WorkingPapers No. 12 SOCIUM SFB 1342 - Heinz Rothgang Johanna Fischer Meika Sternkopf Lorraine Frisina Doetter

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WorkingPapers No. 12 SOCIUM SFB 1342 - Heinz Rothgang Johanna Fischer Meika Sternkopf Lorraine Frisina Doetter

WorkingPapers No. 12

           Heinz Rothgang
           Johanna Fischer
           Meika Sternkopf
    Lorraine Frisina Doetter
       The classification of
    distinct long-term care
   systems worldwide: the
   empirical application of
  an actor-centered multi-
     dimensional typology
Heinz Rothgang, Johanna Fischer, Meika Sternkopf, Lorraine Frisina Doetter
 The classification of distinct long-term care systems worldwide: the empirical application of an
 actor-centered multi-dimensional typology
 SOCIUM SFB 1342 WorkingPapers, 12
 Bremen: SOCIUM, SFB 1342, 2021

SOCIUM Forschungszentrum Ungleichheit und Sozialpolitik /
 Research Center on Inequality and Social Policy
SFB 1342 Globale Entwicklungsdynamiken von Sozialpolitik /
 CRC 1342 Global Dynamics of Social Policy

Postadresse / Postaddress:
Postfach 33 04 40, D - 28334 Bremen


[ISSN (Print) 2629-5733]
[ISSN (Online) 2629-5741]

Gefördert durch die Deutsche Forschungsgemeinschaft (DFG)
Projektnummer 374666841 – SFB 1342
Heinz Rothgang
                                       Johanna Fischer
                                       Meika Sternkopf
                                Lorraine Frisina Doetter

          The classification of distinct
   long-term care systems worldwide:
the empirical application of an actor-
 centered multi-dimensional typology

                                          SOCIUM • SFB 1342
                                                     No. 12

          Heinz Rothgang (,
          Johanna Fischer (,
          Meika Sternkopf (,
          Lorraine Frisina Doetter (
          Collaborative Research Centre 1342 ‘Global Dynamics of
          Social Policy’ and SOCIUM Research Center on Inequality and
          Social Policy, University of Bremen.
          Funded by the Deutsche Forschungsgemeinschaft
          (DFG, German Research Foundation) –
          Projektnummer: 374666841 – SFB 1342.
          We would like to thank Antonio Basilicata for his excellent
          contributions to data collection and Ojarmyrat Gandymov for
          assistance with formatting.

       Long-term care (LTC) systems vary between countries in several ways. One im-
       portant difference exists with regard to the question of who, that is which type
       of corporate actor, takes over the main responsibility in providing, financing and
       regulating LTC. In this article, we employ a multi-dimensional, actor-centered ty-
       pology of LTC systems to classify all distinct LTC systems existing worldwide at the
       point in time when they were first established. In doing so, the article contributes
       to comparative LTC research by including novel cases and adding a historical
       perspective. Our 18 cases fall into eight types, which we combine tentatively into
       three distinct clusters: A predominantly state regulated and financed cluster, a
       state regulated cluster with mixed financing and provision, and a cluster with pri-
       vate regulation and provision plus societal financing. We find that the state plays
       the major role in regulation (dominant in 16 countries) and financing (dominant
       in 11 countries), while in provision we see a broader distribution with societal
       and private for-profit actors taking a major role. Interestingly, and in contrast to
       healthcare systems, no societal pure type emerges, not even among social insur-
       ance countries.


  Die weltweit existierenden Pflegesicherungssysteme unterscheiden sich von Land
  zu Land in vielfacher Hinsicht. Ein wichtiger Unterschied besteht darin, welche
  Akteure die Hauptverantwortung für die Leistungserbringung, Finanzierung und
  Regulierung der Langzeitpflege (LZP) inne haben. In diesem Beitrag verwenden
  wir eine mehrdimensionale, akteurszentrierte Typologie, um alle weltweit vorhan-
  denen eigenständigen LZP-Systeme zum Zeitpunkt ihrer Einführung zu klassifizie-
  ren. Damit wird die vergleichende LZP-Forschung in zwei Richtungen erweitert:
  Zum einen werden Fälle einbezogen, die in vergleichenden Darstellungen bis-
  lang häufig nicht berücksichtigt werden und zum anderen wird eine historische
  Perspektive hinzufügt. Die 18 Länder mit eigenständigen Sicherungssystemen ge-
  hören zu acht Typen, die wir zu drei verschiedenen Clustern zusammenfassen:
  Ein staatlich reguliertes und finanziertes Cluster, ein staatlich reguliertes Cluster
  mit unterschiedlichen Akteuren in Finanzierung und Leistungserbringung und ein
  Cluster mit privater Regulierung und Erbringung plus gesellschaftlicher Finanzie-
  rung. Der Staat ist dabei der dominante Akteur bei der Regulierung (16 Länder)
  und der Finanzierung (11 Länder), während wir bei der Leistungserbringung eine
  breitere Verteilung sehen, bei der gesellschaftliche und private, gewinnorientierte
  Akteure eine große Rolle spielen. Interessanterweise gibt es im Gegensatz zu
  Gesundheitssystemen kein System mit der Dominanz gesellschaftlicher Akteure
  in allen drei Dimensionen – auch nicht in Ländern mit einer sozialen Pflegeversi-

                              SOCIUM • SFB 1342 WorkingPapers No. 12                      [iii]

  1.       Introduction ................................................................................................ 1

  2.       LTC systems throughout the world .................................................................... 2

  3.       Theoretical background ................................................................................ 3

  4.       Methods and data ....................................................................................... 6

  4.1      Operationalization ...................................................................................... 7
  4.1.1 Classified unit ........................................................................................... 7
  4.1.2 Provision dimension ................................................................................... 9
  4.1.3 Financing dimension ................................................................................ 10
  4.1.4 Regulation dimension ............................................................................... 11

  4.2      Data ....................................................................................................... 13

  5.       Classification results ................................................................................... 13

  6.       Discussion ................................................................................................ 15

  7.       Conclusion ............................................................................................... 17

  References ......................................................................................................... 19

  Appendix .......................................................................................................... 25

                                          SOCIUM • SFB 1342 WorkingPapers No. 12                                             [v]
1. Introduction                                     sibility for LTC provision, financing and reg-
                                                    ulation (see e.g. Lyon & Glucksmann, 2008;
                                                    Ochiai, 2009; Rodrigues & Nies, 2013). In
In the last decades, long-term care (LTC) is        analyzing the resultant ‘care-mix’ of LTC sys-
increasingly developing into a distinct social      tems, we can, for instance, gain important
policy field. While the need for long-term          insights into the role of the state and of public
assistance with daily living due to physical        versus private actors. Furthermore, this focus
and/or mental impairments is not a novel            sheds light on interaction logics present in
phenomenon per se, developments such as             LTC systems and their associated outcomes
global demographic aging, changing family           (Fischer, Frisina Doetter, & Rothgang, 2021;
structures and the emergence of a (human)           Rothgang & Fischer, 2019).
rights perspective on disability and aging              Adopting an actor-centered perspective,
(see e.g., Birtha, Rodrigues, Zólyomi, San-         the present article compares distinct LTC sys-
du, & Schulmann, 2019) have contributed to          tems throughout the world, identifying clus-
the recognition of LTC as a ‘new social risk’       ters or types of countries. We ask the follow-
necessitating public attention (Greve, 2018;        ing question: How do distinct LTC systems
Österle & Rothgang, 2021). This develop-            differ with respect to actor types dominant
ment is visible both on the inter- and transna-     in service provision, financing and regula-
tional level – where international and region-      tion? To systematically analyze the variation,
al organizations have increasingly come to          we make use of a multi-dimensional, ac-
address LTC (e.g. Esquivel, 2017; European          tor-centered typology of LTC systems recently
Commission [EC], 2013; Organisation for             developed by Fischer et al. (2021). Typolo-
Economic Cooperation and Development                gies constitute useful instruments for com-
[OECD], 2005; Scheil-Adlung, 2015; World            parative research, helping to transparently
Health Organization [WHO], 2017) – and              conceptualize categories for comparison
in individual countries worldwide. Concern-         and sort complex empirical cases accord-
ing the latter, LTC is still a more salient topic   ing to their similarities and differences. The
in the richer and older welfare states in the       field of (country) comparative social policy
Global North, but is increasingly becoming          has extensively engaged in identifying types
a field of political concern in countries and       of welfare regimes and policies during the
regions in the Global South such as Latin           last decades (see e.g. Lalioti, 2021; Powell,
America, China, and Southeast Asia as well          Yörük, & Bargu, 2020) and classifications
(Loichinger & Pothisiri, 2018; Luo & Zhan,          focusing on LTC in particular have also been
2018; Nieves Rico & Robles, 2019).                  put forward since the 1990s (see Section 3).
    Irrespective of a growing, yet tentative        The present article aims to add to this litera-
trend in LTC as a field of social protection,       ture by taking a rigorous multi-dimensional
societies differ in the question of who takes       approach towards classifying LTC systems
over responsibility for caring for LTC depen-       as well as incorporating both a more global
dent people. This issue becomes of partic-          and historical perspective by focusing on the
ular interest to social policy scholars once        complete population of distinct LTC systems
care is no longer a mainly ‘private’ matter         at the time point of system introduction.
and welfare states take over formal, legal              The paper is structured as follows. In Sec-
obligations for LTC, establishing LTC systems       tion 2, we briefly present the definition and
under public responsibility. With the (partial)     empirical instances of what we have termed
‘socialization’ of LTC, different types of actors   distinct LTC systems, which constitute our
such as the state, corporate societal-based         population of subsequently classified cas-
organizations, commercial entities or fami-         es. Section 3 provides the theoretical back-
lies can take over varying degrees of respon-       ground of typological research in the field

                                    SOCIUM • SFB 1342 WorkingPapers No. 12                      [1]
of LTC policy, with a particular focus on out-                    (ii) and the elements of the LTC system are
lining the multi-dimensions, actor centered                       some-what integrated, i.e. managed by one/
typology which we use as the classificatory                       several designated agencies (iii) (De Carval-
framework for comparing LTC systems. Sub-                         ho & Fischer, 2020, p. 13). Moreover, when-
sequently, the method of classification, op-                      ever the LTC system/policy differs between
erationalization of the typology’s dimensions                     age groups, we focus on LTC for the elderly
and data used are described in detail. We                         as the population group with highest levels
then move on to present and interpret the re-                     of care dependency (Colombo, Llena-Nozal,
sults of our classification in Section 5, while                   Mercier, & Tjadens, 2011; WHO, 2015, pp.
Section 6 continues to put them into per-                         67–68).
spective with existing research and discusses                         When applying this definition, approxi-
limitations of our approach. Finally, we con-                     mately 50 countries worldwide have so far
clude by reflecting on the insights and further                   established public LTC systems (Fischer, Pol-
use of the typology.                                              te, & Sternkopf, 2021; Fischer & Sternkopf,
                                                                  forthcoming). However, some of these first
                                                                  LTC related laws represent rather incipient
2. LTC systems throughout                                         and rudimentary forms of LTC systems. While,
          the world                                               per definition, LTC benefits for at least some
                                                                  share of the population have been formal-
                                                                  ly introduced in all these cases, LTC benefits
LTC systems can be defined in different terms,                    may be granted as part of another welfare
for instance by stressing normative aspects                       state program as LTC is not (yet) conceived
of “appropriate, affordable, accessible” care                     of as specific social risk in its own right and
(WHO, 2017) or a focus on public funding                          a separate field of social policy making. In
(Spasova et al., 2018). The concept used in                       consequence, it is useful to distinguish yet
this article builds on an extensive discussion                    another form of systems to capture more in-
of health and LTC systems by De Carval-                           dependent and mature developments in the
ho and Fischer (2020). Accordingly, a LTC                         field. We therefore introduced the concept of
system can in general be described as the                         distinct LTC systems (under public responsi-
sum of provision, financing and regulatory                        bility) adding to the public system definition
arrangements in a society. In line with our                       outlined above the criterion of LTC being ac-
research focus on social policy and state re-                     knowledged as a distinct social risk that is in-
sponsibility, we limit our analytical focus by                    stitutionally treated as a social policy field of
studying LTC systems under public responsi-                       its own and has achieved a certain degree of
bility. These, in turn, can – according to a                      independence for other programs (cf. Fisch-
statutory, formal understanding – be seen to                      er et al., 2021). These more fullfledged sys-
exist in a country if country-wide legislation                    tems lend themselves much more to a com-
(i) establishes entitlements for LTC benefits                     prehensive comparative analysis than single

Figure 1.
Timeline of introducing distinct LTC systems

  Netherlands                Sweden            Israel       Germany                            South Korea       Uruguay
   1967                       1980             1986          1994        1998                   2007              2015

                    1974             1982                  1993       1997                   2006               2014        2019

                   Denmark           Finland            Austria      Australia         Czech Republic        United      Singapore
                                     Norway                          Japan             Portugal              Kingdom

Source: own illustration.

LTC benefits integrated in different parts of             (Austria, Czech Republic) and Southern Eu-
the health and/or social care systems.                    ropean (Spain, Portugal) cases as well as
    Up to now, our research has identified                Australia. In 2014 and 2019, respectively,
a population of 18 distinct LTC systems ex-               the United Kingdom (UK)2 as the pioneer
isting worldwide.1 The timeline of adoption               having introduced first elder care provisions
listing all countries is presented in Figure 1.           in 1948, and its former colony Singapore
Accordingly, the first distinct LTC system was            updated and unified their legal LTC-regu-
the introduction of the Algemene Wet Bijzon-              lated frameworks, establishing distinct sys-
dere Ziektekosten (AWBZ, Exceptional Medi-                tems. Furthermore, with Uruguay’s Sistema
cal Expenses Act) in the Netherlands in 1967              National Integrado de Cuidados (SNIC, Na-
(Companje, 2014), followed by the Den-                    tional System of Care), the first country from
mark, Finland, Norway and Sweden. While                   the American continent joined in recognizing
modern stateled development of institution-               LTC as a distinct area for social protection in
al and home care services for the elderly in              2015 (Nieves Rico & Robles, 2019). In the
Scandinavian countries can even be dated                  remainder of the article, these 18 systems
back to the middle of the 20th century (Sipilä            will be classified at the point of their respec-
et al., 2000), the incremental development                tive introduction point.
of LTC policies seems to culminate in the
adoption of unifying, universal acts passed
in the 1970 and early 1980s, respectively.                3.	Theoretical background
Subsequently, in the late 1980s, Israel es-
tablished a social insurance scheme dealing
specifically with the risk of LTC dependency              The use of classifications to order and make
as the second country worldwide (H. Schmid,               sense of our empirical world is by no means
2005), passing (to our knowledge) the first               an exclusive characteristic of the social sci-
law which focused solely on the social pro-               ences or sciences in general. It is, first and
tection for LTC (the previous introductions               foremost, a fundamentally human and intrin-
all include other elements of social and/or               sic aspect of cognition, which automatically
healthcare into their foundational laws as                engages in the joint processes of compari-
well). In later years, only few countries have            son and categorization (Freeman & Frisina,
chosen to follow this path of introducing dis-            2010). This regularly entails the grouping
tinct social LTC insurance schemes: Germa-                together of similar types of a given category
ny in 1994, Japan in 1997, Luxembourg in                  or phenomenon to create typologies, which
1998 and South Korea in 2007 (Campbell,                   helps further reduce the cognitive workload
Ikegami, & Kwon, 2009; Companje, 2014).                   otherwise involved in the generation of al-
Furthermore, in the 1990s and 2000s, sev-                 ways new classificatory labels. Not only are
eral more countries which previously had                  typologies useful in grouping together in-
decentralized systems or single, non-dis-                 stances bearing a shared set of attributes,
tinct programs, introduced distinct LTC sys-              they also facilitate the drawing of expecta-
tems. Among them were Central European                    tions related to those attributes. They are
                                                          therefore a highly useful tool in comparative
1   For a detailed description of the procedure and
    data sources used for identifying system introduc-
    tions, see Fischer and Sternkopf (forthcoming).
    The introduction dates (both date of adoption and     2   More specifically, we refer here to the Care Act
    dejure implementation as well as a brief descrip-         regulating LTC in England, the largest nation of
    tion of the system and a justification for counting       the UK (see also Section 4). However, both Scot-
    the case as a distinct LTC system are provided in         land and Wales also passed novel LTC acts in
    the country data tables in the Appendix.                  2013 and 2014 Snell (2015), respectively.

                                        SOCIUM • SFB 1342 WorkingPapers No. 12                          [3]
While no shortage of critical attention       also have an explicit focus on comparing
on (specific) typologies exists (see e.g. Arts    public schemes specifically (e.g. Colom-
& Gelissen, 2010; Collier, Laporte, & Sea-        bo et al., 2011; Joshua, 2017; Pacolet et
wright, 2012), a number of well-constructed       al., 1999; Rothgang, 2009). To our knowl-
classificatory systems have come to domi-         edge, all countries whose LTC systems have
nate the field of comparative social policy,      been included in published typologies so
not least of all that of Esping-Andersen’s        far are situated in Europe and/or are mem-
(1990) seminal welfare state regimes. Typol-      ber states of the Organisation of Economic
ogies are particularly abundant in the study      Cooperation and Development (OECD). A
of healthcare systems – a field of scholarship    diverse set of criteria is used in extant typo-
spanning roughly six decades since Roemer’s       logical research for sorting empirical cases.
classification of health departments and          Most commonly, LTC financing is addressed,
medical care in the 1960s (cf. Ariaans, Lin-      followed by aspects of coverage and regula-
den, & Wendt, 2021; De Carvalho, Schmid,          tion, service provision and the integration of
& Fischer, 2020). Despite its relative infancy    schemes/systems. Among the most frequent-
as a policy field, since the mid-1990s LTC        ly used criteria is the distinction between tax
has also seen the emergence of classificatory     and contribution based-financing schemes
work. Most notably, in the research of Ant-       (e.g. Colombo et al., 2011, Pacolet et al.,
tonen and Sipilä (1996) and Bettio and Plan-      1999; Simonazzi, 2008), population cover-
tenga (2004) that takes a comprehensive           age (Colombo et al., 2011; Kraus, Riedel,
(social) care perspective to LTC, integrating     Mot, Willemé, & Röhrling, 2010; Ranci &
both child and elder care arrangements into       Pavolini, 2013a), and the prominence of for-
one framework. This approach has its merits       mal vs. informal care (Roit & Le Bihan, 2010;
and is particularly useful for broad and gen-     Kraus et al., 2010; Nies et al., 2013).
dered understandings of the welfare state.            Taken together, existing classificatory ap-
However, it falls short in capturing key dif-     proaches have strongly contributed to the
ferences in the nature of benefits and degree     conceptual and empirical understanding of
of familialism distinguishing the two policy      the variety of LTC systems. As established in a
fields in many countries.                         review of 17 classifications (see Fischer et al.,
    Not until the work of Pacolet, Bouten, Hil-   2021), however, these typologies are subject
de Lanoye, and Versieck (1999) and Timo-          to number of important limitations. First, the
nen (2005) did typologies with an exclusive       specification of criteria and/or underlying
analytical focus on LTC start to populate the     procedure/methods for typology construc-
field of comparative social policy. Since then,   tion is not always clear; second, the appli-
several typologies that have sorted countries     cability of classifications to regions beyond
according to their LTC arrangements, both         Europe is hardly discussed; third, they show
with and without an agerelated focus. More        a paucity of information on the multi-dimen-
recently, multiple quantitatively-derived clas-   sional aspects of LTC systems.
sifications of LTC systems using clustering           Bearing these issues in mind, Fischer et al.
methods and standardized data have been           (2021) put forth a deductively derived, ac-
put forward as well (Ariaans et al., 2021; Da-    tor-centered typology that incorporates three
miani et al., 2011; Halásková et al., 2017;       dimensions of the LTC system that have also
Kraus et al., 2010), adding yet another layer     been used in healthcare typologies (Böhm,
to the typological study of LTC systems.          Schmid, Götze, Landwehr, & Rothgang,
    While many studies classify whole coun-       2013; Wendt, Frisina, & Rothgang, 2009):
tries’ LTC regimes (e.g. Halásková, Bednář,       The first, service provision, refers to the most
& Halásková, 2017; Nies, Leichsenring, &          elementary function of the system involving
Mak, 2013; Ranci & Pavolini, 2013a), some         the actual task of caring. Care can consist

of medically-related tasks, such as adminis-       dimension they mostly take the form of social
tering medicines and maintaining hygiene,          insurance bodies. Societal actors (self-)reg-
household-related tasks such as washing or         ulate mainly through collective negotiations
cooking, as well as strengthening societal         (Rothgang et al., 2010, p. 14).
participation and providing emotional sup-             Moving on to private actors, thirdly, there
port. The second dimension, financing, re-         are private for-profit actors, e.g. nursing
fers to the resources necessary for ‘produc-       homes or home care services, which can de-
ing’ care, either in the form of monetary re-      liver care, and financing agencies in the form
sources or, in case of informal, unpaid care       of private insurances collecting premiums. It
provision, through time and foregone earn-         is important to note that private for-profit ac-
ings (WHO, 2015, p. 131). Finally, the third       tors in the provision dimension comprise a
dimension, regulation, that is the “interven-      spectrum of providers reaching from domes-
tion in the behavior or activities of individual   tic care workers, which often work (and live)
and/or corporate actors” (Koop & Lodge,            in the care recipient’s household to large
2017, p. 97), influences and modifies the          formalized corporations. Fourthly, private in-
production structure of care and crucially         dividual actors, defined as persons from the
shapes the system (Mayntz & Scharpf, 1995).        care recipient’s network, i.e. family mem-
    For each of these dimensions different cri-    bers, neighbors or friends (Timonen, 2009),
teria can be analyzed. We concentrate on the       are crucial in many LTC systems in providing
question of who bears responsibility because       (informal) care. Through out-of-pocket pay-
this is one crucial category in the analysis of    ments, care-recipients and their relatives are
care and social policy, providing insights, for    also an important financing source, even in
instance, into redistribution processes, legiti-   LTC systems under public responsibility (e.g.
macy, social structures, and norms. To some        Colombo et al., 2011; Rodrigues & Nies,
extent, this focus can also inform us about        2013). It is important to note that while both
how and what happens within each dimen-            forms of private actors have limited means
sion, especially the associated interaction        by setting general, external standards, they
logics (Fischer, Frisina Doetter, & Rothgang,      can (self-)regulate (Rothgang et al., 2010;
2021; Rothgang & Fischer, 2019). In a sec-         see also Black, 2001; Braithwaite, Makkai,
ond step, therefore, Fischer et al.’s (2021)       & Braithwaite, 2007). In the regulation di-
LTC typology conceptualizes (up to) five types     mension, we capture this mode of regulation
of (quasi-)corporate actors which take over        by private actors jointly. Lastly, global actors
responsibility for provision, financing and/       such as foreign state, international govern-
or regulation of the LTC system: State, soci-      mental or non-governmental organizations
etal actors, private for-profit actors, private    might be involved in LTC systems in any of
individual actors and global actors. Firstly,      the three dimensions. However, this is not
the state is defined as the public institutions    the case for the population of distinct LTC
in the political-administrative system of a        systems under public responsibility analyzed
country (Johnson, 1999), comprising differ-        in this article, which is why we abstain from
ent – central, regional, local – state levels      discussing this actor group further.
and as such is a relevant actor in all three           Fischer et al.´s (2021) typology endeav-
dimensions. Secondly, societal actors are          ors to deliver a widely applicable classifica-
characterized by their formal, non-profit,         tory framework to identify the role of specific
non-governmental status and collective sel-        actors across the multi-dimensional universe
forganization (Johnson, 1999; Wendt et al.,        of the LTC system. It is an ambitious response
2009). Societal actors appear as providers,        to the aforementioned limitations of extant
for example in the form of charitable or mu-       typological approaches – one which re-
tual aid organizations, while in the financing     sults in a total of 100 LTC system types (see

                                   SOCIUM • SFB 1342 WorkingPapers No. 12                     [5]
Figure 2.
Typological attribute space of the multi-dimensional, actor-centered typology

                                                                                   P R OV IS I O N
 REGULATION         FINANCING                                                      Private for-profit   Private individu-    Global
                                                    State        Societal actors
                                                                                        actors              al actors        actors
                    State                         Type 1             Type 2             Type 3               Type 4          Type 5

                    Societal actors                Type 6            Type 7             Type 8               Type 9          Type 10

 State              Private for-profit actors     Type 11            Type 12           Type 13              Type 14          Type 15

                    Private individual actors     Type 16            Type 17           Type 18              Type 19          Type 20

                    Global actors                 Type 21            Type 22           Type 23              Type 24          Type 25

                    State                         Type 26            Type 27           Type 28              Type 29          Type 30

                    Societal actors               Type 31           Type 32            Type 33              Type 34          Type 35

 Societal actors    Private for-profit actors     Type 36            Type 37           Type 38              Type 39          Type 40

                    Private individual actors     Type 41            Type 42           Type 43              Type 44          Type 45

                    Global actors                 Type 46            Type 47           Type 48              Type 49          Type 50

                    State                         Type 51            Type 52           Type 53              Type 54          Type 55

                    Societal actors               Type 56            Type 57           Type 58              Type 59          Type 60

 Private actors     Private for-profit actors     Type 61            Type 62          Type 63               Type 64          Type 65

                    Private individual actors     Type 66            Type 67           Type 68             Type 69           Type 70

                    Global actors                 Type 71            Type 72           Type 73              Type 74          Type 75

                    State                         Type 76            Type 77           Type 78              Type 79          Type 80

                    Societal actors               Type 81            Type 82           Type 83              Type 84          Type 85

 Global actors      Private for-profit actors     Type 86            Type 87           Type 88              Type 89          Type 90

                    Private individual actors     Type 91            Type 92           Type 93              Type 94          Type 95

                    Global actors                 Type 96            Type 97           Type 98              Type 99         Type 100

*Note: Bold highlighted types are pure types with one dominant actor only; grey highlighted types are presumably unlikely/implausible.

Source: Fischer et al., 2021.

Figure 2). Of these, five emerge as ‘pure’                           4.	Methods and data
types consisting of one actor dominating all
three dimensions.                                                    As outlined above, the typology we use for
    Thus far, this typology has yet to be ap-                        classifying countries’ LTC systems in this ar-
plied with empirical rigor to verify its applica-                    ticle consists of predefined types created by
bility and utility as a classificatory framework                     intersecting the three dimensions and five/
for LTC systems worldwide. The present con-                          four actor types systematically (see Figure
tribution sets out to do just that, traversing                       2). Consequently, each of the resulting types
the globe for empirical instances of distinct                        can be depicted as a configuration, that is
LTC systems and classifying them in line with                        as a combination of its properties which
Fischer et al.’s typology.                                           together define the type as a whole (Kvist,
                                                                     2006). Similarly, each empirical case of a
                                                                     LTC system can be conceived of as a config-
                                                                     uration of attributes in different dimensions

(Rihoux & Ragin, 2009; Wagemann, 2015).                  ployed for classifying health care systems by
Following this logic, we can classify an em-             Böhm et al. (2013) – is exactly the approach
pirical case – that is, put it into a ‘cell’ – by        we follow. Our sorting is based on the logic
identifying which type’s configuration has the           that the homogeneity of both cases – one
highest overlap with the properties of a case.           with 100 % and one with 60 % societal ac-
This can be done most easily when regard-                tor based LTC provision – is higher than with
ing each dimension – service provision, fi-              other cases where there is no or a minor role
nancing and regulation – separately during               of societal actors in care provision (cf. Kelle &
the initial stage of the classification process.         Kluge, 2010, pp. 100–101). Therefore, the
    However, it is important to note that, as            classification process marks these two cas-
LTC systems are very complex, cases do of-               es as similar by assigning them to the same
ten not completely conform to any type. That             type. Subsequently, when the dominant actor
is, adherence of real cases to the deductive-            in each dimension has been determined for
ly constructed types of the typology can be              a certain case, the country is classified ac-
stronger or weaker (Kvist, 2006; Schneider               cording to the resulting configurational set-
& Wagemann, 2012, pp. 97–98). For in-                    ting and assigned to the respectively type in
stance, if care in a LTC system is exclusive-            typology matrix. In the remainder of this sec-
ly provided by societal actors, the country              tion we discuss the operationalization of the
strongly confirms to the ‘extreme’ expression            coding process (Section 4.1) and the data
in the provision dimension; if there is a mix of         basis for classifying (Section 4.2) in some
providing actors with societal actors making             detail.
up the majority but not as the sole actor type
(e.g. a mix of 60 % societal actors, 30 % pri-           4.1 Operationalization
vate for-profit actors, and 10 % by state-run
facilities), societal actors are still dominant
in the provision dimension but to a small-               For each of the three dimensions – regula-
er degree. While both of these exemplary                 tion, financing, and service provision – op-
cases differ to some extent, they can still be           erationalization rules have to be determined
assigned unambiguously to a cell in Figure               (Section 4.1.2 to 4.1.4). Before diving into
2, indicating that societal actors dominate              this, however, we have to clarify what consti-
the provision dimension. It should be noted              tutes a case in the subsequent analysis (Sec-
that any classification of metric data, as e.g.          tion 4.1.1).
the share of financing that different actors
provide, leads to a loss of information. As a            4.1.1 Classified unit
consequence, even small changes may lead
to a reclassification of a system, if the metric         The aim of this article is to systematical-
value is close to the threshold. The classifi-           ly compare and, hence fore, classify cases
cation of a system is, therefore, not a suffi-           of distinct LTC systems in various countries.
cient substitute for an in-depth study of the            But what constitutes a ‘case’ in our study?
respective case, but is suitable for providing           In general, a case can be described as “an
an overview on how cases compare to each                 instance of a class of events” (George &
other.                                                   Bennett, 2005, p. 17), with the event being
    The above route of classifying cases by              defined by spatial, topical, and/or temporal
identifying the dominant actor type per di-              boundaries (Bennett & Checkel, 2015). First-
mensions3 – which has previously been em-                ly, regarding the spatial confinements, cases

3   In some cases, only a relative dominance, i.e. be-      can be identified. If this was the case, it is noted
    ing the strongest actor but below a share of 50 %       in the data table in the appendix.

                                       SOCIUM • SFB 1342 WorkingPapers No. 12                             [7]
are equated with countries, meaning that the            dominant in different schemes. If this was the
LTC system needs to be institutionalized by             case, we took the major LTC scheme for iden-
nationwide legislation and be applicable –              tifying dominant actors only. For instance,
albeit with potential regional modifications            with the distinct LTC system introduction in
– to the whole country’s territory.4 Secondly,          Germany in 1994, both a social LTC insur-
the topical focus is on classifying LTC sys-            ance (LTCI) scheme and a mandatory pri-
tems. We define long-term care as being                 vate LTC insurance schemes were introduced
“concerned with a range of services and as-             (Rothgang, 2010). As the social LTCI at that
sistance provided to care dependent persons             time (and also later on) covered approxi-
who need support with daily living activities           mately 90 % of the population (Rothgang,
over an extended time period due to physical            2009b), we have chosen to use this scheme
and/or mental impairments” (De Carvalho &               for classifying Germany in the regulatory di-
Fischer, 2020, p. 8). The concept of a LTC              mension. For countries where the regulatory
system, refers to the provision, financing and          dimensions are based on parts of the overall
regulatory arrangements in a society deal-              public LTC system only, this is documented
ing specifically with LTC as an area of social          in the Appendix (row ‘Dominant scheme for
protection for (at least) (parts of) the elderly        classification (if applicable)’). Similarly, for
population.                                             some countries statistical data on financing
    If a system does not cover the whole                and service provision is only available for the
country, we need a further specification. On            country level, but not for the public LTC sys-
the one hand, the LTC arrangement of the                tem. This is, for instance, the case with data
whole country can be classified, including              following the System of Health Accounts
both the public scheme(s) and all other (e.g.           (SHA) standard (OECD, WHO, & Eurostat,
privately paid, informally provided) LTC. On            2011), the most important internationally
the other hand, the analysis can be limited             comparative data on financing shares. Using
to the LTC system under public responsibility           such data for classification can be regard-
(see Section 2). Conceptually, we follow the            ed as a conservative estimate of public LTC
latter approach, not least as only systems un-          system financing shares because typically the
der public responsibility may guarantee ac-             share of private financing and service provi-
cess to care for the whole population, which            sion in the system under public responsibility
is crucial from a human rights perspective.             is lower than in the rest of the country’s LTC
Nevertheless, due to data availability in               provision.
some cases we have to use countrywide data                  Besides the spatial and topical definition
instead. In countries with more than one LTC            of cases, the temporal boundary is also im-
scheme simultaneous focus on the whole                  portant. Temporally, we focus on the intro-
public arrangement is sometimes not feasi-              duction point of each distinct LTC system.
ble, especially when analyzing the regulation           Empirical data about provider and financ-
dimension where diverging actors might be               ing shares in particular are only telling after
                                                        the system has been implemented. There-
                                                        fore, we have used, if available, data for
4   One partial exception is the United Kingdom (UK),   the time span of (approximately) three years
    where, since the inception of the devolution pro-
                                                        after the de jure implementation of the law
    cess in 1999, policies for social care/long-term
    care are (partly) the political competence of the   to stay both close to the introduction date
    individual nations, i.e. England, Scotland, Wales   and the (initial) design of the introduced sys-
    and Northern Ireland, respectively (Bell, 2010;     tem. However, there are also cases where
    Glendinning, 2013). Therefore, the current legal    the dominant actor type has switched within
    acts do not necessarily cover the United Kingdom
                                                        the first years after system introduction, for
    as a whole. Whenever necessary we focus on En-
    gland as the by far largest part of the country.    instance in the financing dimension in the

Netherlands (state −> societal actors) or the             well as regulatory competencies do often
provision dimension in Israel (societal actors            differ between both settings. Residential care
−> private for-profit actors). In these cases,            is provided continuously around the clock
we have taken the initially dominant actor                for care dependent persons living jointly in
to characterize the system at its introduction            a specific institution, for example a nursing
point.5 In short, a case in this study can be             home or assisted living facility (Rothgang &
described as the complete distinct LTC system             Fischer, 2019; WHO, 2015, p. 129). In con-
under public responsibility within a country at           trast, the terms ‘home and community care’
the point of its introduction.                            or ‘community-based care’ summarize “all
                                                          forms of care that do not require an older
4.1.2 Provision dimension                                 person to reside permanently in an institu-
                                                          tional care setting” (WHO, 2015, p. 129). It
LTC provision as one of our dimensions for                comprises both assistance with personal care
classifying systems can take the form of for-             and household activities in the care recipi-
mal care, i.e. paid, (semi-)professional care             ent’s home as well as facilities like day care
provided in an organized setting, and infor-              centers (Timonen, 2008, p. 142).
mal care, which is provided in unregulated                    In order to determine the dominant actor
‘private’ settings, often by family members,              type in service provision we follow a three-
or fall between the poles of this ideal-typ-              step approach (see Figure 3). First, we re-
ical formal-informal distinction (Pfau-Effin-             cord the share of the three main LTC benefit
ger & Rostgaard, 2011; Timonen, 2009;                     types i.e., in-kind residential care services,
WHO, 2015, pp. 129–130). The form of                      in-kind home and community care services,
care crucially depends on the benefits avail-             and monetary benefits. In doing so, we use,
able within the LTC system: While benefits in             where possible, data on their respective pro-
the form of in-kind services generally trans-             portion in the overall care-mix based on the
late into formal care provision conducted                 number of care recipients under each benefit
by state, societal or private for-profit actors,          type.6 Second, the shares of actor types are
monetary transfers in the form of vouchers                recorded for each relevant benefit type sepa-
or cash benefits can – often depending also               rately. In the case of (unregulated) monetary
on the regulation for their use – result in a             benefits there is often no data available on
spectrum between informal and formal care                 where the money goes. In conjunction with
arrangements provided (e.g. Da Roit & Le Bi-              evidence from secondary literature, howev-
han, 2010; Le Bihan, Da Roit, & Sopadzhi-                 er, we can normally assume that most un-
yan, 2019). In the population of distinct LTC             regulated cash benefits translate into care
systems classified in this paper, there is only           provision by private individual actors, that is
one country offering exclusively cash benefits            mostly family members and/or domestic care
(Singapore), while most countries offer only              workers (e.g. Da Roit & Le Bihan, 2010; Rie-
in-kind benefits or a combination of in-kind              del & Kraus, 2016). If we have evidence that
services and cash benefits. Furthermore, in               cash benefits are used to finance live-ins, i.e.
the category of in-kind benefits/formal care,             mostly migrants living in the household of a
it is important to distinguish between resi-              care-dependent person in order to assist him
dential/institutional care versus home and                or her, we subsume this arrangement under
community care as providing actor types as
                                                          6   While there are other measures such as expen-
                                                              diture, or, for formal care, granted hours of care
5   In the appendix, the political adoption date of the       or number of employees in each sector, which
    law as well as the de jure implementation date at         could be used alternatively, data on the number
    which the law formally enters into force are spec-        of recipients is most often available and counts all
    ified for each country.                                   care recipients equally.

                                        SOCIUM • SFB 1342 WorkingPapers No. 12                              [9]
Figure 3.
 Calculation of dominant actor in the provision dimension

 Source: own illustration.

private for-profit care-giving. Third, with the   both funding from social and/or private in-
information from step two and three, we cal-      surance depending on the concrete design
culate (if necessary) the total share of each     of the scheme. This is further discussed be-
providing actor type in the whole LTC system.     low. For 12 out of 18 countries, respective
                                                  data for a year close to the LTC system intro-
4.1.3 Financing dimension                         duction point can be found in the OECD sta-
                                                  tistics.7 Even though the statistics refer to the
The operationalization of the financing di-       whole country and not the public LTC system
mension is mostly straight forward as we can      only, they provide – especially if triangulated
equate financing sources with actor types (cf.    with national sources and case descriptions
Böhm et al., 2013). Generally, four types         – valuable standardized and comparable in-
of domestic financing sources which corre-        formation on dominant financing schemes.
spond to the four domestic actor types out-           However, it has to be noted that the cor-
lined in the typology (Fischer et al., 2021)      relation between private for-profit actors and
can be distinguished: Tax revenues (state),       the SHA classification poses some problems.
social insurance contributions (societal ac-      In general, private insurance schemes can
tors), private insurance premiums (private        take a compulsory or voluntary form, which
for-profit actors), and household out-of-         comes with different implications regarding
pocket expenditure (OOP) (private individual      the role of the state and the social protec-
actors) (Rothgang & Fischer, 2019). To reap       tion of the schemes (OECD et al., 2011).
the benefit of using comparable data across       Therefore, the SHA methodology (OECD
countries, whenever possible we relied on         et al., 2011) classifies compulsory private
SHA-based (see OECD et al., 2011) inter-          insurance (HF.1.2.2) and voluntary health
national comparative data from the health         insurance schemes (HF.2.1) in two different
expenditure and financing database provid-        categories which stresses the – undisputable
ed by the OECD. When doing so, we used            strong – relation of the former with social in-
the following SHA categories to determine         surance schemes. However, as in our analyt-
actor shares: Government schemes (HF.1.1)         ical framework regulation is considered also
for state financing, social health insurance      separately from financing we maintain that
(HF.1.2.1) for societal actors, voluntary         both mandatory and voluntary private insur-
health care payment schemes (HF.2) for pri-
vate for-profit actors, and household out-of-     7   Respective data were unavailable for Israel, the
pocket payments (HF.3) for private individual         Netherlands, Norway and Sweden (due to later
actors. The categories compulsory contribu-           start of the time series) and the non-OECD mem-
                                                      bers Singapore and Uruguay. For these cases
tory health insurance (HF.1.2) and compul-
                                                      national data and secondary sources were used
sory private insurance (HF.1.2.2) can contain         instead

ance provide – differently regulated – hints         Figure 4.
on the relevance of private for-profit actors in     Regulatory relationships and objects
the financing dimension. This is why we clas-        in the LTC system
sify financing in Singapore – the only classi-
fied case where actuarial private insurance
premiums are a major financing source – as
dominated by private for-profit actors even
though the scheme is (partly) mandatory.

4.1.4 Regulation dimension
Regulation is a particularly broad category.
Regarding the field of LTC, for instance the
available ‘benefit package’, quality, care           Source: own illustration based on Rothgang et al., 2010.

providers’ standards or the extent of choice
of care recipients can be centrally regulated            To get a more detailed picture of what
– e.g. by the state or an (social) insurance         goes on in the regulation dimension of each
body – or left to selfregulation of involved         case, we use a differentiated approach of
actors (e.g. Braithwaite et al., 2007; Da            categorizing several regulatory subdimen-
Roit & Le Bihan, 2010; Kraus et al., 2010;           sions or relations and combine the informa-
Murakami & Colombo, 2013; Rothgang                   tion to arrive at a final classification. In doing
& Fischer, 2019). Consequently, there are            so, we draw on earlier works on health care
multiple ways of operationalizing the regu-          systems which have conceptualized regulato-
lation dimension of the typology. The easi-          ry relations and objects (Böhm et al., 2013,
est – and probably most limited – possibility        2012; Wendt et al., 2009), adapting them
is to record who – that is which organiza-           to the context of LTC systems. The concep-
tion/agency, and, based on this, which actor         tualization departs from the point that in any
type – is generally responsible for regulat-         healthcare/LTC system there are three groups
ing the LTC system without formally consid-          of actors involved which form a triangular re-
ering any specific aspects of regulation.8 In        lationship: care providers, financing bodies,
LTC systems under public responsibility, this        and (potential) care recipients (Rothgang et
will generally be the state directly, in the         al., 2010, p. 11). The content of these re-
form of the central government, provinces/           lationships – visualized as the sides of the
federal states and/or municipalities or other        triangle in Figure 4 – can be regulated.
public bodies such as LTC or health insur-               For the relation between financing bod-
ance funds. Therefore, this form of opera-           ies and (potential) care recipients (side A
tionalization automatically limits the kinds         in Figure 4), there are two main objectives:
of actors which can achieve dominance in             The entitlement/eligibility (1) describes which
the regulation dimension to public actors,           (potential) care recipients have access to LTC
i.e. state or societal actors. Furthermore,          benefits. Following the ‘who’ question, here,
identifying the main regulator by looking at         we can either focus on who decides the enti-
the generally responsible organization(s) in         tlement and eligibility criteria (e.g. citizenship
the LTC system is a quite crude way of mea-          status, formal employment, dependency lev-
surement.                                            els, age thresholds) defining inclusion (1a),
                                                     or ask which actor is responsible for execut-
                                                     ing eligibility assessment procedures (mostly
8 For each case, this information is recorded in the
                                                     care dependency assessment) (1b). As noted
  data table in the appendix (row ‘dominant actor
  agency’).                                          by Böhm et al. (2013) for healthcare systems

                                    SOCIUM • SFB 1342 WorkingPapers No. 12                                  [11]
already, there is no variation in the former        or determined by providers themselves (for
point (1a); in all (studied) systems defining       instance in a so-called “Pork Barrel Market”
entitlement/eligibility criteria is exclusively     as termed by Gingrich (2011)).
the responsibility of the state (see data ta-           Lastly, there is relation C connecting (po-
bles in Appendix). Therefore, we exclude this       tential) care recipients and care providers.
category for classifying and focus solely on        This relationship is, on the one hand, about
question 1b, that is who is responsible for         looking at the regulation of care recipients to
eligibility assessment? In this relation we also    choose a concrete provider (5), that is who
look at a second question: Who decides if           decides which provider will deliver care to the
and how much to pay/contribute to the sys-          benefit recipient? If beneficiaries can choose
tem (2)? The question can be applied both           a provider themselves, the category is classi-
to co-payments – i.e. who decides if and            fied as private (individual), if care managers
what sum of co-payments the care recipient          (or similar) take over the decision depending
needs to pay – and/or contribution or premi-        on who employs the care manager the cate-
um rates – i.e. who decided if contributions/       gory is classified as state, societal or private
premiums need to be payed and what their            (collective). On the other hand, the decision
level is. Interestingly, this regulatory relation   which care benefits – that is, in-kind residen-
is also strongly– albeit not exclusively – pop-     tial or home/community care or cash ben-
ulated – by the state.                              efits (see above) – a care recipient gets can
    Moving on to the relationship between fi-       also be decided by different actor types (6).
nancing bodies and care providers (side B           There are two steps to consider here: Firstly,
of the triangle), the access of providers to        if there is only one benefit type offered by
the public LTC system (3) and the system of         law, the state regulates the choice of benefits.
remuneration of providers (4) are relevant          Secondly, if there are several benefit types on
here. It is important to note that in systems       offer (e.g. residential care and home care),
with cash transfers and in-kind services, for-      the care recipient might be free to choose
mal as well as informal providers might need        (‘private’), or care managers (or similar) em-
to be considered (separately). Regarding the        ployed by other actor types might determine
provider access, we are looking at who de-          the benefit for each care recipient.
fines if and under which conditions providers           Summing up, based on previous concep-
can offer services in the public LTC system.        tualizations of health care system regulation
While in most countries there is the necessity      we have identified six relevant regulatory
to get a general license to operate a care          categories which we used for classifying the
facility/service, we are specifically interested    regulation dimension of the LTC systems. In
in who controls provider access to provide          doing so, we have adhered to the following
publicly regulated/financed benefits. If there      rules/steps:
is no specific entry requirement, provider ac-
cess is classified as ‘private’, otherwise as       1. If necessary, the principal LTC scheme in
‘state’ or ‘societal’ depending on the (domi-          the country for classifying regulation is de-
nant) regulator. Furthermore, concerning the           fined (see above).
remuneration, we ask who decides or nego-
tiates the payments/fees provider receive for       2. Data for each of the six regulatory sub-
offering (certain) care services? Remunera-            dimensions (1-6) is collected. In case the-
tion levels can for instance be determined by          re are regulatory differences for several
the state – which is mostly the case for the           benefit types (e.g. for residential care and
level of cash benefits, but sometimes also for         cash benefits), if possible information on
formal in-kind care provision –, negotiated            both is recorded.
between providers and financing agencies

3. Additionally, the organization/agency ing). All data sources used per (sub-)dimen-
   which is generally responsible for regula- sion and country are specified a country data
   ting the LTC system is recorded (7).         tables in the appendix, with a reference list
                                                provider for each country separately below
4. Based on the raw data, the 1-2 dominant- each country data table. For reporting reli-
   ly involved actors in regulating the respec- ability of the data/results, for the actor clas-
   tive sub-dimension (1-7) are identified. If sification in each (sub-)dimension, the confi-
   two actors are identified and data allows dence in the data/actor rating was recorded
   for it, one actor is marked as most do- following a three-point scale: High confi-
   minant (in bold letters). If the two actors dence is achieved if the data is confirmed ei-
   derive from the fact that benefit types are ther by a law or reliable primary data source
   regulated differently, the dominant bene- (e.g. official statistics) directly or by at least
   fit type according to the data collected two independent secondary sources and
   for the provision dimension is marked as retrieved information is non-contradictory.
   most dominant.                               Results are rated with medium confidence if
                                                there is only one reliable secondary source
5. Based on the actors identified for each of providing the necessary information or there
   the six relations, the overall dominant ac- is some ambiguity/unclarity about domi-
   tor is determined. Each of our six relations nant actors from the available information.
   is weighted equally. If there is one actor All data that were extremely ambiguous or
   in a sub-dimension, this counts with a va- uncertain, or based on sources that are not
   lue of 1. If a sub-dimension is populated deemed reliable by the researcher, are rated
   by two actors, each of them count with as low confidence. Overall, due to lack of
   a value of 0.5. The actor type achieving data in two cases, i.e. Luxembourg and Sin-
   the highest value is rated as the dominant gapore, it was not possible to determine one
   actor type.                                  single dominant provider type. In these cas-
                                                es, we resorted to combining two actor types
6. In case two actor types are equally strong in the provision dimensions to classify these
   according to step (5), sub-dimension 7 cases. Furthermore, data for the regulatory
   capturing the general regulatory agency sub-dimension of benefit choice in Portugal
   is used as a tie-breaker.                    was missing.

4.2 Data
                                                    5.	Classification results
Multiple data sources were used for identify-
ing dominant actors in each dimension: the          Figure 5 shows the results of the classifica-
laws introducing the LTC system, academic           tion exercise: The 18 countries with a distinct
publications and reports and grey literature,       LTC system can be classified into altogeth-
both on single countries or with a compar-          er 8 types. When introduced, the systems
ative focus, statistics (as a primary statistical   of the Nordic countries Denmark, Finland,
source mostly the OECD health expenditure           Norway and Sweden fell under Type 1, rep-
and financing database as outlined above),          resenting state-domination in regulation, fi-
national online newspaper articles and (of-         nancing and provision. Eight other countries
ficial) websites about the LTC schemes, as          also show state-domination in regulation
well as primary data collected through the          and financing, however, with service provi-
project’s Expert Survey on Long-Term Care in        sion dominated by societal actors (Australia,
2020/21 (see Fischer & Sternkopf, forthcom-         Netherlands, and Portugal, Type 2), private

                                    SOCIUM • SFB 1342 WorkingPapers No. 12                  [13]
Figure 5.
Multi-dimensional actor-centered distinct LTC system classification

Source: own illustration based on data sources and dimension-specific classification results specified in the Appendix. Cluster A is high-
lighted red; Cluster B green; and Cluster C blue.

for-profit actors (Spain, United Kingdom,                                 Finally, a third cluster (Cluster C, high-
Uruguay, Type 3), and private individual ac-                          lighted in blue, see Figure 5) can be iden-
tors (Austria, Czech Republic, Type 4) respec-                        tified with dominant regulation by private
tively. At the point of introduction, the LTC                         actors, societal financing and care provision
systems of 12 out of the 18 countries classi-                         through private actors (South Korea and
fied thus belonged to a cluster with predom-                          Germany, Type 58 and 59). The dominance
inant state regulation and financing (Cluster                         of private actors in the regulation dimension
A, highlighted in red, see Figure 5).                                 comes as a surprise: In an initial theoretical
    A second cluster combing state regulation                         assessment of the plausibility of types, private
with different actors dominating financing                            regulation paired with societal financing was
and care provision (Cluster B, highlighted in                         deemed as implausible following the ‘hierar-
green, see Figure 5). can be found in an-                             chy rule’ hypothesized by Böhm et al. (2013)
other four countries. While the combina-                              (see Figure 2).
tion of societal financing and societal and                               These results are remarkable as stateled
private for-profit provision is populated by                          systems with state regulation and financing
Japan, Luxembourg and Israel (Type 7/8),                              are by far the most common, comprising
state regulation, private for-profit financing                        two thirds of all systems under scrutiny, while
and private (for-profit and individual) care                          there is no counterpart to this in form of so-
provision can be found in Singapore (Type                             cietal-dominated systems as can be found in
13/14). While both state financing (eleven                            the field of healthcare.
countries) and societal financing (five coun-                             Although in the Netherlands, Israel, Ger-
tries) are quite common, Singapore occupies                           many, Luxembourg, Japan, and South Korea
a unique position among the classified LTC                            social insurance systems were introduced,
systems being the only country with a domi-                           they don’t appear as such in Figure 5. While
nance in private (for-profit) financing.                              financing – as the central definition criteri-
                                                                      on of a social insurance system – is indeed

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