Introduction Because of increasing longevity and decreasing fertility rates, the number of people aged 65 years and above is growing in absolute terms and as a proportion of the population in Asia and the Pacific. Between 2020 and 2050, their number is expected to increase to over 900 million from 396 million, and 240 million will be over 80 years old. Traditionally, families provided care for older people, but this is no longer sufficient nor sustainable. Care has become increasingly complex and various key socioeconomic developments and trends—such as migration, urbanization, increased female workforce participation, and smaller family sizes—have impacted on the roles and responsibilities in the family. How can countries in the region address the large gap between the need for aged care and supply? This article is adapted from Leadership and Governance of Long-Term Care in Asia and the Pacific. It identifies key governance factors to consider in improving long-term care systems and takes into account the systemic gaps highlighted during the coronavirus disease (COVID-19) pandemic. Examples of effective approaches illustrate how countries can tailor reforms and measures to their unique needs. Analysis Long-term care refers to the support provided and activities undertaken by informal caregivers (including family, friends, or neighbors) or by formal caregivers (public, private, or organized voluntary providers) to ensure that a person can optimize his or her functional ability and maintain the highest possible quality of life. A long-term care system consists of all organizations, institutions, resources, and people involved in carrying out these activities. The World Health Organization identifies governance and leadership as a cross-cutting building block of a long-term care system that encompasses the overall responsibility for the design and functioning of a health system. Strong governance ensures implementation of effective long-term care strategies and requires (i) engaging stakeholders at all stages; (ii) clarifying roles and responsibilities of all actors engaged in the design, delivery, and monitoring of long-term care; and (iii) developing structures and mechanisms to ensure smooth coordination and collaboration Stakeholder engagement Progress in long-term care systems is tied to strong leadership, high-level champions, effective multistakeholder engagement, and advocacy. As long-term care requires a whole-of-government and whole-of-society approach, it needs a clear lead and engagement from multisector, cross-departmental and multidisciplinary stakeholders. High-level leadership from offices or ministries responsible for overall socioeconomic development and planning help facilitate long-term care system development. At the same time, building coalitions and coordinating with a broad range of stakeholders—including persons with care and support needs, their families, and communities; academics; for-profit, nonprofit, and public health and social care providers; and other sectors (e.g., transport, housing, urban planning, labor, and education)—are important to ensure access, coverage, quality, and safety for all who need long-term care. Various mechanisms can be established to support multistakeholder participation at the national and local levels. Multistakeholder forums, consultations, and advisory groups can help ensure whole-sector input for planning, monitoring, and evaluation. Joint activity by multistakeholder partnerships can also enhance service delivery at the local level. In Thailand, the National Health Assembly, organized by the National Health Commission, brings together the government, academic, and grassroots organizations annually to discuss public health policy. It is through this body that the Thailand national definition of long-term care was developed and approved. Well-defined roles and responsibilities Having clear organizational structures for long-term care helps ensure effective and efficient strategy implementation. Clearly assigning responsibility for its different components is often needed. This could entail shifting the roles of existing ministries or departments or creating new organizations with explicit tasks related to long-term care. Establishing coordination mechanisms and giving clear authority are necessary. As many countries and areas in Asia and the Pacific operate a decentralized or partly decentralized system, responsibilities for different elements of long-term care is divided among national, provincial, city, and local levels. Thus, further division or unification, the level where different types of decisions will be made, and the process of coordination must be carefully considered. Establishment of structures and mechanisms Laws, policies, and strategies provide comprehensive guidance for the development of long-term care systems. Laws set the legal framework, while policies give shape to the system. Strategies help outline policy implementation. These three components cover key issues, such as the process of developing long-term care services, eligibility criteria, equity and access, care providers, financing, quality management and improvement. The development of regulatory frameworks ensures the efficiency and quality of care provided, alongside the development of care standards for public, private, and voluntary providers across different settings (i.e., home, community, or institutions), with clear mechanisms for their enforcement. In Japan, the Long-Term Care Insurance Act of 1997 (amended or partially revised in 2005, 2008, 2011, and 2017) is the main legal framework under which care has been organized. Established in 2001, the Ministry of Health, Labour and Welfare is responsible for all five key aspects of governance of long-term care and develops policies, planning, and evaluation of long-term care. Putting in place governance structures can also guarantee equity, prevent abuse, and promote continued public investment in the system. The process of accountability is often supported by independent quality commissions and mechanisms for independent oversight, monitoring, reviews, and audits; rules for long-term providers; and public access to policies, laws, regulations, and reports. In England in the United Kingdom, the Care Quality Commission ensures that health and social care services provide people with safe, effective, compassionate, and high-quality care, and promotes care services improvement. It registers care providers; monitors, inspects, and rates services; and acts to protect people who use these services, among others. It can also restrict or suspend services, cancel a care provider’s registration, and prosecute care providers. Long-term care and COVID-19 As of October 2020, 46% of COVID-19 deaths across a sample of 21 countries have been linked to long-term care home residents. High numbers of deaths were reported in long-term care facilities in North America and Europe, while figures have been relatively low in facilities in East Asia. These highlight the importance of clear leadership, regulatory environment, and coordination. In many of the East Asian countries, which had experience with previous pandemics, particularly Serious Acute Respiratory Syndrome (SARS) in 2003, service providers were already mandated to have infection control and epidemic protocols in place. The risk of COVID-19 for persons who received care was recognized quickly. In the Republic of Korea, guidelines for the social welfare sector were enacted and monitored from late January 2020. The National Health Insurance Service also released a COVID-19 response manual for all welfare and long-term care facilities on 20 February 2020. Lessons and Considerations Good governance is needed to ensure an adequate supply of workforce participants, the equity and quality of service provision, affordable services and sustainable financing, streamlined information systems, and sufficient supply of needed products. Key considerations for countries and municipalities developing long-term care systems include the following: No one-size-fits-all approach A long-term care system and its governance are influenced by numerous factors unique to each country and area, including political and economic context; social and cultural factors; existing health and social welfare system structure; and international good practices. Since long-term care needs span medical care, social care, psychosocial support, and enabling environments, it requires multisector and multistakeholder collaboration to plan and deliver. The need for continual adaptation Improvements and adjustments need to be made over time. The COVID-19 pandemic has exposed the strengths and weaknesses in the systems of governance of long-term care and highlighted areas of improvement. Difficulty in identifying focal agencies within a government A clear niche for strategic planning for long-term care; leadership, implementation, and management; and quality management and improvement does not often exist. Social welfare ministries are often mandated to provide for the welfare of older people, while health ministries are tasked to facilitate universal health coverage. One approach seen in Singapore is for all long-term care to be consolidated and coordinated under the Ministry of Health. Risk of unequal access to long-term care due to decentralization Effective and coordinated service delivery for users at the local level is important for long-term care. Rural and remote communities are often at risk of poorer access to quality care. In Japan, municipalities have an operational role to ensure the delivery of equitable services to balance equity and practical management concerns. Role of the state versus the market in shaping governance needs and risks To ensure that needed services are available and affordable to all, governments can take on different roles, such as providing care directly, regulating care, and shaping long-term care markets. However, markets often grow faster than the capacity of the state to regulate them. In the Republic of Korea, the establishment of the long-term care insurance program in 2008 rapidly increased the number of private providers but without adequate quality management in place. Building multistakeholder partnerships with the private sector and other stakeholders is crucial for progress. Difficulty in securing sources of funding Lack of investment often hampers implementation of laws, policies, and services related to long-term care in the region. Investing in long-term care can be promoted by highlighting how funding long-term care systems can positively influence other domains of socioeconomic development, such as through job creation, increased female labor force participation, and provision of health and income security for older people and their families. Challenges in multilevel governance There is a need for clear roles and mandates of each level of government and stronger regulatory, financing, implementing and oversight responsibilities of public institutions. Multilevel governance requires well-defined responsibilities, distribution of resources, and effective coordination mechanisms and data systems to capture and provide accurate information.  This is based upon the definitions of long-term care found in a World Health Organization (WHO) Study Group report on home-based long-term care. WHO. 2000. Home-Based Long-Term Care: Report of a WHO Study Group and WHO. 2015. World Report on Ageing and Health. Geneva.  National Health Commission Office of Thailand and Cornell University, INSEAD, and WIPO 2019.  H. Kim. 2020. The Impact of COVID-19 on Long-Term Care in South Korea and Measures to Address It. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE. 7 May. Resources Asian Development Bank. Regional: Strengthening Developing Member Countries’ Capacity in Elderly Care. ADB. 2020. Singapore’s Long-Term Care System: Adapting to Population Aging. Manila. C. Littleton, M. Wyse, and W. Walker. 2021. Leadership and Governance of Long-Term Care in Asia and the Pacific. ADB Briefs. 198. Manila: Asian Development Bank. C. Yongho. 2018. The Effects of Marketization of Long-Term Care Services for Older Adults in Korea. Journal of Social Service Research. 45 (4). pp. 1-13. Care Quality Commission website. Cornell University, INSEAD, and WIPO. 2019. The Global Innovation Index 2019: Creating Healthy Lives—The Future of Medication Innovation. Ithaca, Fontainebleau, and Geneva. p. 198. H. Kim. 2020. The Impact of COVID-19 on Long-Term Care in South Korea and Measures to Address It. Report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE. 7 May. National Health Commission Office of Thailand. National Health Assembly. World Health Organization (WHO). 2015. World Report on Ageing and Health. Geneva. WHO. 2000. Home-Based Long-Term Care: Report of a WHO Study Group. Geneva. Ask the Experts Wendy Walker Chief of Social Development Thematic Group, Sustainable Development and Climate Change Department, Asian Development Bank Wendy Walker provides technical leadership in social development and social protection and facilitates collaboration across sector and technical groups in ADB and with external partners. She has been leading ADB’s regional technical assistance programs on aging and long-term care and developed some of ADB's first technical assistance and investment programs in this area in the People’s Republic of China. She has over 25 years of experience and holds an MPhil from the University of Oxford and an MA and a PhD from Johns Hopkins University. Meredith Wyse Senior Social Development Specialist, Sustainable Development and Climate Change Department, Asian Development Bank Meredith Wyse specializes in aging and care. She has extensive experience working in the Asia-Pacific region on issues related to adaptations to population aging and older persons, with a specific focus on long-term care systems. Prior to joining ADB, she worked for HelpAge International in a range of senior management roles, where she worked in initiatives related to social protection, community development, health and care, and humanitarian responses. Asian Development Bank (ADB) The Asian Development Bank is committed to achieving a prosperous, inclusive, resilient, and sustainable Asia and the Pacific, while sustaining its efforts to eradicate extreme poverty. Established in 1966, it is owned by 68 members—49 from the region. Its main instruments for helping its developing member countries are policy dialogue, loans, equity investments, guarantees, grants, and technical assistance. Follow Asian Development Bank (ADB) on Leave your question or comment in the section below: View the discussion thread.