Social protection

More long-term care services for the elderly needed in Central-Eastern Europe

ILO study highlights shortage of quality long-term services for older people in the region while a significant number of female migrant workers move to Western Europe to fill existing gaps. We asked Kenichi Hirose, co-author of the research with Zofia Czepulis-Rutkowska, to tell us more about these trends.

Comment | 10 February 2017
ILO News: Your study highlights the considerable challenges faced by countries in Central and Eastern Europe with respect to long-term care of the elderly.
Countries face complex challenges in securing accessible, adequate and sustainable long-term care. Traditionally frail elderly people have been cared for at home by their families and the communities they belong to. However, the intra-family provision of long-term care, relying heavily on unpaid female carers, can no longer effectively support the increasing number of elderly. There is a need for formal long-term care provision.

We noticed shortages in the institutional care and the home-based care settings, as well as unequal access to care if we compare urban and rural areas. There are several reasons for that: integrated long-term care systems are usually missing and there is also a lack of coordination between health care and social services.

Due to the limited capacities of institutional care, many applicants are on a waiting list. This also leads to older people being hospitalized for non-medical reasons.

Also, many countries lack adequate home-based care services, including home visit services, day care or short-stay offers in community-based long-term care facilities. This is a key sector to develop to effectively lift the care burden that is currently imposed on family members.

© Matteo Paciotti
ILO News: Do countries in the region invest enough in long-term care services?
The share of public long-term care expenditure in terms of GDP in Central and Eastern Europe countries is generally less than half of that in OECD countries. It represents 0.7 per cent in the Czech Republic, 0.74 per cent in Poland and 0.53 per cent in Serbia compared to 1.7 per cent in OECD countries.

These figures certainly explain why there is a deficit of quality long-term care services. What’s more, the financing relies mostly on national or local government budgets, which means that it is particularly vulnerable to economic shocks.

ILO News: Could cash allowances be a way to improve the system?
Cash benefits in the form of care allowances do exist in the Czech Republic and Serbia. They are useful in the sense that beneficiaries have the freedom to choose services according to their priorities. However, surveys show that a large part of the allowance is actually used for purposes other than the direct acquisition of care services. Also, even if the care allowance is given to family carers, it is usually not enough to fully compensate family members’ lost opportunity costs, e.g. the return they could have earned by doing something else instead of providing care.

Another hurdle is that these allowances can be severely slashed in times of economic crisis. For instance, the Czech care allowance was cut by 60 per cent in 2011 as part of emergency austerity measures. A proposal to replace cash benefits with service vouchers is being discussed in the Czech Republic and Poland but it has not been implemented yet.

There is also a need to encourage more private sector investment in the care industry. Though the public sector should continue to play a central role in ensuring essential care for all, private providers could get involved in certain areas (such as food delivery and domestic help) under proper regulations and quality control.

ILO News: Many elderly people express their preference for staying at home at a later stage in life. How can home-based care be developed?
Home-based care is not only a preferred option by elderly people. It is also more cost-efficient compared to institutional care. Even if there is still a necessity to invest in public infrastructures, the policy to promote home-based care cannot be successfully realized unless workers are able to manage the conflicts between work and care at home. Countries need to implement a set of flexible workplace measures that would allow for a better work-life balance, such as paid care leave and working time arrangements. 

ILO News: The study also highlights the increasing migration of female care workers from the Ukraine to countries in Western Europe, where there is also a shortage of long-term care workers for the elderly. How significant is this trend?
According to data from the State Statistics Service of Ukraine from 2012 conducted in the framework of an ILO-EU project, the number of Ukrainian migrant care workers working for the elderly - but also, in some cases, for children and persons with disabilities - was estimated at 42,800 which represents 3.6 per cent of all migrant workers from Ukraine. Ninety-five per cent are women. Many of them have higher professional qualifications, which reveals a skills-degrading problem.

The major destination countries were Italy (42 per cent), Poland (21 per cent), the Russian Federation (17 per cent), Spain (13 per cent), Austria and Germany (4 per cent each).

Seventy-five per cent of women surveyed said the low pay in Ukraine was their first motivation for working abroad.

The survey also showed a large majority were employed in households based on an oral agreement. Most care providers were working more than 40 hours per week. Only one-quarter of employment contracts provided overtime pay, although a majority had weekly days off.

Another remarkable trend lies in the fact that almost half of these female migrant workers are married. One consequence is the rise in the number of the so-called “Euro orphans” often left under the care of a single parent, grandparents or with other relatives in the Ukraine. Even though they often enjoy better educational opportunities thanks to remittances sent by their parents, there are many reports of negative impacts on their social and emotional development due to insufficient parental care and supervision.

ILO News: How could the situation of long-term home care workers for the elderly be improved?
As we just saw with the example of Ukrainian migrant workers, many of them are women, going to Western Europe to take care of elderly people, the deficit of care workers goes far beyond Central and Eastern Europe. An ILO study from 2015 showed that there is a global shortfall of at least 13.6 million formally employed long-term care workers, including 2.3 million in Europe.

Care work is characterized by irregular working hours, exposure to high physical and psychological stress and the risk of work accidents. Salaries are usually lower than in other related sectors with poor working conditions resulting in high turnover.

So working conditions for care workers should definitely be improved to fill the gaps in these urgently needed services. Because of these poor working conditions, informal employment has developed, which also means less or no protection in terms of labour rights and social security coverage.

ILO News: What steps should countries take to provide better long-term care?
Taking into account profound demographic changes due to population ageing, long-term care is emerging as a global concern for the elderly and their families. Countries need to improve their institutional care infrastructure and develop the mechanisms to support home-based care. For this, they should take the necessary steps to mobilize resources to enhance the financing structure of long-term care systems.

In line with its rights-based approach, the ILO should play a proactive role and support national efforts to establish universal long-term care systems as integral parts of comprehensive social protection systems. The ILO Social Protection Floors Recommendation, 2012 (No 202) can be particularly useful in that respect.