country’s public deficit. This has prompted discussion in other Latin American countries.

Costa Rica will probably be the next country to implement a similar system. On the one hand, the demographic dividend is ending and the country’s population is ageing faster than any other country in the region. Within two decades, the percentage of older adults will double and become larger than that of the younger population (INEC, 2020INSTITUTO NACIONAL DE ESTADÍSTICAS Y CENSOS. Estadísticas de Población. San José: INEC, 2020. Disponível em: <Disponível em: http://www.inec.go.cr/ >. Acesso em: 1 jun. 2020.
http://www.inec.go.cr/... ; UN, 2019UNITED NATIONS. Revision of World Population Prospects. New York, 2019. Disponível em: <Disponível em: https://population.un.org/wpp >. Acesso em: 30 mar. 2020.
https://population.un.org/wpp... ). On the other hand, the country has one of the most developed social security systems in Latin America. Public health expenditure is the third highest in the region (5.7% of the GDP), and spending on pensions amounts to 3.3% of the GDP (OECD, 2015ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Pensions at a Glance: Latin America and the Caribbean. Washington, DC, 2015. DOI: 10.1787/9789264233195-es
https://doi.org/10.1787/9789264233195-es... ; SP, 2018SUPERINTENDENCIA DE PENSIONES. Informes trimestrales 2018. San José, 2018. Disponível em: <Disponível em: https://www.supen.fi.cr/informe-trimestral >. Acesso em: 1 mar. 2020.
https://www.supen.fi.cr/informe-trimestr... ; WHO, 2020WORLD HEALTH ORGANIZATION. Global Health Expenditure Database 2020. Geneva, 2020. Disponível em: <Disponível em: http://apps.who.int/nha/database/Select/Indicators/en >. Acesso em: 20 mar. 2020.
http://apps.who.int/nha/database/Select/... ).

In contrast, the social service system is less developed. Care programs have a limited scope, are focused on low-income people, and prioritize childcare over older adult care (Calvo et al., 2018CALVO, E. et al. Comparative Analysis of Aging Policy Reforms in Argentina, Chile, Costa Rica, and Mexico. Journal of Aging & Social Policy, London, v. 31, n. 3, p. 211-233, 2018. DOI: 10.1080/08959420.2018.1465797
https://doi.org/10.1080/08959420.2018.14... ; Cotlear, 2011COTLEAR, D. Population Aging: Is Latin America Ready? Washington, DC: World Bank, 2011.; Lloyd-Sherlock ., 2017LLOYD-SHERLOCK, P. et al. Volunteer provision of long-term care for older people in Thailand and Costa Rica. Bulletin of World Health Organization, Geneva, v. 95, n. 11, p. 774-778, 2017. DOI: 10.2471/BLT.16.187526
https://doi.org/10.2471/BLT.16.187526... ). The country has neither an LTC system, nor an estimation of its potential demand.

This study diagnoses, for the first time, the long-term care situation in Costa Rica and an estimates the potential demand for this type of care services in the country. The methodology used and the results obtained may be useful for both Costa Rica and other middle-income and Latin-American countries.

Materials and methods

In this study, we have applied a four-part method. First, we analyzed Costa Rica’s National Health Accounts (NHA) (OECD, 2012ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Accounting and Mapping of Long-term Care Expenditure under System of Health Accounts 2011, 2012. Paris, 2012. Disponível em: <Disponível em: https://www.who.int/health-accounts/documentation/AccountingMappingofLTC.pdf?ua=1 >. Acesso em: 20 dez. 2020.
https://www.who.int/health-accounts/docu... ). The data correspond to the 2011 - 2016 period and are broken down by health care functions, providers, and financial schemes. The NHA system includes different accounts that register both LTC-health and LTC-social expenditures (OECD, 2018ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Accounting and Mapping of Long-term Care Expenditure under System of Health Accounts 2011, March 2018. Paris, 2018. Disponível em: <Disponível em: https://www.oecd.org/health/health-systems/AccountingMappingofLTC.pdf >. Acesso em: 3 jun. 2021.
https://www.oecd.org/health/health-syste... ). Most countries only record their health-related expenses (OECD, 2017ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Health at a Glance 2017. Paris, 2017. DOI: 10.1787/health_glance-2017-en
https://doi.org/10.1787/health_glance-20... ), Costa Rica is not an exception in this sense. More specifically, the NHA of Costa Rica only includes three types of LTC expenditure: a) in-patient long-term care (health); b) day long-term care (health); and c) out-patient long-term care (health) (MSP, 2018MINISTERIO DE SALUD PÚBLICA. Sistema de Cuentas de Salud de Costa Rica: 2011-2016. San José, 2018. Disponível em: <Disponível em: https://www.binasss.sa.cr/opac-ms/media/digitales/Informe%20del%20Sistema%20de%20cuentas%20de%20salud%20de%20Costa%20Rica,%202011-2016.pdf >. Acesso em: 5 jun. 2021.
https://www.binasss.sa.cr/opac-ms/media/... ). For this reason, the analysis of the country’s NHA aimed at identifying only the long-term health care expenditure (MSP, 2018MINISTERIO DE SALUD PÚBLICA. Sistema de Cuentas de Salud de Costa Rica: 2011-2016. San José, 2018. Disponível em: <Disponível em: https://www.binasss.sa.cr/opac-ms/media/digitales/Informe%20del%20Sistema%20de%20cuentas%20de%20salud%20de%20Costa%20Rica,%202011-2016.pdf >. Acesso em: 5 jun. 2021.
https://www.binasss.sa.cr/opac-ms/media/... ).

Second, five semi-structured interviews were conducted in April 2018 with public officials in charge of care programs. The duration of each interview was approximately 45 minutes. The interviews aimed to identify and gather information on the existing LTC programs in the country. The institutions were selected according to two criteria: 1) being public, governmental institutions; and 2) coordinating or financing programs for the older dependent population. The identification process happened in three phases: a) we contacted the Instituto Mixto de Ayuda Social (IMAS - Mixed Social Aid Institute), which is formally responsible for LTC services; b) the IMAS suggested a list of four institutions that met the above-mentioned criteria: Consejo Nacional de las Personas con Discapacidad (CONAPDIS - National Council for Persons with Disabilities), Consejo Nacional de la Persona Adulta Mayor (CONAPAM - National Council for Older Adults), Fondo de Desarrollo Social y Asignaciones Familiares (Fund of Social Development and Family Assignations), and Ministerio de Hacienda (Ministry of Finance); c) the representatives of the above-mentioned entities, at our request, suggested several other institutions that should be consulted, which were contacted and the Instituto Nacional de Estadística y Censos (National Institute of Statistics and Census) was added to the list. An interview with the head of every institution - or the second-line manager designated by the head - was conducted.

The interview had open questions about three issues: knowledge of LTC; identification of programs for potentially dependent people (older adults and people with disabilities) under their supervision; valuation of those programs.

Thirdly, the literature review was done in three stages: a) a review of the articles published on scientific journals indexed in Web of Science, Scopus, PubMed and Scielo, in the 2000 - 2020 period. The search terms (in English and Spanish) were: [(long-term care OR dependency care) AND (policy OR system) AND (Costa Rica)]; b) a thorough review of the reports, documents, and statistics available in the database of the five institutions whose representatives were interviewed; c) a snowballing review of the references to articles, books and documents gathered in the two previous stages.

Finally, the data of the National Care Survey (NCS) were analyzed. The survey was carried out between March and May 2018, and the sampling process was biphasic (Table 1). During the first phase, a 12-question questionnaire was administered to a national sample of 6,548 households. The answers were used to estimate the prevalence of long-term care. In the survey, dependent people were defined as people who need help from another person to perform activities of daily living. In the second phase, 2,203 households with care needs were selected. The data gathered in this phase were used to analyze the profile and role of caregivers.

The NCS was conducted by the IMAS and the database used in this study was anonymized. All procedures were in accordance with the ethical standards of the Helsinki Declaration and its later amendments.

Results

The next three sections show the results. The first one contextualizes Costa Rica and its social protection system. The second one describes its LTC programs and their beneficiaries. Finally, the third one presents our estimate of the LTC demand in this country.

Costa Rica and its social protection system

Costa Rica has 5.04 million inhabitants and a per capita Gross Domestic Product (GDP) of USD 12,244 (UN, 2019UNITED NATIONS. Revision of World Population Prospects. New York, 2019. Disponível em: <Disponível em: https://population.un.org/wpp >. Acesso em: 30 mar. 2020.
https://population.un.org/wpp... ; WB, 2019WORLD BANK. World development indicators 2019. Washington, DC, 2019. Disponível em: <Disponível em: https://databank.worldbank.org/source/world-development-indicators >. Acesso em: 11 jun. 2021.
https://databank.worldbank.org/source/wo... ). Up to 26.2% of the population is living in poverty. The country holds the 62^nd position in the United Nations Human Development Index (INEC, 2020INSTITUTO NACIONAL DE ESTADÍSTICAS Y CENSOS. Estadísticas de Población. San José: INEC, 2020. Disponível em: <Disponível em: http://www.inec.go.cr/ >. Acesso em: 1 jun. 2020.
http://www.inec.go.cr/... ; PNUD, 2020PROGRAMA DE LAS NACIONES UNIDAS PARA EL DESARROLLO. Informe sobre Desarrollo Humano 2020. New York: United Nations, 2020. Disponível em: <Disponível em: http://hdr.undp.org/sites/default/files/hdr2020_es.pdf >. Acesso em: 5 jun. 2021.
http://hdr.undp.org/sites/default/files/... ). Up to 10% of the population is 65 years old or over, the life expectancy is 80.4, and the global fertility rate is 1.4 children per woman (UN, 2019UNITED NATIONS. Revision of World Population Prospects. New York, 2019. Disponível em: <Disponível em: https://population.un.org/wpp >. Acesso em: 30 mar. 2020.
https://population.un.org/wpp... ; INEC, 2020INSTITUTO NACIONAL DE ESTADÍSTICAS Y CENSOS. Estadísticas de Población. San José: INEC, 2020. Disponível em: <Disponível em: http://www.inec.go.cr/ >. Acesso em: 1 jun. 2020.
http://www.inec.go.cr/... ).

Costa Rica’s social protection system combines contributive and non-contributive health care, pension, and educational programs, and is complemented by specific programs for the poorer population groups (Román, 2012ROMÁN, I. Sistemas de protección social en América Latina y el Caribe. Costa Rica. Santiago: CEPAL , 2012. Disponível em: <Disponível em: https://repositorio.cepal.org/bitstream/handle/11362/4033/1/S2012968_es.pdf >.Acesso em: 7 jun. 2021.
https://repositorio.cepal.org/bitstream/... ). The financing mechanism is solidarity-based, mainly by using taxes. Among the social programs, note the following: food and care for children, school canteens, social housing, conditioned cash transfers, non-contributive pensions for older adults or people with disabilities, women programs, cash transfers for parents with terminally ill children, care programs for older adults and people with disabilities (Chaverri-Carvajal, 2020CHAVERRI-CARVAJAL, A. Costa Rica y los cuidados de larga duración, un desafío en el umbral del bicentenario. Sur Academia: Revista Académica-Investigativa De La Facultad Jurídica, Social Y Administrativa, Loja, v. 7, n. 14, p. 44-55, 2020. Disponível em: <Disponível em: https://revistas.unl.edu.ec/index.php/suracademia/article/view/761 >. Acesso em: 14 out. 2021.
https://revistas.unl.edu.ec/index.php/su... ).

Social programs providing care for older adults and people with disabilities are characterized by having little funding, being fragmented, and relying on non-profit organizations (CGR, 2016CONTRALORÍA GENERAL DE LA REPÚBLICA. Informe de auditoría de carácter especial sobre la interrelación de los Programas de Transferencias dirigidos a la población Adulta Mayor. Working Paper DFOE-SOC-IF-08-2016. San José, 2016.; Lloyd-Sherlock ., 2017LLOYD-SHERLOCK, P. et al. Volunteer provision of long-term care for older people in Thailand and Costa Rica. Bulletin of World Health Organization, Geneva, v. 95, n. 11, p. 774-778, 2017. DOI: 10.2471/BLT.16.187526
https://doi.org/10.2471/BLT.16.187526... ) (Table 2).

The Government’s concern for older adults has increased due to the widening of the gap between the demand for long-term care services and the current supply. This widening is due to the growth of the older adult population, the increase of life expectancy, the sociocultural changes in family care, and the market limitations of the private sector (Jara-Maleš; Matus-Lopez; Chaverri-Carvajal ., 2020JARA-MALEŠ, P.; MATUS-LOPEZ, M.; CHAVERRI-CARVAJAL, A. Tendencias y desafíos para conformar un sistema de cuidados de larga duración en Costa Rica. Nota Técnica. IDB-TN-1878. Washington, DC: IDB, 2020. Disponível em: <Disponível em: https://publications.iadb.org/publications/spanish/document/Tendencias_y_desaf%C3%ADos_para_conformar_un_sistema_de_cuidados_de_larga_duraci%C3%B3n_en_Costa_Rica.pdf >. Acesso em: 6 jun. 2021.
https://publications.iadb.org/publicatio... ; Morales-Martinez; Rivera-Meza, 2014MORALES-MARTINEZ, F.; RIVERA-MEZA, E. Public policy on aging and elderly: the case of Costa Rica. Gerontechnology, Eindhoven, v. 12, n. 4, p. 209-2013, 2014. DOI: 10.4017/gt.2014.12.4.004.00
https://doi.org/10.4017/gt.2014.12.4.004... ).

The interviews conducted for this study revolve around three issues. First, the preoccupation of how to face the current demographic changes. Second, the concepts of “long-term care” and “dependency system”, which have not yet been fully assimilated. “Disability” is often confused with “dependency” and “long-term hospital stays” (Matus-Lopez, 2021bMATUS-LOPEZ, M. Diferencia entre cuidados a la dependencia y cuidados de larga duración o long-term care. MPRA Working Paper 107959, 2021b. Disponível em: <Disponível em: https://mpra.ub.uni-muenchen.de/id/eprint/107959 >. Acesso em: 14 jun. 2021.
https://mpra.ub.uni-muenchen.de/id/eprin... ). Third, the need to implement systems to assess the quality of the services provided, and the lack of resources to expand the coverage to include non-poor beneficiaries.

LTC programs and beneficiaries

LTC comprises a wide range of services provided to individuals, mainly older adults (OECD, 2020ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Assessing the comparability of long-term care spending estimates under the joint health accounts questionnaire. Paris, 2020. Disponível em: <Disponível em: https://www.oecd.org/health/health-systems/LTC-Spending-Estimates-under-the-Joint-Health-Accounts-Questionnaire.pdf >. Acesso em: 5 jun. 2021.
https://www.oecd.org/health/health-syste... ), who require help from other people to perform activities of daily living (eating, getting dressed, walking, etc.), whether permanently or for a long period of time (EC, 2019EUROPEAN COMMISSION. Health and Long-term Care, 2019. Brussels, 2019. Disponível em: <Disponível em: https://ec.europa.eu/eurostat/web/employment-and-social-inclusion-indicators/social-protection-and-inclusion/health-long-term-care >. Acesso em: 10 nov. 2020.
https://ec.europa.eu/eurostat/web/employ... ; WHO, 2015WORLD HEALTH ORGANIZATION. World Report on Ageing and Health. Geneva, 2015. Disponível em: <Disponível em: https://www.who.int/ageing/events/world-report-2015-launch/en/ >. Acesso em: 10 jun. 2021.
https://www.who.int/ageing/events/world-... ).

The services may be classified into long-term health care (LTC-health) and long-term social care (LTC-social) (EC, 2019EUROPEAN COMMISSION. Health and Long-term Care, 2019. Brussels, 2019. Disponível em: <Disponível em: https://ec.europa.eu/eurostat/web/employment-and-social-inclusion-indicators/social-protection-and-inclusion/health-long-term-care >. Acesso em: 10 nov. 2020.
https://ec.europa.eu/eurostat/web/employ... ; OECD, 2017ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Health at a Glance 2017. Paris, 2017. DOI: 10.1787/health_glance-2017-en
https://doi.org/10.1787/health_glance-20... ). The first comprises specialized medical or nursing services provided in health care centers or nursing facilities for people with severe dependency, with reduced mobility, or in a critical state of health. The second includes socio-health services for people who, compared with the above-mentioned population, are less severely dependent. These services are usually classified as residential care services, when the beneficiaries require a permanent stay in in-patient facilities, and home-based care services, when they can continue living in their homes (Matus-Lopez, 2021bMATUS-LOPEZ, M. Diferencia entre cuidados a la dependencia y cuidados de larga duración o long-term care. MPRA Working Paper 107959, 2021b. Disponível em: <Disponível em: https://mpra.ub.uni-muenchen.de/id/eprint/107959 >. Acesso em: 14 jun. 2021.
https://mpra.ub.uni-muenchen.de/id/eprin... ).

We drew the information about LTC-health from the analysis of the National Health Accounts and the information about LTC-social care from the interviews with representatives of public institutions.

Long-term health care

Costa Rica is one of few countries in the region that break National Health Accounts down by health care functions. In 2018, the tables for the 2011 - 2016 period were published. The results show that, during that period, LTC expenditure amounted to 0.12% of the GDP and 1.54% of the total health care expenditure. By type of service, 77.4% of the expenditure corresponded to hospitalization services, basically in mental health facilities; 17.9% to out-patient health care services; and 4.6% to home-based nursing services (Table 3). No information was available on the number of beneficiaries.

Long-term social care

Long-term care homes

LTC residential centers have no official register. The most recent information is the 2011 Population Census. According to this source, 2,648 people aged 65 or over lived in old people’s homes, which accounted for around 0.85% of the total population in this age group.

In the private sector, the system is fragmented and lacks economies of scale. Each center has a maximum capacity of approximately 20 places, and they are not exclusively for dependent people. Their prices range between USD 830 and USD 2,150 per person per month.

In the public sector, we identified two programs. The CONAPAM (National Council for Older Adults) manages the first. It funds residential care in private centers owned by non-profit organizations, such as community associations and religious agencies. The beneficiaries are older people who are dependent and/or in a situation of family neglect and lack of social and economic assistance. In 2018, 73 associations provided care to 2,155 beneficiaries. Each association received, on average, a subsidy of USD 440 per person per month.

The CONAPDIS (National Council for Persons with Disabilities) manages the second program. It funds services in non-profit residential centers and private homes. It focuses on low-income people of all ages with disabilities. In 2018, this program benefited 1,350 people. Each center received an average subsidy of USD 555 per person per month.

Day-care centers

The public system funds this type of care services for people aged 65 and over who live in poverty or find themselves in situations of social risk. The CONAPAM manages this program, which works similarly to that of the LTC homes - i.e., the public institution funds the work of non-profit organizations, mainly community associations, which provide day-care services, including meals, recreational therapy, social integration, and psychological support. In 2018, 62 associations offered this type of care services to 1,560 people. The public subsidy amounted to USD 175 per person per month.

Home care

Home care is one of the most extended forms of care in Costa Rica. It is part of a network of care services created in 2014 and managed by CONAPAM. Its design is like that of the residential and day-care programs. The program is intended for people aged 60 or more living in poverty or under social risk conditions. In 2018, 59 civil associations provided this kind of services to 13,900 beneficiaries receiving a public subsidy of USD 85 per person per month.

Estimation of the LTC demand and profile of the caregivers

The demand for LTC was defined as the number of people who require help from another person to perform activities of daily living, including walking, washing themselves, eating, getting up/laying down, dressing up or using the WC. Our results show that 13.4% of the people aged 65 and over need this kind of help. The rate is higher among older people and women (Table 4).

The total number of people in this situation is 55,450. According to population projections, this number will reach 183,280 by 2050. By sex, 58.2% of the dependent population are women and 41.8% are men. By age, 48.7% are aged 80 and more.

Up to 84.6% receive help from another person, who is a relative in 90% of the cases. Only 2.1% of Costa Rican dependent people pay for the help they receive. The average care time is 5 days per week and 18 hours per day. The caregivers are women in 69.4% of the cases, and men in 30.6% of them. Their average age is 48 years, 58.9% of them have completed their primary education, and 73.6% do not work outside the home.

Discussion

Until recently, few studies had been made on old-age dependency issues and LTC services in Latin America. However, their numbers have increased in the last few years (Bloeck; Galiani; Ibarrarán, 2019BLOECK, M. C.; GALIANI, S.; IBARRARÁN, P. Long-Term Care in Latin America and the Caribbean: Theory and Policy Considerations. Economía, Baltimore, v. 20, n. 1, p. 1-32, 2019. DOI: 10.1353/eco.2019.0006
https://doi.org/10.1353/eco.2019.0006... ; Matus-Lopez; Cid, 2015MATUS-LOPEZ, M.; CID, C. Building Long-Term Care Policies in Latin America: New Programs in Chile. Journal of the American Medical Directors Association, Washington, DC, v. 16, n. 10, p. 900.e7-10, 2015. DOI: 10.1016/j.jamda.2015.07.018
https://doi.org/10.1016/j.jamda.2015.07.... , ²⁰¹⁶MATUS-LOPEZ, M.; CID, C. New Long-Term Care Policies in Latin America: The National System of Care in Uruguay. Journal of the American Medical Directors Association, Washington, DC, v. 17, n. 7, p. 663-665, 2016. DOI: 10.1016/j.jamda.2016.04.001
https://doi.org/10.1016/j.jamda.2016.04.... ; Minayo, 2019MINAYO, M. C. The imperative of caring for the dependent elderly person. Ciência & Saúde Coletiva, Rio de Janeiro, v. 24, n. 1, p. 247-252, 2019. DOI: 10.1590/1413-81232018241.29912018
https://doi.org/10.1590/1413-81232018241... ; Pelaez; Minoldo, 2018PELAEZ, E.; MINOLDO, S. The impact of population aging on social security and care demands in the Southern Cone. Revista Latinoamericana de Población, Morelos, v. 12, n. 23, p. 62-84, 2018. DOI: 10.31406/n23a4
https://doi.org/10.31406/n23a4... ; Villalobos, 2018VILLALOBOS, P. Is Aging a Problem? Dependency, Long-term Care, and Public Policies in Chile. Pan-American Journal of Public Health, Washington, DC, v. 42, p. e168, 2018. DOI: 10.26633/RPSP.2018.168
https://doi.org/10.26633/RPSP.2018.168... ). Today, several countries are considering implementing a national LTC system. In 2016, for the first time in the region, Uruguay began developing a national care system (Sistema Nacional de Cuidados). Everything seems to indicate that Costa Rica will be the next country to do so.

The public health expenditure of Costa Rica represents 5.7% of its GDP (Calvo et al., 2018CALVO, E. et al. Comparative Analysis of Aging Policy Reforms in Argentina, Chile, Costa Rica, and Mexico. Journal of Aging & Social Policy, London, v. 31, n. 3, p. 211-233, 2018. DOI: 10.1080/08959420.2018.1465797
https://doi.org/10.1080/08959420.2018.14... ). Only two countries in the region make larger expenditures and none has a higher life expectancy rate. However, LTC spending amounted only to 2% of the public health expenditure and 0.11% of the GDP, which is equivalent to 1/10 of the LTC expenditure in rich countries (EC, 2019EUROPEAN COMMISSION. Health and Long-term Care, 2019. Brussels, 2019. Disponível em: <Disponível em: https://ec.europa.eu/eurostat/web/employment-and-social-inclusion-indicators/social-protection-and-inclusion/health-long-term-care >. Acesso em: 10 nov. 2020.
https://ec.europa.eu/eurostat/web/employ... ; OECD, 2017ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT. Health at a Glance 2017. Paris, 2017. DOI: 10.1787/health_glance-2017-en
https://doi.org/10.1787/health_glance-20... ; WHO 2020WORLD HEALTH ORGANIZATION. Global Health Expenditure Database 2020. Geneva, 2020. Disponível em: <Disponível em: http://apps.who.int/nha/database/Select/Indicators/en >. Acesso em: 20 mar. 2020.
http://apps.who.int/nha/database/Select/... ).

Since the beginning of the 2010s, especially since 2014, Costa Rica has been promoting childcare and older adult care policies (Guzmán, 2014GUZMÁN, J. Red nacional de cuido y desarrollo infantil en Costa Rica: el proceso de construcción 2010-2014. Santiago: CEPAL, 2014.; Morales-Martinez; Rivera-Meza, 2014MORALES-MARTINEZ, F.; RIVERA-MEZA, E. Public policy on aging and elderly: the case of Costa Rica. Gerontechnology, Eindhoven, v. 12, n. 4, p. 209-2013, 2014. DOI: 10.4017/gt.2014.12.4.004.00
https://doi.org/10.4017/gt.2014.12.4.004... ). At present, the country has some LTC-related programs aimed primarily at low-income older people or people with disabilities. These programs are subsidiaries, meaning that public institutions do not directly carry out the care work, but fund third parties to perform those services. These third parties are mainly community associations that apply for those funds and constitute a voluntary care network. The total number of beneficiaries is around 20,000, but the percentage of them that need help to perform their activities of daily living remains unknown. Those programs cost USD 31.5 million in total, which represents around 0.1% of the country’s GDP.

Regarding the demand, this study has estimated that approximately one out of eight people over 65 years of age needs help to perform their activities of daily living, reaching around 55,000 in total. Therefore, the current coverage is estimated at below 35%. The fact that 90% of those people receive unpaid care services at their own homes reflects this.

In the coming years, several Latin American countries will be facing a huge demand for long-term care services (Norori, 2018NORORI, M. L. Addressing the “Tsunami” of Long-Term Care Needs in Latin America: Is Preparation Feasible? Journal of the American Medical Directors Association, Washington, DC, v. 19, n. 9, p. 731-732, 2018. DOI: 10.1016/j.jamda.2018.07.013
https://doi.org/10.1016/j.jamda.2018.07.... ). In Costa Rica, one of the countries with the most advanced health care and social policies in the region, implementing an LTC system will cost more than the current fragmented programs. In countries with lower health care and social spending, the challenge is even greater. This study’s results should alert decision makers in those other countries and encourage them to advance in the analysis and estimation of their national demand for long-term care.

This study has two main limitations. The first one is quantifying the percentage of dependent beneficiaries in the total beneficiaries of the existing social services since no dependency assessment scale is applied to them. The second limitation is methodological since the answers to the interviews may have been affected by the government’s will to address this subject.

Acknowledgements

The authors thank all the interviewees for their participation.

References

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