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While reform of care dependency is at the heart of the political agenda in France, how the elderly with loss of autonomy they are accompanied in other countries? This report provides a comparative analysis of systems of care dependency in six EU countries (Germany, Denmark, Italy, Netherlands, United Kingdom, Sweden), and the United States and Japan. This is to relocate the national debate about addiction in an international context in motion, many countries have already begun reforms or being about to do.

The report presents the major issues facing the countries selected, and the responses thereto.

1 - Beyond the heterogeneity of national systems of care dependency, what common trends?

The comparison exercise reveals a great heterogeneity of systems supported. Evidenced by the many terms used to describe the "frail". If we talk of "dependence" in France to specify the frail elderly, many countries do not retain the age requirement and do not operate off the field of disability. Thus, in the Anglo-Saxon and Northern Europe, the entrance is rather by the need for care and support of people: it is the notion of "long-term care" ( long-term care code) is used (or equivalent). This high heterogeneity is also the major role played by local authorities in organizing and financing services related to the management of addiction, which introduces disparities between regions or municipalities remarkable in a country .

While the pioneering countries have systems of care for dependent persons since the late 1960s (Denmark, Sweden and the Netherlands), most other countries do have are that during the 1990s . Recent, these devices are relatively stabilized and are subject to numerous reforms
over the past fifteen years. Beyond the heterogeneity of systems, several converging trends are observable in most countries. The objective of cost reduction is broadly shared and led to an emphasis on home care of elderly dependents as long as possible. Caregivers
and family are the subject of increased attention from government. In almost all countries are developing devices for financial benefits in order to loosen the constraints inherent in the provision of services in kind, to promote free choice of the user and to allow some form of remuneration for family caregivers . There are also forms of competition between care and support.

2 - The aging population: challenges for systems management of addiction?

In the coming years, aging populations will test the systems of care. The proportion of individuals over 80 years will increase in all OECD countries, although they differ in the pace and nature of the aging population. Today, half of the users of
services of long-term care are over 80 years and one in five is under 65 years: the dependence is not only a problem with the great
age, although its prevalence increases sharply with the latter. Despite the difficulty of making population projections, the increase in aid applications
and services can be little doubt: the uncertainties related more to its intensity and the time at which the need arises. Meanwhile, the supply provided by family caregivers and professionals is led to decline: reduced availability of family caregivers (yet potentially more), difficulties in recruiting and retaining labor, already notable in some countries and likely to worsen in the coming years.

All systems of care will then face two major challenges. The first is financial: it is to reconcile the objective of controlling public spending with the protection requirements which suck the elderly frail. The second challenge is organizational: allow better
coverage of the care needs of frail elderly, by providing them with quality care, according to their wishes, either at home or in a suitable structure, including support to different stakeholders (work or family).

3 - How national systems of care are they funded?

In most OECD countries, public financing is dominant. In 2008, public expenditures have averaged 1.2% of GDP in a
set of 25 OECD countries. Beyond the heterogeneity of systems of care dependency, there are three types of public coverage: i) a universal coverage system that provides services to all individuals in need and is organized within a single program (care insurance in Germany, Japan or the Netherlands, tax-funded services in Denmark or Sweden, etc..), ii) a cover system that acts as a safety net for the poor, where access to benefits is subject to a means test (UK, USA), iii) a mixed system that combines these different devices and funding (Italy, France).

In all countries, private insurance plays a minor role, including in countries which have sought to promote its development. A share of spending to
support the elderly or his family: highly variable from one country to another, this participation is sometimes capped (Netherlands). In recent years there has been a
tendency to broaden the funding base of systems management and a tendency to focus more on people who have the greatest needs while universalizing access to benefits.

4 - How the loss of autonomy is evaluated, compensated and prevented?

Entry to all systems of care is determined by assessing the loss of autonomy. Two main methods of assessment are mobilized by country: an instrumental approach that establishes a list of activities that can not be achieved without the assistance or support a third, and an approach based on the notion of "care needs" and that better reflects the social and physical environment of the elderly. This practice of evaluation is always performed at a decentralized level, although the weight of local authorities varies from country to country. It is thus important in Sweden, Japan, the UK, while some countries are developing national evaluation schemes to reduce disparities practices (Germany, Netherlands).

In some countries, benefits are issued directly to the end of this evaluation (Germany, Denmark, Italy). In others, additional criteria - such as age of the person (France, Sweden, United Kingdom) and / or the level of resources (France, Netherlands, United Kingdom) - are mobilized for the award benefits or the amount of their definition. These services are delivered in kind or in money. For reasons of cost and respect the free choice of the user, most countries have opted for cash benefits in the form of "personalized budgets". Their use can be controlled (France) or not (Germany, Italy). Benefit levels are generally defined according to levels of dependence (with the exception of Italy) and vary greatly from one country to another, referring to concepts of management and organization methods highly distinct. The range of services offered also varies greatly from one country to another but also within a
country. More generally, there is huge disparities between regions and even between municipalities within the same country, given the major role of local authorities in the field of care for dependents.

If the objective of preventing the loss of autonomy is now consensus in all developed countries, its implementation is relatively new and remains difficult. Are adopted in many countries specific measures (such as falls prevention programs that have proven effective). Moreover, some countries are trying to introduce a comprehensive approach to prevention in the organizational patterns of care (eg the UK and Germany, to avoid the use of conventional hospitalization unsuited).

5. How to care for the elderly is it organized, at home or in suitable structures?

Home maintenance is a priority in all countries studied, for reasons of costs at community level and to better respond to users' preferences. Its actual implementation varies considerably from country to country depending on the actors responsible for funding and organization, depending on the degree of development of home help services, etc.. Family (family caregivers) plays a major role in most countries. Where the provision of
home services is weak, the family is at the forefront. It may have to resort to migrant workers to ensure continuous monitoring of the most dependent elderly. In countries where service provision is well structured, the family operates in tandem with the government. The role of coordinating the response of different professionals is well served either by the family (Italy) or by a care manager (Germany, Denmark, UK, Sweden, etc..), which ensures however functions vary from countries.

Living areas and support for dependent elderly people are much more diverse. While the medical establishment is a long-stay figure of last resort and that home support is the priority in all countries studied, disparities between countries, however, appear very much depending on whether the question of its living more or less integrated into a comprehensive home care. Specific measures to aid the adaptation of single units were adopted in most countries. In addition, there is a strong diversification of living space intermediate between home strict sense and the medical establishment: community habitats in order to maintain a social life (Netherlands, UK, Germany), forms of individual units connected to
offers of services for people who already have significant loss of autonomy (Denmark), etc.. Forms of support have also medicalized diversified, moving toward temporary supported for audiences with low or medium levels of dependence (of structures called "short stay" hospital at home, etc..). In some countries is some specialization of childcare facilities by public (including people with dementia). Often, lack of places in the relevant structures leads to sub-optimal situations (inadequate care given the degree of dependency).

For ten years, the quality of policies tend to be organized: they relate primarily to the time management in institutions. In
the most advanced countries, the user and his family are increasingly associated with these approaches. It is through these reflections on the quality of care in old age that the intervention of family caregivers should be considered, in tandem with that of professional speakers.

6 - How do the systems of care do they support family caregivers?

Support for caregivers becomes, in recent years, one of the major dimensions of political support for addiction. Family caregivers,
who include two-thirds of women for nearly 80% of hours of help and care provided to elderly dependents. One observes a more
marked at these informal caregivers in a national context of budget cuts, including in countries where formal care is the most developed (Nordic, Netherlands). More or less supported by country, the support systems are very varied forms of monetary compensation for loss of income (or specific benefit from the benefit paid to the person assisted), leave (paid or unpaid, short or long term ), stop information, single point of contact ( care manager ), training, respite facilities, etc.. All of these measures is part of the logic of prevention of situations of exhaustion of carers and poor care of the elderly, or even abuse.

What can we learn from this international comparison?

To summarize, several trends can be observed globally in most countries:

• systems deliver support services that are increasingly universal and targeted on those with the highest needs;
• priority is given to home care through political structuring of the offer of home services, home adaptation, diversification of living space and support to family caregivers;
• actor coordination remains a major issue of political support in old age;
• the importance of policies to prevent the loss of autonomy is recognized everywhere. However, despite positive results, these programs are still underdeveloped.

• Coordinators: Virginia Gimbert and William Malochet, Centre d'analyse stratégique

• With contributions by Francesca Colombo and Jerome Mercier, Organization for Economic Cooperation and Development ; of Sylvie Cohu and Diane Lequet-Slama, Research Branch, research, evaluation and statistics

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