First published in April 1948 as the Bulletin of the International Social Security Association, this year marks the 75th anniversary of what, since January 1967, we have all come to know as the International Social Security Review. To mark this important anniversary, this special double issue, “The human right to long-term care for the elderly: Extending the role of social security programmes”, talks to current debates on social security coverage extension in a context of population ageing. There is a case to be made for revising the international social security standards to formally recognize long-term care for the elderly, possibly as a distinct branch of social security. At the heart of this discussion, the questions to be addressed by all countries are the roles that social security systems can and should play in helping to meet the long-term medical and social care needs of elders.

With the acceleration of population ageing, healthy ageing is becoming an imperative for all. Social protection systems have an important role to play in this endeavour. Through a life cycle approach, social protection systems can support i) the prevention of disability in old age (i.e. by addressing the social determinants of health and rehabilitation), ii) effective access to long-term care without hardship for those who need it, and iii) decent work in the care economy. To do so will require adopting a gender-transformative approach. Indeed, women are disproportionately represented among both older persons and long-term care providers in their diversity. Further, to adequately contribute to healthy ageing and effective access to long-term care without hardship as a rights-based entitlement, social protection systems will need to build strong coordination between health care, social care and other social policies. This article highlights the key entry points for social protection systems to contribute to the United Nations Decade of Healthy Ageing, building on the rights-based approach of human rights and international social security standards.

The family is the dominant player in India’s current long-term care (LTC) system. Yet informal family-based arrangements will be insufficient to accommodate India’s growing need for LTC due to increasing longevity and geographic mobility, the prevalence of chronic disease and disability among the elderly, and the decline of extended family living arrangements. Addressing the growing need for LTC will require a robust expansion of the current LTC system, especially its non-familial components. This overhaul will require investments in infrastructure, human resources and legal and regulatory environments. The objectives of this study are to i) provide a descriptive summary and analysis of the LTC system in India, with attention to cross-state heterogeneity and to the financial, social and cultural factors that impede the operation of India’s LTC system; ii) estimate and assess the current and future need for LTC and its critical financial and human inputs; and iii) critically analyse and discuss the institutions and policies, technologies and behaviours needed to bring capacity comfortably into conformance with the need for LTC.

In this article, we provide an overview of the current long-term care (LTC) landscape across low- and middle-income countries (LMICs), based on an analysis and synthesis of literature review findings. We begin with a brief assessment of LTC needs on the demand side, followed by a supply side assessment of the available mix of formal LTC services vis-à-vis informal care provision. Next, we describe and discuss the role of government policies in LTC provision and governance. We conclude by discussing and offering practical LTC policy considerations for LMICs, drawing on experiences, best practices and lessons learned from high-income countries.

Care for the elderly is one of the most important socioeconomic issues arising from the ageing of the population. Given the declining workforce in the care and health sectors, difficulties exist already in fully meeting care needs. Moreover, deinstitutionalization, which involves a transition from institutional to community-based care, requires an increase in human resources in the care and health sectors. The article addresses long-term care systems for the elderly and the conditions affecting the possibility for the Visegrád countries (Czechia, Hungary, Poland and Slovakia) to transition from a post-socialist model (familialism by default/unsupported familialization) to a European care model based on deinstitutionalization. A further aim of the article is to show some differences in the provision of long-term care for the elderly that are observed in Central Europe, and to underline that their specific characteristics should be taken into account when planning and designing public policies and guidelines for social policy at the European Union level.

Older people and their care workers have been disproportionately affected by the COVID-19 pandemic. Many OECD Member countries have taken measures to contain the spread of the infection and improve the care workforce. Yet the health crisis is highlighting and exacerbating pre-existing structural problems in the long-term care (LTC) sector. In many OECD Member countries, recruiting enough workers in LTC remains a challenge and care workers experience difficult working conditions. Skills mismatch and poor integration with the rest of health care lie at the root of preventable hospital admissions even in normal times. Such challenges are likely to become ever more acute if no further action is taken given the speed of population ageing. Policies to improve recruitment and which also address retention through training, improvements in coordination and productivity, leveraging the effect of digital technologies, are needed.

This article investigates challenges of ageing for long-term care. The analysis proceeds in three steps. In the first step, we estimate the prospective care demand for 30 developed countries based on projected ageing and disabilities among the elderly. In the second step, we outline challenges for care systems with respect to shortages of care workers, increasing skill requirements for care workers, barriers to universal and equitable access to care, and cost containment subject to adequate care quality. In the third step, we identify solutions for these challenges by comparing the care systems of Germany, Israel, Japan, the Netherlands, and the Republic of Korea.

The article sets out key elements of the policy agenda for enhanced integration between health and social care for older people in high-income countries and demonstrates its wider relevance to low- and middle-income countries (LMICs). The article then explores the context for this agenda in Brazil, including growing demand for long-term care (LTC) and current institutional arrangements. It goes on to discuss a case study project of partnering for LTC between local social assistance and health agencies in the Brazilian city of Belo Horizonte. It identifies challenges and potential benefits of this partnership model, offering policy insights for LTC policy in Brazil and other countries.

This article analyses Cuba’s pension system from 2006–2021 with respect to its financial and actuarial sustainability and impact on the population. It includes discussion of the ageing population; the sharp cut in social expenditures since 2009; the deficit in pension financing and the impact of the 2008 parametric reform; the devaluation of pensions; structural reforms and the expansion of poverty and the curtailing of social assistance; the impact of the current economic crisis on pensions; and projections of the future financial sustainability of pensions.

Based on original evidence from the European Social Policy Network (ESPN), the article investigates the extent to which self-employed and non-standard workers, who are less protected by “ordinary” social protection, were included in “extraordinary” income protection and job retention schemes during the COVID-19 pandemic in the European Union (EU) and the United Kingdom. When the crisis hit, countries quickly introduced unprecedented emergency income replacement measures for the self-employed. Nevertheless, most of these schemes provided only basic support through lump sums and were, in some cases, subject to a variety of eligibility conditions. Non-standard workers were in general included in job retention schemes, but substantial gaps remained in some countries. The article discusses how such gaps were addressed in five EU Member States. The article concludes by highlighting some policy pointers for better and more adequate “extraordinary” income protection for the self-employed and non-standard workers in times of crisis.

Universal Health Coverage (UHC) and Social Health Protection (SHP) are key policy foci that cut across all dimensions of the 2030 Sustainable Development Goals agenda. Understanding of these two concepts, their fundamentals and relations would improve health policy development and implementation to attain UHC and effectively protect the health of people and save lives and livelihoods. The COVID-19 pandemic has provided useful lessons to improve multi-sector activities to strengthen and finance health and social protection systems. The aim of this article is to provide conceptual clarity on the contribution of the global frameworks on SHP to the policy goal of UHC. In doing so, the article contributes to health financing and social security related policy discussions and advocates for much needed integrated policy actions at global as well as country levels. It discusses the origins of the two concepts and the relevance of SHP to health systems financing for UHC. Although country situations differ, the main findings, especially for low- and middle-income countries, are highlighted and summarized.

In 2019, the Government of Egypt issued a new legal framework for its social insurance system. Aside from providing a unified scheme covering different groups of workers, the new regulation allowed for systemic and parametric reforms that were aimed in large part at addressing the challenge of workers’ low enrolment in social insurance, with an emphasis on informal workers. The reforms reduced the rate of contributions paid by employees and employers, increased the penalties for employers who do not register their workers, and improved the benefits structure. The law also specified provisions to facilitate the enrolment of informal workers by offering to cover the employer’s share of their contributions. However, the law limited such improved access to nine specific categories of informal workers, a decision that fails to recognize the diversity of informal forms of work. Based on the analysis of the characteristics of contributors to the previous system, this article argues that structural barriers pertaining to the large numbers of low-earners and informal enterprises in the economy will likely hinder the expansion of system enrolment despite the legal reforms.

In an effort to establish universal health coverage (UHC), Senegal set up two departmental health insurance units (UDAM) to scale-up health insurance to rural communities. Part of this innovation meant that health insurance was longer managed by volunteers, but by professionals. Several years after the conclusion of the project in 2017 that supported their initial development, both UDAMs still operate successfully. This mixed methods research aims to understand the factors that have contributed to the sustainability of both UDAMs, as well as discuss the remaining challenges. The factors deemed favourable to sustainability are actions undertaken to ensure financial stability and organizational risk taking. However, the mobilization of the population, relationships with health professionals and the role of the State have been more difficult to organize. Challenges concern the payment of subsidies and the supply of medicines by the State and partnership with the health care system, the maintenance of contributions, the digitalization of administration, as well as fraud and abuse.

Using unique administrative register data, we investigate old-age retirement under the statutory pension scheme in Finland. The analysis is based on multi-outcome modelling of pensions and working lives together with a range of explanatory variables. An adaptive multi-outcome LAD-lasso regression method is applied to obtain estimates of earnings and socioeconomic factors affecting old-age retirement and to decide which of these variables should be included in our model. The proposed statistical technique produces robust and less biased regression coefficient estimates in the context of skewed outcome distributions and an excess number of zeros in some of the explanatory variables. The results underline the importance of late life course earnings and employment to the final amount of pension and reveal differences in pension outcomes across socioeconomic groups. We conclude that adaptive LAD-lasso regression is a promising statistical technique that could be usefully employed in studying various topics in the pension industry.

This article analyses whether and to what extent social protection expenditure varies with institutional quality and people’s preferences using cross-section and cross-country panel data. It uses data on expenditure taken from the International Labour Office database focusing on 52 low- and middle-income countries and on 80 high-, low- and middle-income countries. The results show that both factors have an impact for the group of low- and middle-income countries, but also for all the countries in the sample. The estimates are robust to different definitions of the dependent variables and different measures for the quality of institutions. Our results suggest that it is worthwhile to continue enhancing the capacity of institutions and public authorities as well as to channel people’s preferences on social protection interventions into the planning and budgeting process where the decisions on social protection programmes are taken and resources allocated.

Using the Ghanaian LEAP benefit programme as a case study, we investigate how administrators, service personnel and beneficiaries perceive and respond to implementation dilemmas. The investigation focuses on the LEAP benefit for caregivers of children, which is conditional on children’s school attendance, health check‑ups and vaccinations. An ethical dilemma concerns whether non-compliance should be sanctioned, since this may push caregivers and their children deeper into poverty. Other dilemmas concern how administrative resources should be allocated for the targeting, monitoring, sanctioning and exiting of beneficiaries; how spending should be allocated between providing cash benefits and securing health and education services of sufficient quality; whether available money should be spread widely but thinly to provide incentives for many caregivers to send children to schools and attend health check-ups, or be targeted more narrowly to enhance relief for the very poorest; and whether funding would be less forthcoming if the minimum benefit was not a conditional cash transfer (CCT). We discuss whether similar dilemmas are likely to be present in other low- and middle-income countries operating similar CCTs, and whether some of these also apply to “active” minimum benefits implemented in high-income countries.

The impact of the COVID-19 pandemic threatens the viability of Chile’s defined contribution (DC) pension system, undermining its financial foundation and exposing its vulnerability to political risk. The COVID-19 crisis led to the approval of three rounds of emergency withdrawals of 10 per cent of pension savings (as of April 2021). Utilizing pension funds during an economic crisis is neither new nor uncommon – during the Great Recession, several countries in Central and Eastern Europe diverted DC pension funds to cope with the fiscal stresses. As Chile prepares to draft a new constitution, debates about the efficiency and equity of the pension system are ongoing. In this regard, and as the political response to the pandemic demonstrates, the DC system has failed to live up to its promise of ending political risk and preventing the diversion of pension funds for other expenditures.

Limited evidence on the design and implementation of social protection programmes for people with disabilities in low- and middle-income countries constrains understanding of how their impacts could be improved. The Disability Allowance programme in the Maldives is a non means-tested, monthly cash transfer targeting people with disabilities. Using qualitative methods, process evaluation was used to examine the intervention design, implementation, and likelihood of achieving its intended objectives. There were important strengths of the programme, including the broad definition of disability. We find that delivery could be strengthened through providing greater clarity on eligibility criteria and strengthening human resources to widen the programme’s reach. Intervention fidelity was challenged by inconsistent practice among implementers and lack of established protocols. Most importantly, the absence of linkages with the Medical Welfare scheme that provides assistive devices potentially limits the likelihood of the programme achieving intended objectives.

Addressing the social protection of platform workers, the French legislator in 2016 and then in 2019 made moves to incorporate these workers into the general social security regime with regard to certain covered risks (work injury and occupational diseases), and to improve adequacy (enabling possible access to complementary coverage). However, these moves rest on radically opposed perspectives. Rather than reasserting the legal responsibility of the employer vis-à-vis workers’ health and safety, we see responsibility placed with the platform, but only on a voluntary basis under the aegis of corporate social responsibility. This risks fragmenting social benefits, to be determined by each platform, thus weakening the practices of mutual protection and risk pooling among enterprises and workers that lie at the heart of social security. In doing so, the legislator has broken the link that had as its historic objective the goal of social inclusion and has encouraged in different ways the privatization, or a re-commodification, of social security in the commercial interest of private insurance companies. Moreover, this has been done using the Trojan Horse of the French labour code. This approach is in contrast to the converging position of international organizations, such as the European Union, International Labour Organization or the Organisation for Economic Co-operation and Development, recommending that States establish a right to social protection for all atypical workers and non-salaried workers. Instead of identifying the common challenges that face workers who work for platforms, and offering responses specific to their situation, rather, it considers platform work as one of the new forms of atypical work undertaken by those who may have the status of employee or self-employed.

The right to social security is enshrined in article 23 of the Belgian Constitution. It is the role of the legislator to implement it, to guarantee the right of all to lead a life in accordance with human dignity. Studies show that platform workers face major difficulties in terms of social protection. The aim of this article is to highlight the limits of existing legislative provisions regarding their ability to implement the fundamental right to social security for platform workers. With regard to these legislative provisions, we are interested in both the general regulations that shape the Belgian social security system and the recent measures adopted by the Belgian legislator with regard to the so-called sharing economy. An analysis of these provisions reveals that a number of platform workers are excluded from social security, both de facto and de jure. At the very least, this raises the question of whether the Belgian legislator is complying with the positive obligation to fulfil the constitutional right to social security for platform workers, and the negative obligation, at least, not to undermine it.