Long-Term Care: the All-European Challenge
by Tomáš Szalay & Michaela Laktišová (Health Policy Institute of Slovakia)
There’s a traditional Central European fairy tale. Long before Bismarck, The Three Groschen fairy tale laid out the principles of solidarity. In short, it goes like this…
Once upon a time, a poor man was digging ditches beside the road, when the king himself happened to pass that way and ask him, how much he was paid for such hard work. The answer was – three groschen a day. The king was surprised to hear this and asked him how he could live on three groschen. “
Ah, Your Majesty, if that was all I had to do, it would be easy! But I pay back the first of the three, lend the second and the third is all I have to live of myself,” the digger answered. The king did not understand what he meant, how it was possible to pay back, lend and live on three groschen. He asked for explanation.
“Well, sir,” said the poor man, “it’s like this: I am caring for my father, who is now old and weak. I am paying him back, because he brought me up. But I also have a little son to look after. I am lending him money, so he will pay me back when I grow old. And I myself have to live on the third groschen.”
Three groschen, lending and paying back. For centuries it worked. It’s included in fairy tales. If the family was unable to take care, there was the community and church. But now, we do not have enough children. We do not lend, thus will not get paid back as well. This while we live longer and with the burden of chronic diseases. Most long-term forecasts will never be fulfilled. However, demographic forecasts are of a kind one shouldn’t argue with. We do not question a theoretical threat, but one very concrete, very real and one that’s already here.
The decline in birth rates in Western European countries in the 1970s and 1980s was followed by a similar development in Central and Eastern Europe in the 1990s, after the Fall of the Berlin Wall. The opportunity to travel, do business, realize one’s own dreams, as well as the painful transition to a market economy accompanied by rising unemployment, have led to the postponement of the founding of families. Children have become an obstacle to consuming newly acquired freedom.
The composition of population in the East is therefore relatively favourable now, but the outlook is grim. Let’s take Slovakia as an example: the aged dependency ratio (number of 65+ per productive population 15-64) was 1 per 5 in 2014, but as early as in 2030 it will be 1 per 3. In the European context, this is one of the fastest on-going demographic changes. Over the same period, the EU’s aged dependency ratio will grow at half the pace compared to Slovakia. The country will age absurdly fast, changing from one of the youngest to one of the oldest on the continent in less than two decades.
Ageing population in combination with the 21st century epidemic of chronic diseases means increasing demand for long-term care. And demography has one more negative effect: it reduces the supply of available human workforce, both formal and informal. In the case of informal care, referred to as the back-bone of long-term care, the family's ability to provide self-care will be more and more limited. Declining birth rate reduces the number of potential caregivers within the family. Children are more often living further away from their parents, so they are unable to provide the necessary care on an intensive basis. Alongside this development we are facing a shift in the values of individual societies. Old values are challenged, new ones arise. Our model of family life and the structure of the family is changing.
However, there are lot of regional differences: differences in culture and context, in policies and legislation, in ways of funding or levels of expenditure, even the long-term care definition differs between countries. Thus, there is no universal solution, only country- or region-specific ones.
Countries in Northwest Europe invest more public expenditures in formal care and provide less informal care. Mediterranean countries and Ireland rely on family-based informal care, with low public expenditure and low coverage. And then there are the transition countries in Central and Eastern Europe with a legacy of state welfare regimes replacing family care. It is one of the region’s specifics which makes the situation more severe.
After the Second World War, countries of Central and Eastern Europe have been through the Soviet ideological experiment. Although these countries’ experiences cannot be homogenised, the state paternalism contributed in varying degrees to the erosion of family values, different from the West. The state took responsibility for taking care of old and sick family members, and children as well, so that women could join the labour force. This was the Marxist way to the social emancipation of women. And of course, it had its impact on family life and the availability of informal care.
Typically, long-term care services were concentrated in residential facilities. Institutionalisation of clients isolated them from normal life and further deepened the client’s dependence on formal care. Decline in family involvement lead to today’s ambivalent attitude towards the responsibility for a family member, according to polls.
Western European countries are solving the demand/supply gap of caregivers mainly through care drain. The wage gradient fuels the mobility of health workers from Central and Eastern Europe to the West. Acute hospitals in Bulgaria or Romania lack nurses who are taking care of elderly people in Austria or Germany. There is no common European interest in this area; what prevails are the selfish interests of individual Member States profiting from the healthcare workforce migration. Freedom of movement doesn’t impact only the labour market of skilled professionals and thus the provision of formal care. Working abroad hurts the availability of informal care as well. While trying to reduce economic and social disparities, EU membership is increasing other disparities.
In this context, one sensitive but important issue needs to be mentioned. The European Union is facing an unprecedented migration crisis. While not everyone agrees, migration can be an opportunity. For example, it could help solving the workforce problem of long-term care. Low-paid, low-qualified, unattractive labour might represent an ideal entry-level job for migrants that can help adapting and fitting in the new society. Paradoxically, while the countries of Central and Eastern Europe face the largest demographic challenge and the largest care drain, at the same time they hold strongly anti-immigration attitudes.
Let me wrap up some of the main shortcomings of the current LTC system in Slovakia. There might be an overlap with other countries’ problems:
- Lack of an integrated model for long-term care;
- Strong institutional, organisational, regulatory and financial division of social care and healthcare;
- Lack of a holistic approach;
- Shuffling people reliant on long-term care between the healthcare and social service systems;
- Low level of continuity of care between different providers;
- No coordination among sectors in assisting persons with combined health and social needs;
- Limited or no exchange of care-related data;
- Insufficient support of prevention and rehabilitation aimed at improving a person’s health condition and eliminating dependence;
- Lack of accessible, high-quality and financially-sustainable services for long-term social and healthcare;
- Different financing of care provision in social and in healthcare facilities;
- Insufficient network/coverage of community services, including home care agencies and insufficient financial support for these services from public funds, including public health insurance;
- Lacking or inefficient mechanisms of support of long-term health and social care at home;
- Lack of personnel in both social and healthcare providers;
- Fragmented legislative framework;
- Inconsistency: declaring human rights principles on one hand but failing to create conditions for their practical implementation on the other hand;
- Information asymmetry.
While the borderline between social and health needs of an LTC-eligible individual is blurred, there are strict institutional barriers. Different evolution of health and social systems led to parallel institutions, competencies, budgets or staff. Clients/patients in the transition (grey) zone might not get all the necessary attention and care because of those barriers.
The challenge is how to create a system of long-term care between artificially divided systems of health and social care? How to move from passive and paternalistic social care to motivating and activating social assistance, how to achieve an individual's integration into society, how to get away from fragmented social care to a flexible system of tools that can be effectively combined?
It is a cross-cutting policy issue. Reform of roles and competencies is very demanding. It will hit many stakeholders, distort financial flows, deviate equilibrium of status quo. The change will require a lot of energy, and political goodwill. In the short run of election periods, the costs may seem to outweigh the potential short-time revenue. Facing the rise of populism, politicians would prefer rather symptomatic than causal remedies. Inevitably, solutions have to be complex, deep, multi-level, starting with respect for the elderly and their role in the society.
The demand for long-term care might be reduced through prevention and rehabilitation. Prevention starts with healthy lifestyle and responsibility for one’s own health. The extension or restoration of older people's autonomy and their capacity to live independently has to be part of the policy mix.
Integration of long-term care should deal with both integration of various types of long-term care services and integration with the social system and healthcare system as well. The institutional care and community-based care are not in a mutually exclusive relationship. Adding informal care in the mix, their mutual complementarity should be the desirable goal.
The solution should enable and empower progressive transition from institutional to community and home care. Alternatives to the residential care have to be developed. The public financing mix should be relating to the client, not to institutions.
Incentivisation of informal carers could reduce the pressure on formal care. Technology can contribute to lower workforce demand (just a couple of years ago Japanese robot-carers seemed weird, strange and cold. Now they are considered a real alternative.).
In this article, we were supposed to answer the question why it is important that long-term care is included in the Social Pillar? Just to remind you, principle #18 of the European Pillar of Social Rights says: “Everyone has the right to affordable long-term care services of good quality, in particular home-care and community-based services.” The European Union can not guarantee and enforce such a right without attacking the sovereignty of member states. There are more acute vital problems the EU has to deal with and the legitimacy of the EU role in this agenda is questionable.
Even if the EU would try, harmonization is impossible. There is no one-size-fits-all solution. Contextual and cultural dependencies are crucial for a successful implementation of policies. The principal question of eligibility and entitlement for long-term care is solved differently in different countries. And financing is the crucial issue with any policy implementations.
Quotation of Edison’s scepticism – “Ideas without execution are hallucinations.” – might sound arrogant in this context, but what are we left with? What exactly is the tangible content and consequence of the Social Pillar principle? One has to admit that in the changing world, context and culture evolve as well, and opinions might change. The big picture was drawn above. Demographic changes, epidemiology of chronic diseases will push the demand for long-term care services, and the sustainability of formal and informal care is at risk. Who will physically take care of our parents? And who will take care of us, when we get older? Tangible problems may facilitate changes in the values of the society quite rapidly.
Inclusion of long-term care in the European Pillar of Social Rights might help to prioritize the agenda in Member States. It is necessary to draw attention to a problem that goes beyond political generations. The role of the EU can be in unifying, collecting, sharing and benchmarking relevant data: with different definitions and settings in each Member State, objective comparison is hard. And if you can't measure it, you can't manage it.
Promote social innovations. Share experiences – and not only successful cases, but fails as well. Different paths of divergent systems offer a valuable source of lesson and inspiration. Invite the private sector to help drive the necessary changes. Any solution will be an on-going, perpetual process.
[Tomáš Szalay and Michaela Laktišová are researchers at the Health Policy Institute in Bratislava, Slovakia.]