Peter Lloyd-Sherlock and Karla Giacomin

With contributions from Poliana Fialho de Carvalho, Wanderson Bomfim and Renan Amaral

Key points:

•  Demand from poor Brazilians for free places in long-term care facilities (LTCFs) is growing much more quickly than the capacity of government agencies.

•  An intervention successfully applied in three Brazilian municipalities (Programa Maior Cuidado, PMC) has substantially reduced this demand by supporting homecare.

•  A recent study of 1,602 older people in need of an LTCFs who were instead enrolled in PMC found fewer than 14 a year were institutionalised.

•  The Interamerican Development Bank estimates the cost per person of PMC is about a quarter of the amount typically paid by municipalities to LTCFs.

•  Brazil’s new National Care Plan is a once-in-a-generation opportunity to extend this successful strategy across Brazil.

In Brazil, the number of people aged 70 and over will almost triple between 2020 and 2050, from 13 to 37 million. Due to disabilities and prevalent chronic comorbidities, about 20% of this population is currently dependent on care, with higher rates among the poor (Aranco et al., 2022; Peroni et al., 2023). The main policy response of the Brazilian state has been to operate and provide subsidies to long-term care facilities (LTCFs), usually funded by municipal social assistance departments. Over the past decade, the number of LTCFs has increased hugely. In Belo Horizonte, for example, the number of LTCFs tripled from 77 to over 200 during the last ten year. And the cost of supporting these LTCFs has also increased. In Belo Horizonte, which is quite representative, the municipality provides a subsidy of about 3,000 reais per month for each older person residing in an LTCF. In cities like São Paulo, this rises to about 5,000 reais per month.

Yet, despite the rapid growth in the number of LTCFs and related social assistance expenditures, the number of places is falling further and further behind the exploding levels of need, especially among poorer social groups. In cities like BH or Salvador, each neighbourhood social assistance post (CRAS) is accustomed to receiving several requests every month by families desperate to find an LTCF place for an older relative. Quite rightly, this is seen by the CRAS as an option of last resort, both due to the cost and the reality that most older people prefer to remain in their own homes, if possible. This requires social assistants from these CRAS to conduct detailed evaluations of each applicants’ level of need and suitability. This includes home visits, liaison with local primary health care centres and the elaboration of detailed reports demonstrating no other option is possible. The information is then passed along to higher-level Social Assistance Departments which then attempt to locate a suitable LTCF place. This almost never happens immediately, due to a chronic shortage of supply. So many older people remain on waiting lists for weeks or months, frequently dying before a place becomes available. And it is not unusual for family members to make a legal challenge to speed up the process. This causes more work and more expense and does not change the fundamental problem -there are simply not enough places.

These frustrating experiences are taking up large amounts of social assistants’ time. For example, one CRAS director estimated that assessing each applicant required at least 15 hours of staff time. This does not include the additional costs at the higher-level social assistance department and the separate costs of inspecting and regulating these LTCFs.

A number of municipalities have developed a new strategy to meet the needs of poor care-dependent older people which is considerably cheaper than supporting LTCFs, enables many older people to remain at home and improves the lives of their family caregivers.

How does this work?

The initiative, known as Programa Maior Cuidado (PMC), supports dependent older people in poor communities. Health posts and social assistance centres identify eligible families and provide integrated support. Trained paid caregivers provide families 10-20 hours of support a week. More details about PMC are available here https://publications.iadb.org/en/publications/portuguese/viewer/Programa-Maior-Cuidado-uma-intervenc%C3%A3o-integrada-de-base-comunitaria-para-idosos.pdf

We have been studying PMC for several years, with a particular focus on how it affects older people in need of care. Among other things, we have found that PMC improves older people’s health and eases pressure on hospitals and primary health care (Lloyd-Sherlock et al, 2022; Lloyd-Sherlock et al, 2023). This prompted the World Health Organisation to promote PMC as the only model of best practice in care for older people available in Latin America (WHO, 2023).

PMC also does much to improve family caregivers’ quality of life and opportunity to continue in paid work (https://cuidadosa.org/wp-content/uploads/2025/09/Ganhando-um-pouco-mais.pdf; https://cuidadosa.org/wp-content/uploads/2025/09/Os-efeitos-do-Programa-Maior-Cuidado-na-saude-dos-cuidadores-familiares.pdf).

There is also powerful evidence that PMC makes a very large contribution to alleviating pressures on LTCF places. The simple reason for this is that almost all the older people included in PMC would require institutionalisation without this support. Many of the people are identified as requiring PMC when a family member reaches out to the CRAS to provide an LTCF place, because they are no longer able to meet this person’s needs. In territories where PMC operates, social assistants now have another option before resorting to institutionalisation. Many of these families are, in fact, willing to care for their older relative, and would be able to do this perfectly well, if they were provided with a few hours of weekly assistance by PMC.

One of the clearest examples of this is the challenges many families face in assisting older people to bathe. When an older person is unable to do this independently, especially if they have limited mobility and conditions like dementia, bathing often requires assistance from a professional PMC carer. According to a social assistant who works with PMC:

Mr. Josias is unable to leave his bed and overweight. So, his transfer to the bathroom is a problem. It takes some strength… the PMC caregiver is able to put him in a wheelchair or a bath chair, take him to the bathroom and bathe him… The family caregiver is his wife who is an older woman. She doesn’t have that strength. Their daughter who lives upstairs but she has her own health problems.

Cases like this occur very often. When receiving help from PMC with these particularly demanding care tasks, family caregivers are able to do much of the other caregiving themselves. If they do not receive this help, the situation of the older person can become impossible, and institutionalisation is the only solution.

International studies of PMC demonstrate this effect. For example, one study analysed the experiences of 1,602 older people included in PMC over a seven-year period. It found that only 97 of these people were admitted to an LTCF (fewer than 14 a year) (Aredes et al, 2021). Testimonies from social assistants working with PMC show how it is possible to keep these numbers so low. One recently told us about:

Dona Juana is aged 88, is unable to leave her bed, has dementia and is overweight. Her daughter, Adela, is 62 has her own health issues. She isn’t able to help her mother bathe or manage her incontinence. Dona Juana has a son, but he lives some miles away and is only able to help at weekends. Adela went to a CRAS to see if they could offer a LTCF place for her mother, as she “just couldn’t cope anymore”. Instead, the CRAS team included them in PMC instead and they have remained in PMC ever since. Both Juana and Adela say they much prefer this option.

Another social assistant told us about a similar case:

Maria Jesus is aged 85 and unable to leave her bed. Her daughter, Elizabete, is aged 65 and has several chronic diseases and was experiencing moderate to severe depression. In 2020, like Adela, Elizabete, went to a CRAS to request an LTCF place for Maria Jesus. When social workers visited her home to assess their eligibility for PMC, they observed that Maria Jesus was in a very poor condition and that her daughter was experiencing multiple problems. As well as PMC, they included them in a more general Programme of Support for Vulnerable Families (PAIF). After some months, Maria Jesus regained some mobility and was able to walk around the house with a frame and bathe herself independently. She no longer needed to use incontinence pads, which had been a major expense for the family. As Maria Jesus became more independent, it was possible to reduce the weekly PMC support from 20 to ten hours. Elizabete says her mental health has improved and that she is doing better at caring for her mother.  

One woman caring for her mother who has advanced dementia told us:

There was someone in my family, I won’t mention any names, who wanted me to put her in a care home. I didn’t agree… This relative came here to take her, but my mum said it like this, “No!” And so, this relative said they would report me to a social worker if I didn’t let her go into a care home… [After joining PMC] the PMC caregivers say that she has to try to walk with a frame. Because she hadn’t been walking for a long time. She was just in bed. And then she started walking.

PMC does not mean that LTCFs will never be needed; for example, family circumstances can change over time. Even in these cases, however, PMC can facilitate the transition from home to LTCF. A CRAS social worker described the following case:

An older married couple and their sister-in-law were living with their nephew, who came along to the CRAS to ask if we could find LTCF places for them all. When social workers visited their home, they found the older people were experiencing a high level of neglect. The family were then enrolled into PMC, and we hoped this would improve their situation. For about a year, between them, the PMC carer and the nephew were able to meet these care needs, but then the nephew’s work situation changed, and he had little time in the home. Social workers suggested to the three older people that they move into a LTCF. They agreed, so long as they could all go to the same one. The social worker and PMC carer remained working with them until they were settled into the LTCF, to reduce the stress of this big change in their lives.  

The Interamerican Development Bank has estimated that the monthly cost of supporting an older person to remain at home with PMC is approximately a quarter the monthly cost of a LTCF (BID, 2024). Government departments of social assistance now have an immediate opportunity to extend interventions like PMC across Brazil, as part of the new National Care Plan. The argument for doing this is compelling.

[1] This paper is part of a project developed within the framework of the project Initiatives to Strengthen Care Policies in Latin America and the Caribbean, led by the Group for the Analysis of Development (GRADE), in collaboration with the Global Alliance for Care (GAC), the United Nations Research Institute for Social

Development (UNRISD), and with funding from the International Development Research Centre (IDRC). For further information, see https://sites.google.com/view/carefundeconomyla

REFERENCES

Aranco, Natalia et al. 2022. “Aging in Latin America and the Caribbean: social protection and quality of life of older persons”. Inter-American Development Bank (IADB). https://publications.iadb.org/en/aging-latin-america-and-caribbean-social-protection-and-quality-life-older-persons

Aredes J de S, Billings J, Giacomin KC, et al. (2021) Integrated Care in the Community: The Case of the Programa Maior Cuidado (Older Adult Care Programme) in Belo Horizonte-Minas Gerais, BRA. International Journal of Integrated Care 2021;21. http://www.ijic.org/articles/10.5334/ijic.5619/

Banco Interamericano de Desenvolvimento (BID). Divisão de Proteção Social e Saúde (2024). Programa Maior Cuidado: An Integrated Community-Based Intervention on Care for Older People. [https://doi.org/10.18235/0005535]

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P.Lloyd-Sherlock, P.Carvalho.K.Giacomin and L.Sempe (2023) Addressing pressures on health services in Brazil through community-based care for poor older people: a qualitative study. Lancet Americas 2023;27: 100619.

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WHO (2023) Framework for countries to achieve an integrated continuum of long-term care. https://iris.who.int/server/api/core/bitstreams/7eea5d40-06e6-4702-b42d-6f89c7c70474/content