Rapid ageing has put long-term care on the top of the agenda of social security reforms. In this context, the COVID-19 pandemic has further underscored the importance of investment and collaborative action to establish effective mechanisms and ensure that the elderly have access to health and LTC services without undue financial burden. It highlights the need to address major structural challenges in order to improve the safety and resilience of LTC systems.

In the complex and multi-sectoral field of LTC, there is no one-size-fits-all solution. There are significant differences between and within countries in the way LTC is organized, delivered and financed. A number of countries are considering establishing a formal long-term care (LTC) programme as part of their social security system. Others plan different types of reforms.

Meeting the LTC challenge requires social security institutions to develop responses including better coordination among institutions, jurisdictions and service providers, a strengthened role of prevention and health promotion, rehabilitation, ageing in place strategies as well as the innovative use of technologies.

Acknowledging the increasingly pressing nature of the LTC challenge and based on previous publications, including a 2019 ISSA technical report, the members of the International Social Security Association (ISSA) therefore made “Meeting the evolving needs of an ageing population” one of the Association’s triennial priorities 2020–2022.

Through a range of activities including studies and webinars, the ISSA therefore explores how adequate and quality LTC and ageing-in-place services can be provided in a financially sustainable way.

The first step in solving a problem is to understand it better. An introductory webinar – organized on 25 November 2020 – therefore provided an overview of the challenges and strategies proposed by the most relevant international organizations, with experts from the International Labour Organization (ILO), the World Health Organisation (WHO), the Organisation for Economic Co-operation and Development (OECD) and the European Commission (EC). It offered a unique occasion to learn how these organizations coordinate efforts at the international level to support the development of national LTC programmes and how COVID-19 influences these efforts.

A second ISSA Webinar on LTC, organized in collaboration with the ISSA European Network on 9 December 2020, provided a solid overview of challenges and innovative solutions in a comparative perspective across Europe. It elaborated further on issues and responses to growing LTC needs, building on the experiences shared by international experts. ISSA member organizations from France, Hungary and Poland shared their concerns and solutions.

In this context, this article outlines the key issues raised by international organizations and discusses different aspects related to human resources for LTC. It is a first in a series of publications of the ISSA on different aspects of LTC during the triennium.

Urgent LTC challenge on a global scale

The ILO, WHO, OECD and the EC are in full agreement on the broad challenge to be addressed, its urgency and the emphasis on the need for social security. Access and adequacy, quality issues and financial sustainability are high on the agenda.

The organizations highlighted that LTC for the elderly is not a well-defined and institutionalized social policy field. Rather, it is often characterized by a fragmentation of responsibilities and a lack of coordination between health and social aspects. Governance of the LTC system involves multiple sectors, different ministries and different levels of government, making coordination difficult. It tends to have low political priority, where political attention to its importance is often secondary to health care.

Paths to solutions

a) Recommendations of international organizations

In view of the financing and sustainability challenge faced by social security systems in the context of demographic change, the ILO underlines the vital role of the Governments in forecasting the long-term balance between resources and expenditure in order to guarantee that institutions will meet their obligations towards older persons. There is a need for a holistic approach in the multi-dimensional field of social protection benefits, care services, leave policies, family-friendly working arrangements and care-related public infrastructures.

Adding life to years is the overarching priority of the WHO Decade on Healthy Ageing, promoting the vision of a world in which everyone can live a long and healthy life. The action areas include changing how we think, feel and act towards age and ageing. According to the WHO, there is a need to develop communities in ways that foster the abilities of older people, delivering person-centred, integrated care and primary health services that are responsive to older people and provide them access to LTC when needed.

In measuring the effectiveness of social security, the OECD draws attention to the importance of the financial protection provided by social security systems and the gaps that exist. Without this protection, the total costs of LTC for older people are unaffordable in a large majority of OECD and EU countries. Even with benefits, older people in many places could fall into poverty. The introduction of a new LTC benefit or scheme, or a change of rules in specific LTC benefits or schemes, are possible solutions according to the OECD.

The European Commission is developing responses to ensure that everyone has the right to affordable long-term care services of good quality, in particular home-care and community-based services. It recommends better integration of health and social services for adequate home care.

b) A focus on human resources for care

Human resources and ageing populations

Many care systems face challenges such as a shortage of skilled workers and, simultaneously, an increasing demand for long-term care owing to demographic change. The COVID-19 pandemic has further exposed this lack of human resources, not only in healthcare settings but also in LTC facilities.

Analyzing the labour market and conducting needs-based planning to optimize current and future workforces, and to meet the needs of ageing populations are key in the development of a sustainable, appropriately trained, deployed and managed health workforce. Better working conditions and higher pay, training, regulations and in-kind-benefits are tools commonly considered to be important enabling factors.

In many countries, the lack of accessible formal LTC facilities seems to be the main reason for the expansion of informal care, which provides the backbone of LTC. Other reasons include the low quality of LTC, a biased subsidisation of LTC, the shortage of institutional and community services, the non-affordability of LTC and, last but not least, the traditional model of intergenerational and familial relations.

The employment challenge also covers the need to address informal/undeclared work in LTC, to open up skills validation and upskilling to informal learners to assist them in becoming LTC professionals. It is key to guarantee that workers enjoy proper and attractive working conditions and an adequate work-life balance.

Staffing of nursing homes

The existence, usage and benefits of digital technologies in nursing care may hold part of the solutions to problems such as the shortage of skilled workers and the increasing demand for LTC.

In Germany, research on digital technologies for nursing care is looking into the possibility of using these technologies to facilitate or even substitute for some aspects of human nursing work and contribute to mitigate the rapidly rising costs of care and shortages of skilled workers. Research on outpatient, informal and cross-sectoral care is also exploring the potential of digital technologies to improve the independence of care-recipients and unburdening formal and informal carers.

Migrant care and LTC

In recent decades, LTC provided by migrants has increased in both formal and informal settings. As LTC is highly labour intensive, meeting the growing demand for LTC will depend on the ability to recruit and retain sufficient numbers of carers, whether in institutional settings or within homes. Many European countries have responded to this challenge by employing a considerable number of carers from other countries, whether from Europe or beyond. This raises a number of important issues for policy and practice for both source and host countries. Migrant care workers operate based on labour market regulations and the rule of free movement of workers between EU countries. In several countries, migrants can be legally employed by households (Germany, Italy and Poland). Sometimes, however, the work takes place in a “grey zone” of the economy. Where appropriate regulation is lacking, the quality of services may be affected and the risk of unfair treatment of carers increases.

Coordination at EU level

Since 2012, the EU has been working on changing the provisions on the coordination of social security systems towards introducing the new social risk of dependency. The legal aspects include the social security coordination in Europe, contributing to clarify the rights to services and cash benefits of older persons with long-term care needs who move to a European Union country other than their country of origin. The provision of LTC requires various legal, organizational and financial solutions aimed at providing long-term care benefits in a broad sense. Identifying a new social risk at the level of national or EU law opens the possibility of building a new branch of social security and guarantees other activities for the development of LTC.

c) The provision of care to the elderly

To reduce discontinuities in the healthcare pathway and avoidable hospitalizations, countries develop responses to ensure coordinated, ongoing and appropriate care, allowing the person to remain at home for as long as possible. Supporting the autonomy of everyone throughout their lives makes it possible to restore seniors to their rightful place, at the heart of a caring and inclusive society.

In France, pilots for autonomy-preserving senior health pathways (PAERPA) are in place, where a primary healthcare team is set up to implement a personalized healthcare plan from a combined social welfare and healthcare perspective. The COVID-19 crisis has boosted partnerships and increased the need for coordination, especially on prevention.

The ISSA will further analyze these important aspects in upcoming articles.

The way ahead

Access to social security is a human right and responds to life-cycle risks. It is widely recognized that the social security right to LTC remains urgently unmet.

Ageing populations call for profound changes. All countries face an increasing demand for LTC and there is no panacea. Social and healthcare models need to be redesigned in order to allow a greater focus on prevention, to address staff shortages and improve access to person-centred quality care. A proper integration of health and social care delivery around patients would help to control costs and improve care quality.

Promoting age-friendly environments are a priority, where older people regardless of their potential limitations can age safely according to their choices. People who gain healthy life years can continue to contribute to society and reduce the impact of ageing on healthcare systems, which in turn will be beneficial to all.

ISSA members are facing these challenges. International cooperation is key to designing responses to address the urgent LTC needs. The exchange of information among ISSA members will continue in the upcoming ISSA webinars on LTC as well as articles, to identify paths for solutions in a comparative perspective.

Further reading

WHO. 2019. Decade of healthy ageing 2020-2030. Geneva, World Health Organization.

WHO. 2020. COVID-19 and the decade of healthy ageing. Geneva, World Health Organization.