ADMINISTRATION ON AGING. GLOBAL COMPARISON OF FORMAL AND INFORMAL CAREGIVING
European Scientific Journal December 2013 /SPECIAL/ edition vol.2 ISSN: 1857 - 7881 (Print) e
ADMINISTRATION ON AGING. GLOBAL COMPARISON OF FORMAL AND INFORMAL CAREGIVING
Gogi Batiashvili 0
Full Otar Gerzmava 0
0 Grigol Robakidze University , Georgia
Countries in regions of the world are managing aging populations differently, but each country offers lessons to be learned. Countries used as examples include Germany, Australia, Japan, Uruguay, Kenya, Hungary, and the United States. All of these countries have some type of formal, informal, or both systems in place to care for older persons. These countries, among others throughout the world, will have to confront decreasing familial caregivers together with longer life expectancy. Other issues to consider include policy formation, resource allocation, health care, and diversity.
Global aging; health care and aging; long term care
Among a range of countries, the topic of aging has become increasingly discussed in
terms of demographic transitions and elder care. By the year 2050, projections indicate that 60
countries will have at least two million people aged 60 years or older, up from 26 countries in
2011. As can be seen in Table 1, all regions of the world will experience an increase in the
number of older adults in 2030. The developed world is presently experiencing much higher
percentages of older individuals as compared to developing countries; however, this will not
be the case in the future due to the demographic transition of developed and developing
countries. In 2050, it is projected that the developed world will have only 22 percent of the
worlds oldest population (Kinsella & Philips, 2005).
Table 1: Percent of Population over 65 years by Region (2000, 2015, 2030)
2030 20.0 5.4
2000 10.1 2.3
2015 12.4 3.1
2030 16.3 4.4
2000 2.9 0.3
2015 3.1 0.4
2030 3.6 0.5
Note: From International Data Base, by U.S Census Bureau, 2006, U.S Census Bureau.
The countries discussed throughout this article were chosen to represent the regions
outlined in Table 1. These regions include: Asia, Latin America, Europe, North America,
Oceania, and Africa. By researching countries located in various regions of the world, a better
understanding of the transcultural trends, similarities, and differences in aging can be
observed on a global level. The nations ability to understand how their country needs to
approach an aging population, together with how other countries approach an aging
population, is very important to the development and improvement of formal and informal
systems of health care.
Several countries within different regions of the world are managing aging populations
and each country offers lessons to be learned relative to its ability or inability to manage this
population. The countries discussed throughout this article include the following: Germany
(Western Europe), Australia (Oceania), Japan (Asia), Uruguay (Latin America), Kenya
(Africa), Hungary (Eastern Europe), and the United States (North America). Each country
offers different formal and informal systems of health care, specifically long term care (LTC),
to the older populations in each county. As can be seen in Table 2 and Table 3, each country
has different population statistics, which may effect how these systems of health care are
administered. This article will present the formal and informal systems of care in the above
outlined countries, followed by a discussion of these countries and what can be learned from
their ability or inability to manage the aging population. For the purposes of this article, the
World Health Organization (WHO) defines informal care as specific care provided by the
family and formal care as that provided by the state or the market in the form of state funded
or private health insurance (WHO, 2000).
Germany offers a social insurance system to its citizens through income-related
contributions paid by both employees and employers (International Reform Monitor [IRM],
2006). If an individual earns more than the defined income, the health care consumer has the
option to purchase private health insurance. In 2001, over 90 percent of the population was
covered by compulsory health insurance, while less then 0.2 percent of the population
remained uninsured (Docteur & Oxley, 2003). Germanys estimated public spending on LTC
as a percentage of gross domestic product (GDP) from 1992-1995 was 0.82 percent, as
compared to 11.1 percent total national health expenditure as percent of GDP in 2003 (IRM,
Public LTC insurance has been a part of Germanys social security system since
January 1, 1995 (IRM, 2006b). The LTC insurance provides nursing and in-home benefits to
people of all ages with severe disabilities (Gibson, 2003). In 1998, Germany devoted almost
half of its LTC insurance program to noninstitutional services (Cueller & Wiener, 2000). The
countrys ability to contribute a large percentage of its LTC insurance to noninstitutional
services demonstrates that Germany values informal care by family members because it
performs a central role in the care of the elderly. To further the family caregiving goal, up to
four weeks of respite care is provided for informal caregivers and pension credit is awarded to
persons providing high levels of unpaid services (Cueller & Wiener, 2000). Caregivers
providing 14 or more hours of care per week are eligible for contributions to statutory pension
and accident insurance together with counseling/training and respite services (IRM, 2006b).
In 1998, approximately 550,000 individuals received pension contributions, with 93
percent being women and 55 percent between 50 and 65 years of age (Cueller & Wiener,
Care receivers have the option of accepting cash to pay caregivers, accepting
professional care, or a combination of both. Since the introduction of LTC insurance in
Germany, the majority of care receivers have preferred cash (71 percent in 1997), supporting
the notion of familial responsibility and caregiver preference among care receivers (Theobald,
Australia offers universal health care coverage; therefore, all of its citizens have health
care coverage. It is through the public health insurance system, namely Medicare, that LTC
services are funded (IRM, 2006a). The Commonwealth of Australia created Australias Aged
Care System with the purpose to support healthy aging for older Australians and quality,
cost, effective care for frail older people and support of their carers (Department of Human
Services [DHS], 2003). The aged care system delivers residential (high level nursing home
care and low level hostel care) and community care (informal care).
There is no obligation for family members to provide informal care; however, it is
generally expected by the state that family will provide care. In fact, 75 percent of
community care is provided by the family (IRM, 2006a). In order to encourage potential
carers, the government offers specific allowances and payments what will be discussed below.
As of 1998, 2.3 million Australians, or one in five households, provided informal care
(National Alliance for Caregiving, 2003).
Australia offers carers extensive respite care through the National Respite for Carers
Program (NRCP) of either residential respite or through approximately 90 community-based
Carer Respite Centers (DHS, 2005). Carers also receive a carer allowance based on
eligibility. The allowance covers carers who look after a child or adult who need additional
attention as a result of a severe disability or medical condition (DHS, 2004). In addition to
the carer allowance, a carer can also be eligible for a carer payment. The payment is
administered as an income support for carers who are unable to support themselves through
full participation in the work force as a result of their carer role (DHS, 2004).
Among the numerous services offered to carers and older adults is the Aged Care
Assessment Program (ACAP). Through the ACAP, Aged Care Assessment Teams (ACATs)
provide expert assessment of eligibility for services and advice regarding the long term needs
of the frail aged (DHS, 2003). Ultimately, Australias formal and informal care systems
intertwine to offer a full service system to older Australians.
As of 2004, Japan was the second oldest country in the world at approximately 19
percent aged 65 or older. Japan implemented a LTC social insurance program in April 2000
that covers nursing home and home/community-based services, including home-helpers, adult
day centers, assistive devices, and minor home remodeling for those aged 40 years or older
(Gibson, 2003). Half of the LTC insurance system currently in place is financed through tax,
and the remaining 50 percent comes from contributions collected from adults aged 40 years
and older or from a co-payment of 10 percent of the costs of care (IRM, 2006c). Those who
are aged 65 years or older and those aged 40-64 with age-related disabilities are eligible for
insurance coverage (Gibson, 2003). The system explained above has been implemented with
relatively no problems and, thus far, it seems to be a success (Ministry of Health, Labour and
Welfare [MHLW], 2002).
Japans culture surrounds itself with the concept of filial piety or taking care of
ones own parents. In fact, direct relatives within three generations of relationship may be
legally responsible for an elderly individual (IRM, 2006c). Contrary to the concept of filial
piety, the Japanese government has acknowledged through recent policy implementations
that elderly care has shifted away from the family and toward the state. However, the
government still recognizes the importance of family or informal caregiving; and therefore,
introduced a measure of in-cash assistance to those caring for elderly people at home (IRM,
2006c). The assistance comes in the form of a fixed-amount grant to the families. Caregivers
are also eligible for up to 1-week respite stay per month based on the level of disability of the
person being cared for by the caregiver (Gibson, 2003).
Uruguays population was approximately 3.5 million in 2001 (Pan American Health
Organization [PAHO], 2001). The country represents the largest population of people 60
years and older in Latin America, thereby making it the oldest country in this region
(Collymore, 2000). Uruguay is indeed the oldest country in the western hemisphere with 17.3
percent of its population over the age of 60 in 1997, followed by the United States at 16.5
percent (NIH, PAHO, U.S. Census Bureau, 1999). As is the situation in other less developed
countries, rates of chronic and disabling illnesses are greater among elderly, yet the
availability and utilization of health services is considerably lower as compared to developed
The public health system in Uruguay consists of both a public and private sector. In
terms of coverage, the State Health Services Administration (ASSE) serves 33.7 percent of
the population, the Consortium of Humanities Centers and Institutes (CHCIs) 46.6 percent,
the Armed Forces Health Service 4.2 percent, the Police Health Service 1.8 percent, and other
institutions 1.2 percent (PAHO, 2001). Approximately 11.7 percent of the population does
not have formal coverage (WHO, 2006). Uruguay does not have a reliable registry of LTC
institutions or residences implemented to monitor its citizens (United Nations Economic
Commission for Latin America and the Caribbean [UNECLAC], 2003). The lack of
availability of a reliable registry not only makes it difficult to calculate an accurate number of
institutionalized older persons, but also indicates the lack of priority given to the issue.
Due to globalization and modernization trends such as migration to urban settings and
women in the work force, Uruguay is also experiencing fewer families assisting their elderly
relatives. In Latin America, family members are the primary caregivers for older persons,
with a high proportion, approximately 90 percent of family caregivers, being women. Most
caregivers are over 50 years old and are subject to emotional and financial problems
(UNECLAC, 2003). Despite these problems, no Latin American country has a caregiver
support policy or a plan for developing options for providing day care to disabled persons
According to a 1999 census report, approximately 1.5 million people (4.8 percent of
the total population) are aged 60 years and above in Kenya (Olum, 2005). Although Africa
will be considered relatively young through 2050, it has been found that its youth dependency
will be reduced by 57 percent while its old age dependency will increase by 93 percent by
2050 (Kalasa, 2001). Therefore, Africas policy on aging will become an increasingly
important health policy issue.
The Government of Kenya has already addressed the aging issue by implementing a
National Policy on Aging together with the 9th National Developmental Plan. These measures
do not specifically address health care; however, the purpose is to facilitate the needs and
concerns of older persons. Kenya must depend on family support for many who need care
because of the deteriorating financial and human resources for health services (Olum, 2005).
As experienced by other developing countries, Kenya has noted the disintegration of the
extended family support system due to urbanization and modernization, thus placing older
persons in unsatisfactory conditions both in the formal and informal setting. Kenya recognizes
the need for LTC programs to ensure socio-economic support and security for the elderly
Although Kenya has initiated governmental policy reforms to address aging,
implementation of new public programs was a priority due to Kenyas increased poverty,
malnutrition, HIV/AIDS, and decreasing life expectancy - 60 years in 1993 to 51 in 1998
(Bedi et al., 2004). The key participants in Kenyas health system are the Ministry of Health,
non-government organizations (NGOs), private for-profit health systems, and local
government authorities. At each level of care, curative, prevention and promotional services
are offered (Bedi et al., 2004). The public sector has a dominant representation in health
centers (79%), subhealth centers (92%), and dispensaries (60%) while the NGOs lead in
health clinics, maternity and nursing homes (94%) and medical centers (86%) (Bedi et al.,
2004, p. 27). The government finances approximately 50 percent of health care costs and
private arrangements, such as insurance or out-of-pocket spending, account for 42 percent,
while NGOs, missions and donors, among other institutions, finance 6 percent (Bedi et al.,
Hungary has the population of approximately 10 million people that is expected to
decrease to approximately 7.5 million by 2050. As the number of the working population
decreases in Hungary, the number of people 60 years or older will double, moving the
dependency ratio from 8.2 percent in 2000 to an expected 12.5 percent in 2050 (WHO,
2006a). Hungary offers free access to health care for all citizens, thereby indirectly benefiting
the elderly. Hungarys health care system is primarily funded through the Health Insurance
Fund (HIF), which receives contributions from employers and employees, and deficits are
covered by state funds (Goglio, 2005).
Hungary also offers a well-developed home health care and home social-assistance
system (Burns & Cekota, 2002). However, Hungary only has one nursing-home bed for every
140 individuals over the age of 65, increasing the unmet demand for nursing home placement
and in-patient geriatric care (Burns & Cekota, 2002). The services offered by the government
are supplemented by traditional informal caregiving. Many elderly live with their children or
grandchildren who are legally obligated to care for their older relatives (Burns & Cekota,
2002). Family members caring for the elderly relatives are entitled to a care fee which
makes them eligible for social insurance as determined by The Act of Social Assistance.
(Aman, Buchele & Kalisch, 1998, p. 171).
The United States
In 2004, the United States ranked 38th in the worlds oldest countries. The U.S. is
relatively young with 12.4 percent of the population over the age of 65, as compared to
European standards where 19 of the 20 oldest countries in the world are located in Europe
(Kinsella & Philips, 2005). However, by 2050 the U.S. is expected to observe 9 percent
increase in the percentage of people over the age of 60 as a result of the aging baby boomer
generation - those born between 1946 and 1964 (UN, 2006). Additionally, the U.S. spends
more of its GDP on health care, at 15.2 percent, as compared to any other developed nation
The U.S. offers universal health care coverage to its citizens over the age of 65 and
those disabled under the age of 65 through the Medicare program. Under Medicare, a portion
of nursing home care is covered for a short period of time followed by either a private
insurance or out-of-pocket payment method (IRM, 2006d). Under the Medicaid program, long
term nursing home care is available after the recipient has spent down all income and assets
thereby allowing them to qualify for Medicaid.
The aging of the population in the U.S. will put a strain on the current health care
system and on informal caregivers throughout the country. Caregiving prevalence estimates
were 24 to 27.6 million in 1997 (Arno, Levine, & Memmott, 1999). Using midrange figures,
the national economic value of informal caregiving in 1997 was $196 billion (Arno, Levine,
& Memmott, 1999). The U.S. enacted the Family and Medical Leave Act of 1993 (FMLA)
which offers 12 workweeks of unpaid leave. In addition to the FMLA, the National Family
Caregiver Support Act (NFCSA), authorized by the Older Americans Act of 2000, allows
states to provide a continuum of caregiver services that best meet caregivers and individual
needs. These may include information, assistance and other services (Administration on
Aging, 2003). Medicare and Medicaid also offer limited home care services to caregivers in
the form of home nursing services, social services, counseling, medications, physical and
occupational therapy, household services, and nutritional services.
Table 3: Family Caregiver Policy
Note: From The Road to Recognition: International Review of Public Policies to Support Family and Informal
Caregiving, by Feinberg, L. & Montgomery, A., 2003, Family Caregiver Alliance.
All countries discussed above have some type of formal, informal, or both systems in
place to care for older persons. Each country uses only a fraction of the percentage of GDP
allocated to health expenditures for LTC. Less developed countries, such as Kenya and
Uruguay, have a less developed system of care for their elderly populations as a result of
inadequate resources to address aging. These less developed countries ultimately have to
distribute their resources to other issues such as basic public health including basic health
care, disease prevention or control, or sanitation, as opposed to LTC.
The review of the current literature supports the notion that no country has the
answer to dealing with aging population. All countries are simultaneously dealing with less
familial support of elderly family members as a result of modernization and globalization. As
discussed above, not all countries researched offer the same support for caregivers, and some
countries do not offer any formal support. Countries such as Australia have extensive
measures implemented, while other countries are considering new initiatives.
It is suggested that just because an intervention strategy works in one country, the
measure may not necessarily be implemented successfully in another country. Many different
social standards, including but not limited to language, cultural diversity, customs, beliefs,
religion, and values must be considered when implementing a measure to address health care
services. In addition to social standards, a country must also be economically able to
implement certain health care measures. For example, a country must consider whether it has
the financial means to add a LTC program and take into consideration whether that same
measure fits with the social standards of the society in which it will be implemented. Many
countries have adopted policy reforms but have not allocated resources to implement these
Governments may eventually come to the point where many options are offered for
the elderly and their caregivers. All countries will need an aging strategy together with a
caregiver support strategy. The elderly will need access to quality and cost effective formal
health care that may consist of skilled nursing, home health care, or hospice. The field of
geriatrics will also become increasingly important as elderly individuals with comorbidities
have an increased need for primary and specialty health care as they age. Additionally, family
or informal caregivers need a system of respite care and support from the community and
Caregivers should be offered cash payments or allowances as used in Australia.
Moreover, caregivers should have some linkage to public pension plans, considering that their
absence in the formal workforce would prevent them from obtaining a pension or even social
security benefits. Caregivers can also benefit by receiving tax credits for their dependent
family member and the option of making their family member a dependent under the
caregivers health insurance policy. By using these measures, both caregivers and care
receivers would greatly benefit.
Research suggests that globalization or the blending of cultures directly affects each
country studied, thereby introducing a pluralistic approach to elder care. As discussed,
globalization is observed in terms of a decrease in familial support for elderly family
members. Countries that are attempting to implement policy reforms relative to aging or LTC
must consider the cultural diversity of its people because diversity may increase or decrease
the degree of adaptation of the policy relative to social standards, as discussed above. The
proportion of young and old individuals may also effect policy adaptation as social standards
within these age brackets conflict.
The aging world will also produce an intergenerational struggle for resources, as the
increasing elder population will monopolize a large amount of resources, thus reducing the
allocation of revenue to other programs. The leaders of these countries that are facing this
resource struggle will have to allocate resources in the best possible way to improve and
maintain the health of the population as a whole. Their competition for resources and ability
to finance policy reforms create a very important social, economic, and political dynamics. In
order to balance this delicate dynamics, leaders must be open to public debate to better
understand the issues relative to aging.
In addition to resource struggles between generations, population shifts through
migration and immigration are also significant. For example, just as young and old
generations will compete for resources, the U.S. population as a whole will compete for
resources with the countrys estimated 8-9 million illegal immigrants (Center for Immigration
Studies, 2006). Migration and immigration can also reshape the demographics of a country,
thereby directly effecting how a country must manage an aging population.
Society will struggle with the concept of continued aging because as the life
expectancy increases, quality of life does not necessarily increase together with life
expectancy. Countries throughout the world may be faced with deciding what resources
individuals should be entitled to and at what age. Ultimately, the issue comes down to
keeping people alive, but at what cost to society? The same issue will surface debates on
human rights and euthanasia, among others. Overall, countries experiencing aging population
must formulate their policies in a manner that addresses various concerns. Each policy will
require thoughtful formulation that must benefit the older populations within the country and
the families or caregivers of the older population.
Burns A. & Cekota J. (2002). Coping with Population Ageing in Hungary. Organization for
Economic Co-operation and Development. Retrieved July 12, 2006 from
Center for Immigration Studies (CIS). (2006). Current Numbers. CIS. Retrieved October 16,
2006 from http://www.cis.org/topics/currentnumbers.html/
Collymore Y. (2000). Uruguay out Front on Population Aging. Population Reference
Bulletin. Retrieved July 20, 2006 from http://www.prb.org
Department of Human Services (2003). Aged Care in Australia. Canberra, Australia:
Commonwealth of Australia. Department of Human Services (2004). Financial Support for
Carers. Australian Government.
Retrieved July 4, 2006 from
Department of Human Services (2005). Carers. Australian Government. Retrieved July 4,
Docteur E. & Oxley H. Health-Care Systems: Lessons from the Reform Experience. OECD
Health Working Papers 9, Organization for Economic Cooperation and Development, 52.
Feinberg L. & Montgomery A. The Road to Recognition: International Review of Public
Policies to Support Family and Informal Caregiving. Family Caregiver Alliance. San
Francisco, California: National Center on Caregiving. 2003.
Gibson M., Gregory S., & Pandy, S. Long-Term Care in Developed Nations: A Brief
Overview. American Association of Retired Persons Public Policy Institute. Washington,
D.C.: AARP. 2003.
Goglio A. (2005). In search of efficiency: Improving health care in Hungary. Organisation for
Economic Co-operation and Development. Retrieved July 12, 2006 from
International Reform Monitor (2006). Social Policy, Labour Market policy, and Industrial
Relations: Australia. International Reform Monitor. Retrieved July 2, 2006 from
International Reform Monitor ( 2006b ). Social Policy, Labour Market policy, and Industrial Relations: Germany. International Reform Monitor. Retrieved July 2 , 2006 from http://www.reformmonitor.org International Reform Monitor ( 2006c ). Social Policy, Labour Market policy, and Industrial Relations : Japan. International Reform Monitor. http://www.reformmonitor.org International Reform Monitor ( 2006d ). Social Policy, Labour Market policy, and Industrial Relations: United States. International Reform Monitor. Retrieved July 2 , 2006 from http://www.reformmonitor.org Kalasa B. ( 2001 ). Population and Ageing in Africa: a Policy dilemma? United Nations Fund for Population Activities . Retrieved July 2 , 2006 from www.iussp.org/Brazil2001/s80/S84_04_Kalasa.pdf.
Kinsella K. & Velkoff V.A. An Aging World : (U.S. Census Bureau, Series P95/01-1).
Washington, DC: U.S. Government Printing Office. 2001 Kinsella K. & Philips D. Global Aging : The Challenge of Success. Population Bulletin , 60 ( 1 ), 2005 .
Ministry of Health, Labour and Welfare (MHLW) ( 2002 ). Long term care insurance in Japan.
MHLW. Retrieved July 2 , 2006 from http://www.mhlw. go.jp/english/topics/elderly/care/index.html National Alliance for Caregiving ( 2003 ). International Caregiving Legislation: Australia.
National Alliance for Caregiving . Retrieved July 4 , 2006 from http://www.caregiving.org/intcaregiving/australia/australia.htm.
OlumG. ( 2005 ). Report on Status and Implementation of National Policy on Ageing in Kenya.
United Nations Department of Economic and Social Affairs. Retrieved July 2 , 2006 from http://www.un.org Theobald H. Care for the elderly: Welfare system, professionalisation and the question of inequality . 2003 .
The International Journal of Sociology and Social Policy , 23 ( 4 /5), 159 . Retrieved June 1, 2006 , from ABI /INFORM Global database.
UN ( 2012 ). Population Aging 2011 . United Nations. Retrieved August 14 , 2006 from http://www.un.org/esa/population/publications/ageing.
WHO ( 2012 ). Country Profiles on Long-term Care: Hungary . World Health Organization.
Retrieved July 20 , 2006 from http://www.who.int/docstore/ncd WHO ( 2012 ). World Health Organization Statistical Information System . http://www.who.int