An emergency strategy for managing COVID-19 in long-term care facilities in low and middle-income countries: the CIAT Framework (Version 2*)
By Peter Lloyd-Sherlock, Karla Gaicomin, Meirelayne Duarte, Monica Frank, Nelida Redondo, Lucas Sempe, Leon Geffen, Gabrielle Kelly, Veronica Montes de Oca, Marissa Vivaldo, Almudena Ocejo Rojo, Siriphan Sasat
*Note: this is the second iteration of a “live document”, to be developed and updated over time.
The city of Rosario is in Argentina, about 300 kilometres northwest of Buenos Aires. In the early months of the pandemic, it was less affected by COVID-19 than other parts of the country. This quickly changed since September and Rosario is now one of Argentina’s pandemic hot-spots. According to officials, there were at least 183 residential long-term care facilities (LTCFs) for older people operating in the city at the start of the pandemic, with a population of 4,145 (about 0.24% of the city’s total population). By 6 October, the city had reported 223 deaths of which over half (114) were LTCF residents. This means that the risk of dying from COVID-19 for this population was more than 200 times higher than the average rate in Rosario. Of the 114 reported LTCF COVID-19 deaths, 90 per cent occurred within the care facility, not in a hospital setting. In other words, residents who were experiencing severe respiratory distress and other acute symptoms were not being admitted to hospital and were not receiving ventilation.
There is a broad misperception that long-term care facilities (LTCFs) are virtually non-existent in low and middle-income countries (LMICs). In fact, there are large and rapidly growing networks of residential care services for older people in Latin America, many parts of Asia, South Africa and other middle-income settings (Camarano et al, 2010; Cheung Wong and Leung, 2012; Lloyd-Sherlock, 2019). In high-income countries, there is a large body of evidence that LTCF populations have been the most high-risk group for COVID-19 mortality and this is generating (belatedly) a strong policy focus on this issue (Comas-Herrera et al, 2020; Cousins, 2020).
This paper draws on available evidence to assess the COVID-19 vulnerability of LTCFs in different LMICs, taking note of specific features of provision before and during the pandemic. Based on this assessment, it sets out a broad framework for guiding emergency interventions to address these vulnerabilities. Drawing on stakeholder engagement in different LMICs, the paper reviews ongoing interventions by different government agencies and situates them within our policy framework.
General features of LTCFs in middle-income countries and vulnerability to COVID-19.
LTCFs in LMICs are highly diverse, as are the wider cultural and institutional contexts within which they operate. Despite this, research and stakeholder insights from a range of countries and local settings (Argentina, Brazil, Mexico, South Africa, Thailand and China) reveal some broadly generalizable features of interest (Lloyd-Sherlock, Sasat, Sanee, Miyoshi & Lee, 2020; Lloyd-Sherlock, Penhale and Redondo, 2019a; Rosenthal, E., Jehn, E. and Galván, 2010; Feng et al, 2020). This section briefly summarises these, focussing on elements that differ from those commonly seen in high-income countries and that relate to COVID-19 vulnerability.
- LTCFs are predominantly operated by the private sector.
Many LMIC governments run small numbers of facilities, but often these deny admission to older people with complex care needs such as dementia. In Bangkok, for example, there are just two government-operated care homes, with a combined capacity of around 350 residents. Older people seeking admission to these two homes must not suffer from communicable diseases, any psychiatric problem, or serious functional impairments (Lloyd-Sherlock, Sasat, Sanee, Miyoshi & Lee, 2020).
In some LMICs many LTCFS have traditionally been operated by religious organisations and NGOs. However, provision is increasingly dominated by private for-profit organisations (INAPAM, 2020). This is a fast-growing and (at least before the pandemic) often lucrative industry. It is highly diverse sector, with market segmentation ranging from luxury facilities for the very rich to much more basic, informal facilities. For example, a study in the Argentine city of La Plata identified over 60 LTCFs, including informal “boarding houses” with untrained staff, as well as luxury nursing homes claiming to have a full range of therapeutic services (Lloyd-Sherlock, Penhale and Redondo, 2019a). According to a local official in Thailand:
“There are thousands of them. You can find them at every corner of Bangkok… There are places set up by non-experts who lack professional knowledge… It’s unclear who is responsible for registration or control” (Lloyd-Sherlock, Sasat, Sanee, Miyoshi & Lee, 2020).
- Many LTCFs are not registered with official agencies and hence “invisible” to the responsible authorities.
Among the more informal facilities, many are not listed or registered with the responsible government agencies. In some LMICs, it is estimated that there are at least as many unregistered, “invisible” facilities as there are official ones. The main form of evidence that these invisible care homes exist is from media reports. For example, in February 2018, it was reported that of 30 care homes operating in the Argentine city of Tres Arroyos (population 57,000), 27 were completely unregulated. And there are also many establishments we might call “de facto care homes”, such as casual hostels with permanent populations that have aged over time. These facilities may not define themselves as LTCFs, but they are for the purposes of this pandemic. A study on South Africa notes that, whilst over 400 LTCFs were registered with official agencies, it is thought that there are also growing numbers of informal, unregistered care homes. According to a representative of the South African Human Rights Commission:
“We don’t know precisely how many (unregulated LTCFs) there are out there, but we know that people have a tendency of opening their houses and converting them into residential homes for older persons…In Pretoria there are about six places operating within a very small radius from one another and they are functioning without control … We are saying that these places need to be registered so they comply with standards” (SAHRC, 2010).
- Regulation and quality assurance are almost entirely lacking.
Any state regulation of unregistered care homes is by definition impossible and there is no evidence of this role being played by non-state actors or self-regulation. There are no examples in LMICs of government agencies providing public information (such as websites) listing facilities and providing information about their service quality. Even registered LTCFs are weakly regulated, if at all, even when funded by the state. A primary health care professional in Bangkok mentioned that they were not permitted to visit providers, even if they had concerns about particular residents. A care home director in the same city observed:
“Yes, a public health official comes, but not more than once a year. Usually, we just need to submit some documents to show that we comply with their standards. The documents are mainly about the services we offer and the design of the building. They don’t go into any detail” (Lloyd-Sherlock, Sasat, Sanee, Miyoshi & Lee, 2020).
Informants from a local government regulatory agency in Argentina reported that, due to concerns about staff absenteeism, they were prohibited from working outside the city centre office (Lloyd-Sherlock, Penhale and Redondo, 2019a). This prevented them from visiting LTCFs in person. They added that several local LTCFs were owned by former directors of this same regulatory agency.
In 2012 South Africa’s Department of Social Development reported that only 13 of 412 registered LTCFs had been assessed for compliance with norms and standards and that only a quarter of LTCF staff knew about official norms and standards (Department of Social Development, 2012). In 2019 Mexico’s National Institute for Older People (INAPAM) conducted a survey of 415 registered LTCFs. It found that none of these facilities fully complied with official standards and called for urgent action from the federal government (INAPAM, 2020). INAPAM was unable to assess compliance for a further 44 facilities, as their inspectors were not permitted access: no measures were taken against these LTCFs.
- Responsibility for regulation is fragmented and uncoordinated.
In most LMICs the main responsibility for regulating LTCFs is devolved to local government agencies, but coordination between health and social departments is even weaker than in high-income countries. Chile’s national Ministry for Social Assistance funds LTCFs run by private organisations. However, responsibility for visiting and regulating the quality of care provided lies with the Ministry of Health and there is little coordination between the two agencies (Villalobos Dintrans, 2017). A similar division occurs between the Departments of Health and Social Development in South Africa. A study of local LTCF regulation in Argentina asked different agencies if they ever met with their counterparts in other agencies in the same city (Lloyd-Sherlock, Penhale and Redondo, 2019a). All responded that this had not even been considered, despite the proximity of their offices, and strong informal networks (for example, several informants had been trained in the same department of the local university). At the same time, coordination between local agencies and national ones with wider responsibilities for LTCFs is often weak.
- There is evidence of uneven quality and infringements of human rights.
Poor service quality and resident abuse are serious issues in high-income countries (WHO, 2015), but there is evidence that they are especially common and severe across LTCFs in LMICs. In part, this is a result of the limited capacity of responsible agencies to oversee and regulate the sector. It also reflects resource scarcities of different types. Residents usually share rooms, facilities are very limited and skilled staff in short supply. This limited capacity explains why many LTCFs prefer not to admit older people with high levels of dependency and that life expectancy for residents who become care dependent after admission is often short. As a result, a high proportion of residents have few or only limited care needs. For example, a survey of 1,840 LTCFs in Argentina found fewer than 60% of residents had any level of care dependency (Roqué et al, 2016). Similarly, a survey of LTCFs in Belo Horizonte, Brazil found 29% of residents had no care needs (Teixeira Barral de Lacerda et al, 2017). INAPAM’s survey of registered LTCFs in Mexico reported that 42 per cent of older residents had no care needs ([INAPAM), 2020).
There is evidence that many LTCFs, even those with mainly independent residents, operate along the principles of rigid and highly controlling “total institutions”, which were sometimes applied in high-income countries in the past (Mali, 2008). For example, a survey in Argentina found that in 43% residents were prohibited from personalising their bedrooms in any way (Roqué et al, 2016). Some directors and staff have little awareness or understanding about the human rights of residents The same survey in Argentina found only 17% of LTCFs required the consent of older people to be admitted. There is evidence that LTCFs which practise rigid models of control and minimising resident agency have intensified these practices in the context of COVID-19 infection control to a degree described by The Lancet as “dehumanising” (Lancet, 2020).
- LTCFs face similar issues with staffing as those in high-income countries, but more severely.
Often LTCF staff are unqualified, low-paid and work on a part-time basis across multiple care homes. The wider lack of regulation of LTCFs permits these practices. A South African survey of 405 regulated homes in 2010 found that over a fifth of care homes never had access to a trained nurse. There were indications of poor conditions for care home staff, including low pay and a lack of managerial support (Department of Social Development, 2010). A qualitative study of LTCF staff in South Africa found low pay, irregular work patterns, inadequate training and high ratios of residents to staff (Mapira, Kelly and Geffen, 2019). The survey of LTCFs in La Plata, Argentina found that many care homes were at times left under the supervision of a single unqualified worker (Lloyd-Sherlock, Penhale and Redondo, 2019a). The low status and exploitation of LTCF staff is a key contributory factor to the poor quality of care provided to residents.
The CIAT Framework.
The CIAT Framework combines and summarises broad elements for an emergency strategy to address the potential effects of COVID-19 in LMICs. It has been developed by an informal network of experts and draws on actual experiences in different countries and cities.
The different steps and components for the Framework are summarised in Figure 1.
Step 1: COORDINATE.
- Any strategy must be led by an inter-agency and inter-disciplinary Task Force, with seamless coordination between health and social agencies.
- The Task Force must have backing from the highest levels of government (such as the president’s or mayor’s office).
- The Task Force must urgently develop a basic and feasible set of guidance, suited to the realities of local LTCFs.
Creating a seamless inter-agency task force like this is essential for many reasons, not least to avoid the following experience reported in the UK:
“On March 17, Sir Simon Stevens, the NHS chief executive, said hospitals had to get 90,000 beds cleared, so they needed to get 30,000 people out. So they sent patients with no tests into care homes. They said: “We don’t need tests — you’ve just got to take them.”
“We discharged known, suspected, and unknown cases into care homes which were unprepared, with no formal warning that the patients were infected, no testing available, and no PPE to prevent transmission. We actively seeded this into the very population that was most vulnerable.”
Coordination between local government social and health agencies responsible for LTCFs has historically been even more limited than in many high-income countries. Past experience shows that inter-agency cooperation happens most quickly when it is given full backing from highest levels of government (such as the president’s or mayor’s office). LTCFs must be seen as a national priority: just as important as “mainstream” health services. High-income countries have learned this to their cost and LMICs seem to be repeating this mistake.
Inter-sectoral collaboration is never easy, but there are some positive examples from LMICs. In the Brazilian state of Bahia, a new official entity (the Inter-sectoral Commission for Monitoring LTCFs) was established in April 2020, with membership including the departments of health and social development, among others (http://www.saude.ba.gov.br/2020/07/06/creasi-integra-comissao-que-realiza-acompanhamento-das-instituicoes-de-longa-permanencia-do-estado-da-bahia/). In the Brazilian city of Fortaleza, the local health department has worked in partnership with the local social assistance department since the pandemic began. This has included developing joint surveys of care homes and a coordinated strategy (https://www.corona-older.com/post/letter-from-brazil-covid-19-and-older-people-in-fortaleza-brazil-s-worst-hit-city).
In South Africa inter-agency coordination has been quite limited at the level of local government. Nationally, the National Institute of Communicable Diseases collaborated with the Department of Health and Department of Social Development to establish an epidemiological surveillance programme of 19 facilities was identified. However, this was limited to collecting information on reported COVID-19 cases and deaths in these facilities. No efforts were made to cover the other 2000 or so LTCFs registered with the Department of Social Development or to collect data on other issues (Cowper et al, 2020).
The Task Force must urgently develop a basic and feasible set of guidance and or protocols, suited to the realities of local LTCFs. Some LMIC governments have been slow to provide information and emergency guidance for care homes. Organisations such as WHO have published detailed guidance and increasing numbers of LMIC governments are doing the same. These are very good in technical terms, but limited funds, resources and infrastructure mean that many of their recommendations will be unfeasible for the large majority of LTCFs in LMICs. Also, they are strongly focussed on infection control and pay less attention to the many other ways in which the pandemic can affect LTCFs, residents, families and staff.
Although the WGO guidance is a useful reference point, the Task Force should quickly identify the simplest and most affordable measures that can realistically be implemented in all LTCFs, including the most precarious and poorly resourced. This should be specific to local context and updated as new knowledge emerges.
South Africa’s Western Cape Province have drawn on WHO, CDC and Department of Health guidelines to produce their own practical guidelines for prevention and management in LTCFs (https://coronavirus.westerncape.gov.za/resources). They provide clear and simple information on basic infection control, including posters in different languages. They reflect some specific aspects of local context, such as the widespread sharing of rooms, but do not address other specific challenges related to the limited local availability of PPE, thermometers and other equipment.
Step 2. IDENTIFY.
- The Task Force must develop specific strategies to locate and develop constructive engagement with all LTCFs in their area: registered, unregistered and de facto ones.
- The Task Force should be empowered to offer all facilities some form of “amnesty” for past and ongoing infractions of official LTCF standards, on condition that they cooperate with the CIAT Strategy.
It will not be possible to support LTCFs or their residents if public agencies are unaware of their existence, have poor information about them or are unable to persuade them to engage. Large numbers of facilities are unregistered and, even for those that are, official information is often minimal and unreliable. As such, the Task Force will need to rapidly find ways to locate and engage with all facilities. For example, unregistered homes may be located by local NGOs, civil society organisations, key informants and appeals to the general public.
In Bahia state, Brazil, the Inter-sectoral Commission for Monitoring LTCFs developed an effective strategy to identify all LTCFs. It reviewed, verified and combined existing lists of LTCFs held separately by different local agencies. Additionally, information about LTCFs was obtained from health and social assistance managers. All LTCFs were contacted either by phone or email. When this was not possible, the Commission requested to local agencies to verify their records (http://www.saude.ba.gov.br/2020/07/06/creasi-integra-comissao-que-realiza-acompanhamento-das-instituicoes-de-longa-permanencia-do-estado-da-bahia/). By September 2020, they had identified 200 facilities, including more informal arrangements that did not self-identify as LTCFs.
It is essential that all LTCFs be offered some form of “amnesty” for past and ongoing infractions of official standards, so long as they agree to cooperate in the CIAT Strategy. If LTCF directors are concerned about possible prosecution, they are unlikely to engage and are unlikely to report truthfully about the situation in their homes. This amnesty should be framed as a pragmatic, temporary emergency measure. It will be politically controversial, hence the need for high-level political support for the Task Force. It should not extend to very serious cases of abuse of residents (falling short of the required number of smoke alarms is one thing; serious abuse is quite another).
A key element of LTCF amnesties will be the legal status of different sets of guidance, protocols, advice and standard, including those that pre-date the pandemic and those which have since been produced. If these set out legally mandated requirements, some LTCFs may perceive them as a threat and be reluctant to engage with them.
The recent case of an Argentine LTCF demonstrates the need to change from a business as usual approach to a more pragmatic and flexible one. Following the deaths of five residents from Covid-19, the Director (who had notified the authorities of the first case several weeks previously, but had received almost no external assistance) was put under investigation for failing to comply with highly demanding and detailed official care standards that pre-dated the epidemic. This approach will have discouraged other LTCFs from cooperating with official agencies and for unregulated homes to come out of the shadows. It may well also lead to under-reporting of Covid-19 deaths by LTCFs.
Despite the controversial nature of care home amnesties, some local governments have already introduced emergency legislation to permit this, including the Province of Buenos Aires on 9 May 2020. In this case, the term “amnesty” is avoided and replaced by the concept of “progressively regularising” LTCFs. This permits facilities that were not previously registered and/or were not compliant with required standards to continue operating without prosecution until a phase of formalisation has been completed (this time period remains undefined) (http://www.saij.gob.ar/15171-local-buenos-aires-declaran-estado-emergencia-sanitaria-establecimientos-geriatricos-gestion-publica-privada-toda-provincia-buenos-aires-).
Step 3. ASSESS
- The Task Force should conduct an emergency survey of local LTCF preparations and vulnerability to COVID-19.
- This survey information can be used to:
Identify LTCFs at greatest risk, based on simple criteria.
Identify specific issues of concern for all LTCFs (equipment, information, space limits, hospitals dumping infected patients, etc.), to prioritise local actions.
This emergency survey should entail a short, focussed and simple online or email questionnaire collecting the most immediately relevant information. Some local governments in LMICs have already run limited surveys along these lines, building on local government coordination and effective mapping of facilities. In Fortaleza it was found that all LTCFs were facing serious challenges to prepare for the pandemic. However, a small number were especially vulnerable, lacking any capacity to screen for potential symptoms and struggling to access daily food and medicines. These high-risk LTCFs were targeted for priority support and the city’s health and social assistance departments continue to work closely with them. Similarly in Bahia, it was possible to collect information from all LTCFs every three days. For those LTCFs in Bahia reporting symptoms or positive cases of COVID-19 more intensive daily monitoring was instigated.
In cities with large numbers of LTCFs, where many are unregistered and where local government capacity is more limited than in Fortaleza or Bahia, assessing facilities will be more challenging. In these cases, NGOs and other organisations may play a key role in identifying and engaging with local LTCFs. This has been done in the Argentine city of La Plata, where Red Mayor, a local NGO, co-developed a website for monitoring and sharing information about both registered and informal LTCF: http://www.redmayorlaplata.com/. In May they collaborated with local LTCFs to run an online survey of Covid-19 preparations. The survey revealed that some LTCFs in the city lacked any protective equipment or capacity to meet new official pandemic care home legislation. They shared their findings with local government agencies who promised to prioritise this issue. Following this, the local government established a new norm that testing should be provided for all LTCF employees.
Step 4. Targeted support.
- LTCFs identified as high-risk should be given priority status for targeted support.
- Focus on cooperative support rather than punitive measures.
- It may be necessary for high-risk LTCFs to be put under direct control of the Task Force if their management is very weak.
There is growing evidence from high-income countries that the effective protection of LTCF residents requires repeated testing of all residents, including those who do not present symptoms (https://www.corona-older.com/post/letter-from-south-korea-covid-19-response-and-questions-on-quality-long-term-care-for-older-adults; Blain et al, 2020). Sadly, this ideal response is far from feasible for most care homes in most LMICs (as well as some high-income countries). Nevertheless, other quite simple and cheap actions can potentially mitigate care home vulnerability, including providing adequate protective equipment and improving general hygiene practice.
A good example of this is the targeted support approach being applied in the Brazilian city of Belo Horizonte (https://www.corona-older.com/webinars). In late April the city government conducted an emergency survey which reached 179 facilities. It applied a number of criteria, including number of residents per room, access to protective equipment and capacity to isolate cases to identify those establishments most in need of support. These LTCFs have received priority support from multi-disciplinary teams, including monitoring of residents for potential Covid-19 symptoms and developing realistic emergency protocols.
Less orthodox strategies include relocating residents with no/low dependency to other locations away from the LTCF, such as hotels, even before any cases are detected there. Where necessary, these relocated residents could be offered an element of care support in the new setting. This would reduce the risk of infection for relocated residents and would increase space and resources available for remaining LTCF residents. A version of this strategy has already been implemented on a limited basis in Chile, with assistance from religious organisations (http://www.desarrollosocialyfamilia.gob.cl/noticias/gobierno-anuncia-medias-para-prevenir-contagio-de-covid-19-en-establecimientos-de-larga-estadia-elea).
Having conducted an online survey of local LTCFs, the task force should sustain this communication, both in terms of monitoring the unfolding situation and in terms of listening to their specific concerns. This can then support specific capacity-building strategies, such as offering emergency online education and training to staff. This strategy has been effectively applied in the Brazilian state of Bahia (http://www.saude.ba.gov.br/2020/07/06/creasi-integra-comissao-que-realiza-acompanhamento-das-instituicoes-de-longa-permanencia-do-estado-da-bahia/). Interventions to support LTCF staff should be mindful of their own concerns, and, in many cases, their limited prior training, low status and insecure work status.
Sustaining the CIAT Framework. Legacy.
The focus of this document is informing emergency strategies to respond to the immediate effects of COVID-19 on LTCFs in low and middle-income countries. Despite its focus on the “here and now”, it is essential to situate these responses within a wider and longer-term strategy. At the very least, the task force should maintain monitoring and evaluation of LTCFs and the effects of its responses for the duration of the pandemic. As the context of the pandemic shifts, there will need to revise strategies: for example, adding new components related to vaccination when this is available. Ideally, the task force should look to share and receive useful knowledge with similar Task Forces in other local governments. Cross-local government communication is often challenging, but one route will be to contribute experiences to the Global Platform site, following the example set by Bahia (http://www.saude.ba.gov.br/2020/07/06/creasi-integra-comissao-que-realiza-acompanhamento-das-instituicoes-de-longa-permanencia-do-estado-da-bahia/).
More ambitiously, efforts should be made to ensure that once the immediate crisis has passed, LTCF policy does not revert to pre-pandemic status. There may be particular opportunities to enhance these policies and to significantly reshape the LTCF sector. First, the engagement and information acquired through emergency responses must be retained and kept up to date. Second, inter-sectoral collaboration must evolve from an ad hoc strategy to a fully institutionalised system. Third, full use must be made of what may well be a narrow window of policy opportunity. The pandemic has brought out into the open the many problems of the LTCF sector and has raised its political and public profile. This interest creates new scope to carry through much-needed reforms. But this interest may not last for long.
 The original source material for this case study is available at https://corona-older.com/2020/10/13/care-homes-and-covid-19-in-an-argentine-provincial-city/
 An earlier version of the CIAT Framework is available at https://corona-older.com/2020/06/09/an-emergency-strategy-for-managing-covid-19-in-care-homes-in-lmics-the-ciat-framework-version-1/
 http://lavozdelpueblo.com.ar/noticia/70298-Tres%20geri%C3%A1tricos%20habilitados%20y%20m%C3%A1s%20de%20veinte%20%22clandestinos%22%20. For other examples of media reports on this in Latin America, see http://www.eltiempo.com/bogota/hogares-geriatricos-un-negociofuera-de-control/16341055 (Colombia), http://elvocero.com/investigan-muertes-en-hogares-de-ancianosfatulos/ (Mexico); http://g1.globo.com/sp/campinas-regiao/noticia/2015/12/policia-militar-de-americanaencontra-duas-casas-de-repouso-clandestinas.html (Brazil); http://www.taringa.net/posts/info/6916249/Cuatro-de-cada-diez-geriatricos-de-Buenos-Aires-sontruchos.html (Argentina).
 For an example from Pakistan, see https://www.geo.tv/latest/285629-dotage-vs-covid-19-how-pakistans-old-age-homes-are-coping-with-coronavirus
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