Long-Term Care Systems: How to Help the Ageing Population

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The number of people in need of long-term care will grow globally due to an ageing population. Russia is no exception. This is why the state is facing the task of creating an effective system of care for people who need it. At a workshop at HSE University, experts discussed how to model such systems and forecast their load.

The HSE Human Capital Multidisciplinary Research Centre held this academic year’s first joint online workshop of the HSE Institute for Social Policy and the World Bank, ‘Modelling a Long-Term Care System: Example of the Republic of Belarus’.

Nithin Umapathi, Senior Economies and head of projects in Social Protection and Jobs at the World Bank, said that an ageing population and growing life expectancy in most countries across the globe demands an increase in the quality of medical care and senior care, which are today mostly organized by families. To reduce the burden on families, it is necessary to develop a sustainable model of a system of care, expanding the role of the private sector and NGOs in such services, as well as developing a system for their assessment. Russia could use the international experience in tackling this.

Oksana Sinyavskaya

Moderator of the workshop, Oksana Sinyavskaya, Deputy Director of the Institute for Social Policy, emphasized that the number of people who need care, including professional care, will continue to grow, which is a new challenge for the care system, since previously, it was mainly families who took care of the elderly. The task of creating a long-term care system is part of Russia’s national ‘Demography’ project, and organsing it is impossible without assessing its effectiveness, as well as demand and budgeting modelling. ‘It is important to look at different approaches, particularly the example of Belarus, which has traditionally been similar to our country in many ways’, she said.

Mitchell Wiener, Senior Specialist for Social Care at World Bank, said that the proportion of people over 70 and 80 who need care is growing globally. The role of states in creating long-term care systems is growing, too. The Belarussian constitution states that families should care for their older relatives, and only seniors without relatives have the right to public support, a situation which creates difficulties for families and has a significant impact on the job market. Data from European Commission reports on population ageing and long-term forecasts have become the methodological foundation for the assessment of potential costs for a long-term care system in Belarus. The authors of the model took into account the number of financially dependent individuals, the proportion of those who had received care at hospitals, benefits for those who receive care at home, age and gender demographics, per capita costs for care at home and at hospitals, as well as the proportion of social benefits in terms of GDP. The forecasts used data from Belstat and local social care bodies.

According to the researchers’ calculations, the number of people who need care will grow from about 590,000 today to 700,000 by 2039, and their share of the total population will also grow. Today, about 30% of those in need get care provided by the state, and in the coming years this number may reach 39%.

Experts form the World Bank have calculated that the cost of long-term care programmes was 0.6% of GDP in Belarus in 2018, and in the coming years it may grow to 0.85% or even higher

For further steps, the experts will need feedback from the government in order to improve the quality of data, clarify the estimated impact of economic changes on the situation, and the death and mean age rates.

Evgeny Yakushev, Head of the Laboratory for Pension System Development, spoke about the development of a similar model for Russia. He mentioned some considerable local differences in terms of the need for care and infrastructural development. In many regions, there are considerable deficits in the care system.

Evgeny Yakushev

HSE experts calculated that the percentage of the population above working age will increase by 17% by 2040, while in certain regions, it may grow by up to 70%. 2,600,000 people is the lower margin of the number of older people who will need long-term care (today, it is 1,500,000). However, this varies considerably by region, and if we merely use average numbers, we risk facing a shortfall in certain locations, Evgeny Yakushev said.

He emphasized that the deficit in self-care in Russia starts at a younger age than in Europe, which means that figures in the forecasts need to be significantly adjusted. Today, 0.28% of GDP is spent on long-term care in Russia, and with the current criteria preserved, this share might grow to 0.62% by 2040. Evgeny Yakushev also mentioned that life expectancy, including healthy life expectancy, largely depends on people’s behaviour, and there is good potential to improve these indicators in Russia.

It should also be noted that between 7 and 8 million people are involved in informal family care for older people, and can spend up to 20 hours a week on it. Family members who are engaged in care are often subject to stress and tend to leave the job market prematurely. Ageing challenges the demand for a transition to a modern long-term care system, Evgeny Yakushev concluded.

Alexander Shkrebelo, executive director of the Association of Long-Term Care Professionals, said that the long-term care system was launched in 2018 in six pilot regions; today, it operates in 24 regions, with about 110,000 individuals using it.

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The work starts from detecting and categorizing those in need and determining the level of their dependence (on a scale of 1 to 5). Then, the form of care and the goals of this care are determined; the family’s support is sought, the volume of medical and social help needed is clarified, and equipment rental stations are organized, as well as education for family members. The volume of help varies depending on the state of the patient’s health and can be increased if this deteriorates.

The level of dependence on other people’s help is assessed according to international standards that take into account acuity of vision and hearing, the ability to dress oneself, cook food and do housework. All elements of the long-term care system are standardized and reflected in regulatory acts.

The most severe (levels 4 and 5) groups include about 12% of all people in need of help. Today, according to Alexander Shkrebelo, the number of those in need of long-term help is fairly stable, but soon, it will grow to 2 million, and then, eventually, to 3 million. He believes that by 2029-2030, the system will be able to replace the ‘shadow’ care sector, and the proportion of in-patient care recipients will grow from the current 18% to 25%.

At the same time, the cost of services is expected to grow: the price of home-care assistance will grow by 50%, and in-patient service by 25%. If private-public partnership mechanisms are used, the prices and budget costs may decrease. There is also a plan to introduce insurance practices into the long-term care system

Yury Voronin, Chief Financial Ombudsman of Russia, believes that the term ‘long-term care’ is not ideal: he suggests replacing it with ‘permanent external care’. ‘I would not flatter ourselves with pilot projects: the problem of our system is that the current methodology was developed by a limited group of people and was never verified’, he said.

Yury Voronin expressed his concern that the development of the care system will start without clear estimations of the number of people in need. He emphasized that health limitations are assessed by institutions which themselves are in need of dramatic improvement and increased funding.

He is also concerned that the time needed for the precise calculation of the number of people requiring care and its level will be lost. ‘We do not know these demographics, and another problem is who will mediate the funding for this care’, the expert said. When the cost of ‘permanent external care’ is calculated, he believes, it makes sense to take into account the employment schedule (which is often 24/7), as well as salaries and social insurance for the staff involved. It is also important to remember that there is a shortage of social care professionals today, and there will be a need to find them on the job market, which has its own specifics. ‘I hope that our concerns will be heard and taken into account in the development of policies in this sphere’, Yury Voronin concluded.

Oksana Sinyavskaya said that the care system is at an evolutionary stage in Russia. Today, the work of social workers at home is limited mostly to social and domestic services, which are not always relevant for people with serious health conditions who require mostly social and medical services.

As the system of care develops, the costs will grow. In order to create a long-term care system, sustainable funding is essential. ‘We need to understand how we will be able to model these sources: through budget funding, insurance payments, or a combination of the two’, said Oksana Sinyavskaya.