LTCcovid Country Profiles

Responses to 1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science.

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.


About this question

Contributors: Joanna Marczak, Ellen Kuhlmann


Introduction: Who are LTC workers, where and how are they employed?

The LTC workforce includes specialized professionals (geriatricians, nurse case management workers, physiotherapists) as well as so-called low skilled care workers. In various countries, the latter group can make up, up to 70% of the LTC workforce responsible for helping older people with activities of daily living (ADLs) (OECD, 2020).

LTC workers are predominantly women and overall, the LTC workforce is ageing itself: in the EU in 2016, the median age of  workers in the sector was 45; in 2019 the share of employees aged 50 or over was close to 38 %. Where data is available it indicates that larger portions of the workforce are working in institutional settings. This reflects a lack of visibility of home care workers but also the distinction between formal and informal workers (source: WHO 2019 LTC report; 2021 Long-term care in the EU). Across the OECD, about 45% of LTC workers are in part-time employment and need to work in multiple jobs (OECD, 2020).

Challenges with attracting workers into LTC sector

Various sources provide a long list of reasons behind the current shortages of LTC Workforce and highlight challenges with future recruitment. For example, an OECD 2020 report  notes lack of professionalisation, limited career opportunities, limited support for training, as exacerbating the workforce shortages  (OECD, 2020).

Similarly, a WHO report quotes low wages and limited training relative to the health workforce, stress, onerous working conditions and a heavy workload that does not reflect their training, all make it hard to attract and retain people in the LTC sector. The report highlights that comprehensive and wide ranging set of  policies are needed to ensure a sustainable supply of LTC workers.

Workforce shortages

Workforce shortages are prominent in countries included in this report, and OECD as well as EU data indicate that most countries around the world are facing LTC staff shortages, although some (e.g. Eastern and Southern European region) more severely than others (e.g.  Nordic countries in Europe). Moreover, at the current pace of an ageing population, it is estimated that the need for LTC workers will need to increase by 40 – 100% just to maintain the current staff ratios, which are already often considered to be insufficient (OECD, 2020).

Migrant care workforce

An explorative comparative study into the situation of migrant carers and COVID-19 health workforce policies in selected EU countries (Kuhlmann et al., 2020) revealed that undersupply of carers coupled with cash-benefits and a culture of family responsibility may result in high inflows of migrant carers, who are channelled in low-level positions or the informal care sector. The sending countries are characterised by very low expenditure and density of LTC care together with strong family subsidiarity and a marginal role of LTC in the wider healthcare system. Consequently, the LTC workforce is poorly developed precisely in those countries, showing the strongest outflows of carers. Inter-governmental labour market arrangements on LTC migrant care may often reduce costs in high income countries, but they are threatening the aim of universal healthcare coverage in the sending countries and hamper the development of a sustainable LTC sector (copied from Kuhlmann et a., 2020).

Covid-19 made the fragile labour market arrangements of migrant carers visible, which may create new health risks for both the individual carer and the population. Country case studies further illustrate the new threats and challenges (examples below copied from Kuhlmann et al., 2020). The pandemic increases the risk of infection for the individual carer if travelling in times of lockdown, coupled with the risk of losing one’s job and income if travel is not permitted. It threatens the healthcare systems of the sending country, which is losing carers in a situation of a pandemic, when they are needed the most; and it threatens the provision of care in the destination country, as access and quality of care may worsen if borders are closed and the mobile carers have left. The pandemic has enhanced a debate over problematic global ‘production chains’ based on cheap labour and a lack of sustainability in European countries, especially in relation to medical protection material. However, very little attention has been paid so far to the ‘global care chains’ and the human resources for health involved in these chains. Finally, from a public health and system perspective, enhancing the mobility of carers through cross-border arrangements during a pandemic is highly problematic and may increase health risks and new outbreaks.

Two important policy recommendations are emerging:

  • – to include LTC migrant carers more systematically in public health and health workforce research and
  • – to develop European health workforce governance which connects health system needs, health labour markets and the needs of the individual migrant carers.

Kuhlmann E, Falkenbach M, Klasa K, Pavolini E, Ungureanu M. Migrant carers in Europe in times of Covid-19: a call to action for public health-informed European health workforce governance, European Journal of Public Health, 2020;30(Suppl. 4):iv22-iv27; DOI:10.1093/eurpub/ckaa126

OECD (2020), Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Health Policy Studies, OECD Publishing, Paris,

International reports and sources

There are a number of useful reports that discuss LTC workforce in different countries, including the following:

OECD 2020. Who Cares? Attracting and Retaining Care Workers for the Elderly

OECD Library_LTC workers

WHO 2019. Integrated Delivery of Long-Term Care

2021 Long-term care in the EU

In 2016, there are 366,000 paid workers (84%) and 68,000 volunteers (16%) delivering aged care. 66% of the paid workers were in direct care roles, including nurses and personal care workers (source: Care, Dignity and Respect report).

Australia has trained and supervises care workers to assist nurses with medicine management. Self-managed teams to give workers more flexibility and control have been shown to boost job satisfaction and reduce turnover (source: OECD).

Last updated: February 15th, 2022

In Austria more than 66,000 personal carers (mostly migrants from neighbouring countries) provide live-in care to around 33,000. About 47,100 staff provide care to care home residents and 18,300 provide home-based care. The share of social care staff who are migrants from neighbouring (Eastern European) countries has increased in recent years. These workers are registered as self-employed, but in practice they are dependent on brokering agencies in their home countries and have precarious working conditions as well as few entitlements to social protection and labour rights. The majority of these workers are women and work in alternate rotas of two weeks or a month (Leichsenring et al. 2021; Leiblfinger, M. at al. 2020).


Leichsenring, K., Schmidt, A.,  Staflinger, H. (2021) ‘Fractures in the Austrian Model of Long-Term Care: What are the Lessons from the First Wave of the COVID-19 Pandemic?’  Journal of Long-Term Care,  pp. 33–42. DOI:

Leiblfinger, M. at al. (2020) ‘Impact of COVID-19 Policy Responses on Live-In Care Workers in Austria, Germany, and Switzerland’ Journal of
Long-Term Care, (2020), pp. 144–150. DOI:

Last updated: February 2nd, 2022

In Belgium, the Wallonia region allows personal care workers to perform nursing tasks when no other care options are available (OECD, 2020).


OECD (2020) Who Cares? Attracting and Retaining Care Workers for the Elderly

Last updated: February 3rd, 2022

Bulgaria established excellence programmes in LTC for nurses (OECD, 2020). However, the country, alongside other Eastern European countries, experiences so called  “care drain’ where many LTC workers moved to work in other EU countries, mostly because of better salaries and better working conditions (European Commission, 2021).


OECD (2020) Who Cares? Attracting and Retaining Care Workers for the Elderly

European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Last updated: February 3rd, 2022

Majority of LTC and AL health care workers in BC are represented by a union, the largest being The Hospital Employers Union (HEU) (source:

Normally, to become a health care assistant, one must complete six to eight months of post-secondary education at their own expense before applying for a position. Due to staffing shortages during COVID-19, BC has launched the subsidized Career Access Program, a sponsorship program where individuals will work as a health support worker while training to become a health care assistant. Applications for the program began in early 2021 (source:;


Last updated: February 11th, 2022

Focussing on Ontario, a published article traces the antecedents of the COVID-19 crisis in long-term care and documents experiences of frontline staff and family members of residents during the pandemic. They argue that the marginalization of both residents and workers in Ontario’s long-term care system over two decades has eroded possibilities for recognition of their personhood. They also question broader societal attitudes toward aging, disability, and death that make possible the abandonment of the frail elderly (Badone, 2021).


Badone, E. (2021). From Cruddiness to Catastrophe: COVID-19 and Long-term Care in Ontario. Medical Anthropology: Cross Cultural Studies in Health and Illness40(5), 389–403.

Last updated: February 11th, 2022   Contributors: William Byrd  |  

Social and Health Care Helpers and Assistants represent most of the long-term care workforce. The Social Care and Health Helper education has a duration of 2 years and 2 months and is focused mainly on tasks related to support with personal care and hygiene as well as household chores. It includes a 20-week introductory basic course. The remainder of the program is a mix of practical training periods and school study. The Social and Health Care Assistant education is a separate education with authorisation which takes 3 years and 10 months, and is focused on the provision of personal care, health promotion, prevention and nursing functions. The Social and Health Care Assistant training is a mix of practical training periods and school study.

In recent years especially the Health and Social Care assistants have been favoured in the sector, not least since the work tasks have become more medicalized. The aim is that all persons working with care should have taken at least the basic qualification program of a Social and Health Care Helper.  Overall, however, the proportion of social and health care staff in LTC without formal qualification has gone up from 13 percent in 2017 to 22 percent in 2021 (FOA, 2021).

While the number of personnel has stagnated or sometimes declined in most residential settings, there has been an increase by almost 10% of staff in employed in home help, following the increase in number of older people in the population. Moreover, between 2005-2015 the number of staff working part time increased (OECD, 2020).

With the introduction of reablement, it is required even more today that care workers in home care work in cross-disciplinary teams when planning and delivering services. Care workers most often work with occupational therapists in reablement services (Rostgaard and Graff, 2016). In accordance, physiotherapists and occupational therapists have increased in numbers during the past decade.

Special assessors are in charge of the assessment of need. This profession was set up in the early 1990s, in order to professionalize and improve the quality of the needs assessment, which was formerly carried out by home helpers. Assessors as a minimum receive a 2 weeks course in assessment. Many of these have worked as home helpers before and often have experience in the field, e.g. a survey carried out in 2007 showed that care assessors on average had worked within the care sector for 3.5 years (Rostgaard, 2007).

As care needs of nursing home residents and home care recipients have increased, staff in both sectors have experienced an increase in health, and nursing-related tasks. LTC workforce also reported higher work intensity (WHO, 2019). The poor working conditions in the sector are well documented as are the problems of recruitment and retainment (eg Rostgaard and Matthiessen, 2016). These problems are also acknowledged in the preparatory work behind the new Senior Citizens’ Act (Social- og Ældreministeriwewt, 2022).


FOA (2021) tor stigning I antallet af ufaglærte I ældreplejen fra 2017 til 2021. Copenhagen: FOA.

OECD (2020) Who Cares? Attracting and Retaining Care Workers for the Elderly

Rostgaard T. (2014) Nordic care and care work in the public service model of Denmark: ideational factors of change. In: Leon M, editor. The transformation of care in European societies. London: Palgrave Macmillan; 2014:182–207.

Rostgaard, T. og Graff, L. (2016) Hænderne i lommen – Borger og medarbejders sam-spil og samarbejde i rehabilitering. Rapport. København: KORA.

Rostgaard T., and Matthiessen U. (2016) Arbejdsvilkår i ældreplejen: mere dokumentation og mindre tid til social omsorg [Working conditions in care for older people: more documentation and less time for social care]. Copenhagen: VIVE – the Danish Centre for Social Science Research; 2016 (KORA Report, No. 28; https://, accessed 20 November 2019).

Rostgaard, T. (2007) Begreber om kvalitet i ældreplejen. Temaer, roller og relationer, Socialforskningsinstituttet 07:13. København: Socialforskningsinstituttet.

Social- og Ældreministeriet (2022) Afrapportering: En ældrepleje med tid til omsorg,

WHO (2019), Denmark: Country case study on the integrated delivery of long-term care. Accessed at:

Last updated: June 28th, 2023

Municipal outsourcing to the private and for-profit sector for provision of sheltered, round-the-clock LTC has significantly increased over the past decade; in recent years, reports of insufficient care and serious maltreatment in these spaces have been met with public outcry for their review. The Act on care services for older people is thus under reform and a minimum number (0.7) of nurses per clients will be required by April 2023. Municipalities appear to be struggling to maintain/keep up with growing need for more formal care services. Additionally, with the population aging and working-age population decreasing, there is a growing concern about the shortage of employees in LTC services (Forma et al., 2020).


Forma, L., Aaltonen, M., Pulkki, J. (2020). ‘COVID-19 and clients of long-term care in Finland- impact and measures to control the virus’, LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 12 June 2020. Retrieved from: Finland:

Last updated: February 10th, 2022

France reported to OECD that it increased wages in LTC and that this was associated with greater recruitment of workers, longer tenure and lower turnover. However, wage increases need to be financed and regulated. Otherwise, wage increases that are not matched by increases in resources lead to increased workload and duties. One-third of institution-based LTC workers were temporary agency workers (source:

The distribution of different workforce roles is as follows:  domiciliary care nurses (SSIAD), 117 093 in 2014; domiciliary care workers, registered with NFPs and public organisations, around 535 000 in 2011; private companies for domiciliary care employ approximately 4% of the workforce. There has been limited success with attempts at professionalisation to improve quality in delivery. There was no increase in staff to resident ratios in care homes between 2011-15 despite increase in demand. Diplomas have been developed over the years, and 62% of workforce has some level of qualification, but despite these workers report low levels of satisfaction and there are frequent strikes. Only 30% of the workforce is employed full-time and wages are low in the sector (c.882€/month, which is equivalent to minimum wage) (source:

Due to the limited attractiveness of the sector, especially in domiciliary care, 20% of demand for places could not be fully allocated in 2019, 25% of businesses have recorded a decrease in the number of supported places, and over 30% of directors of domiciliary care agencies have highlighted lack of staff as a direct cause of place refusals, moreover, 80% of directors think the situation is worsening. The existence of nursing roles in domiciliary care is an additional pressure, as the gap between pay has doubled (200€) (source:

Last updated: January 6th, 2022


The average gross salary of LTC workers per month in Germany (in 2019) ranged between €2146-3032. Average income depended on the level of qualification and sector. Wage rates among those providing home care, on average, appeared to be slightly lower (€2039-2721) than among those working in residential care (€2182- 3099).

Even though salaries in the sector have increased by 28% since 2021, in comparison to the median salary of hospital nurses, LTC workers earn considerably less (Milstein, Mueller & Lorenzoni, 2021). Rothgang, Müller and Preuß (2020) investigated LTC workers’ income satisfaction. They found that the share of LTC workers who are unhappy with their incomes (almost half) is higher than among employees in other jobs (less than 30%). Among people working in care, 53% report having difficulty to live off their income. Among LTC workers, 52% think that their retirement pay will not be sufficient.

Employment conditions

Working conditions are considered poor, especially given the wages and social standing are low, while working hours are unfavourable and physical and psychological strain is high (Lückenbach et al., 2021).

A study found that in comparison with other jobs psychological burden of LTC workers was higher in a number the aspects compared. The report also showed that while the majority of care workers felt their job was important, only 53% of care workers reported that they felt their work was socially recognized (Rothgang, Müller & Preuß, 2020).

Qualification levels

By law, 50% of residential care workers are required to be trained as skilled workers. This requirement, however, is not always met. From March to October 2020 quality controls were suspended during the pandemic to relieve the burden on domiciliary and residential care (Bundesministerium für Gesundheit, 2020; Medizinischer Dienst, 2020).


LTC workforce shortage is one of the main concerns. Projections estimated that Germany will have a shortage of 263,000 full time care workers by 2030 (Lückenbach et al., 2021). In response to this shortage, the Care Staff Strengthening Act created posts for 13,000 additional care workers in residential care. Furthermore, the framework of the ‘Act to Improve Healthcare and Nursing’ secured funding for 20,000 additional nursing assistant positions (European Commission 2021). In addition, efforts to co-operate with countries, especially Mexico, the Philippines and Kosovo, have been made around improving vocational training and recruiting LTC workers (European Commission, 2021).

However, the creation of these additional 13,000 care workers in residential care settings has been criticised as too low and efforts to make jobs more attractive through pay increase have been insufficient to attract people. This law was prepared in 2018 and came into effect in large parts in 2019 (VDEK, 2021).

A 2020 report on care (Barmer Pflegebericht) found that, due to insufficient staffing levels, care workers had to work more overtime, duty rosters couldn’t be adhered to and care workers were called in when they were on leave (Rothgang, Müller & Preuß, 2020)..

A report by the Bertelsmann Stiftung found that future availability of workforce is likely to differ across the country. In most local authority areas and districts in Eastern Germany an increasing number of people with care needs is unlikely to be met by decreasing number of care workers. Challenges were also identified for Bavaria and Schleswig-Holstein, while parts of Westphalia, Hessen and Baden-Württemberg do not expect to experience the same challenges (Hackmann et al., 2016).

Policies to address these issues

On 2 June 2021 the German government passed a new care reform (Pflegereform 2021) that sets out that all LTC workers in care homes need to pay their staff according to a tariff. It is also planned that care homes will be able to recruit more staff. This should be enabled through national guidelines. The reform also plans to provide LTC workers with more responsibility to make independent decision as part of domiciliary care. These changes are scheduled to come to effect in September 2022 (Bundesministerium für Gesundheit (Bundesministerium für Gesundheit, 2021).


European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission ( (Accessed 4 February 2022).

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. Available at: (Accessed 31 January 2022)

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. License: CC BY-NC-SA 3.0 IGO

Rothgang,H. Müller, R. & Preuß, B. (2020) Barmer Pflegereport 2020 – Belastungen der Pflegekräfte und ihre Folgen. BARMER: Berlin. Available at: (Accessed 2 February 2022).

VDEK (2021) Gesetzgebungsverfahren der deutschen Gesundheitspolitik: 2017-2021. Aavailable at: (Accessed 2 February 2022).

Last updated: March 11th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Israel holds a significantly higher ratio of LTC providers to older population compared to other countries, with 11.1 LTC

Israel holds a significantly higher ratio of LTC providers to the older population compared to other countries, with 11.1 LTC workers available per 100 people aged 65+ (e.g. the UK’s ratio is 3.3 for every 100) (source: OECD).

Israel is listed as a country that subsidizes education to attract people into LTC training, including the provision of scholarships for nurses specializing in geriatric care (source: OECD).

Personal, at-home caregivers make up approximately 90% of the LTC workforce in Israel, with the majority of around-the-clock workers consisting of migrants from Southeast Asia (70,00 migrant care workers are currently hosted by Israel, nearly 40% of whom are from the Philippines) who are contracted out to LTC users through agencies (source: OECDAdva). At-home care workers in Israel are granted certain rights (e.g. a separate and private room in the employer’s (user’s) home, weekly vacation days, and 2-hour rest periods). The hourly wage set for long-term care workers by the National Insurance is the minimum hourly wage; caregivers often hold multiple jobs and live on the poverty line. Those with valid work visas are provided with limited health insurance (source: Attal et al, 2020).

Though standards for medical service delivery are particularly high and demanding, Israel’s required training qualifications for long-term caregivers in the community are amongst the lowest among OECD countries (source: Bank of Israel). Digital aids assist personal care workers in performing tasks such as taking a care recipient’s temperature or blood pressure (source: OECD).

Last updated: January 6th, 2022

A recent report from Amnesty International (2021) on health and care workers in Italy found that:

  • 85% of care workers are women, 12% are migrant;
  • Wages in LTC services are lower than those of the NHS
  • The care worker/person aged 65+ ratio is among the lowest in the OECD area: 2 care workers per 100 persons 65+ vs 5 care workers per 100 persons 65+

Moreover, as other countries, Italy is experiencing a shortage of nurses: trade unions claim that healthcare and LTC services are lacking 60.000 FTE nurses. The pandemic experience showed that LTC services are seen as a transitory moment of one’s own career, since many professionals apply to move to the NHS at the first opportunity.

The estimated 1 million informal and migrant care workers are important in providing private home care, but it is estimated that only 40% are employed under a regular employment contracts. The trend to rely on home-based migrant carers has been supported by different policy measures (at local, regional and national level), including training and accreditation programmes for informal and migrant carers, regular contracts for the latter have also been promoted by policy makers  (Barbarella et al. 2018).


Amnesty International (2021) Muzzled and unheard in the pandemic: Urgent need to address concerns of care and health care workers in Italy. Retrieved from EUR30/4875/202

Barbarella F, Casanova G, Chiatti C and Lamura G (2018), ‘Italy: emerging policy developments in the long-term care sector’. CEQUA LTC network report. Retrieved from Italy Country Report

Federazione Nazionale Ordini delle Professioni Infermieristiche. (2021) Vaccinazioni, FNOPI: “oltre 60mila infermieri liberi professionisti sono pronti, ma per loro sono indispensabili maggiori tutele”.

Last updated: February 4th, 2022   Contributors: Elisabetta Notarnicola  |  Eleonora Perobelli  |  

In 2017 there were 5.9 formal LTC workers per 100 older adult population. It is estimated that by 2025 Japan will have a shortage of 380,000 LTC workers.  The country experiences severe and widespread staff shortages and high staff turnover which stem from a number of factors, including: a combination of high requirements for qualifications and low pay compared to other sectors (e.g. retail); low status; very low immigration (Curry et al, 2018;

Care workers are required to hold a qualification earned by sitting a formal examination at worker’s own expense. Providers are required to observe strictly-enforced rules around staff to service user ratios (Ikegami, 2007).

Japan has sponsored basic training programmes for both new students and experienced workers willing to return to work after a long break. These initiatives led to an increase in the number of LTC workers of around 20% between 2011 and 2015. The country also provides scholarships for nurses specialising in geriatric care. Japan has workplace counselling services to promote prevention of accidents and burnout (OECD 2020. Who Cares? Attracting and Retaining Care Workers for the Elderly).


Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from:

Ikegami, N. (2007). ‘Rationale, Design and Sustainability of Long-Term Care Insurance in Japan – In Retrospect’ Social Policy and Society 6(03):423 – 434

Last updated: February 10th, 2022

In 2018, there were 10.7 FT LTC staff per 100 people aged 65 and over, one of the highest in the EU. Wages in the LTC sector are very attractive, especially for commuters from the neighbouring countries. Provides recruit about 45% of their workforce from outside the country, mostly commuters from France, Belgium, and Germany, even though language barriers can be problematic (source: European Commission: 2021 Long-term care in the EU.

Last updated: February 10th, 2022

The government provides subsidies for people wishing to go into LTC training. Dual career track is available for nurses working in general care and geriatrics. The country has developed stress management/coaching programmes on healthier work environment and prevention of work-place accidents for LTC centres to help decrease absenteeism (OECD, 2020).


OECD (2020) Who carers? Attracting and Retaining Care Workers for the Elderly.

Last updated: February 1st, 2022

The Norwegian Men in Health Recruitment Programme was set up to recruit (unemployed) men aged 26-55 to the health and care sector. It entails eight weeks of guided training as health recruits in a regional health institution or health care service. The Programme has been very effective in the Norwegian context to motivate employment of men in LTC sector. A new nationwide strategy has been introduced to improve the digital skills of care workers during initial education (source: OECD: Who Cares? Attracting and Retaining Care Workers for the Elderly).

Last updated: February 10th, 2022

LTC employment is low compared to other EU countries, namely in 2016 there were 0.5 LTC workers per 100 older people (EU-27 average was 3.8). There are inequalities in working conditions and wages between the healthcare and the social sector. The number of carers is increasing, however the country is experiencing ageing of LTC staff will put additional pressure on ensuring adequate staffing levels (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

In 2018, there were 3.9 Formal LTC workers per 100 older adult population. Ninety percent of workforce is personal support workforce. LTC facilities in Korea have mandated staff to resident ratios and a national curriculum of minimum requirements for LTC workers has been established whereby care workers must pass certificate tests. Training and career development options are available for care workers in the form of modular training (sources: who-cares-attracting-and-retaining-elderly-care-workers;; COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: January 6th, 2022

With 1 LTC worker per 100 older people in 2016, compared to 3.8 for the EU-27 average, Romania is among the countries with the lowest number. This situation is partly attributed to Romanian nationals migrating to work in health and social care sectors in the neighbouring, more affluent EU countries. Romania is among the top 20 countries to provide LTC workforce to OECD countries, e.g. Romanian nurses account for half of all foreign trained nurses in Italy. The COVID-19 pandemic may reverse the trend to some extent, increasing the availability of the LTC workforce, due to higher unemployment in the country (hence more people available to work in LTC sector) as well as returned migration during pandemic (source: European Commission: 2021 Long-term care in the EU).

Last updated: February 10th, 2022

The country operates with shortages of workers in LTC sector, which poses challenges to staffing facilities (source: Responding to COVID-19 in Residential Care: The Singapore Experience – Resources to support community and institutional Long-Term Care responses to COVID-19 (

Last updated: January 6th, 2022

The number of LTC workers per 100 people aged 65 and over is 1.5 worker, which constitutes less than half the EU-27 average. Care provided by family members is the main form of LTC in Slovakia.  More than 90 % of the total LTC workforce in 2016 were women. The majority of LTC workers have a medium level, non-tertiary education. Non-standard employment is not very widespread e.g. the share of temporary employment is less than 10 %, whilst shift work is less than 40 %, far below the EU-27 average (European Commission, 2021).


European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union

Last updated: February 4th, 2022

South Africa has National Norms and Standards (2008) that outline acceptable levels of service to be provided to older people. Recent audits have found many facilities in partial non-compliance. In addition, informal racially discriminatory practices were observed in some facilities, both in terms of admissions and quality of care.

In line with global trends, concerns have been raised about the rapidly increasing aging population in South Africa and the ability of the current healthcare system to keep pace with patient demand, particularly nursing home residents. Evidence suggests that the current workforce in South Africa receive limited training in this area and are largely unprepared to meet the demands of the aging population. Building the capacity and skills of the workforce in South Africa is one approach that could help to improve the early detection of infection and assist the nursing home workforce to provide more effective and timely care, particularly during the current COVID-19 pandemic.

A published paper suggests that decision support tools, such as the Early Detection of Infection Scale, can help ensure consistency and ensure more timely treatment, minimising unplanned admissions and healthcare expenditure. However, the potential benefits or indeed how easily this could be integrated in to nursing homes in South Africa is unknown.


Carey, N., Boersema, G. C., & du Toit, H. S. (2021). Improving early detection of infection in nursing home residents in South Africa. International Journal of Africa Nursing Sciences14.

Last updated: January 6th, 2022   Contributors: William Byrd  |  

Low public spending on LTC, is related to low wages in the sector, for example, the monthly cost per LTC employee is 67% of the average wage in Spain. Poor working conditions are the norm in a sector where women are the majority. In care homes, staff ratios vary markedly between regions and are generally inadequate (Zalakain et al. 2020).

A mostly female and migrant workforce

In 2020 there were 684,949 people working in social care (based on data from the EPA survey), representing 3.7% of the total number of employed persons in Spain. 66.3% of social care workers were employed in private households, either as home carers (17.7%) or as domestic workers (82.3%). Carers working in care homes represented 19.9% of the total care workforce (most them  employed as nursing assistants), and carers in social services without accommodation (mostly home help services, usually referred to as SAD) represent 13.9% of the care workforce.

In all occupations women exceed 90% of the workforce, specially among domestic services, where 98.3% are female. Migrant workers represent 62.2% of domestic workers, 49.2% of home carers and 25.6% of nursing assistants (Roca et al., 2021).

Improving the working conditions of female workers is essential to ensure the quality of care. This is no a homogenous sector since it is very different to work in a care home, in a Home Help Service [SAD], or as a home and care worker (Martínez-Buján, 2011; Moré, 2015; Roca, 2017). But there are some common characteristics among care workers since they all share precarious working conditions. They also share that they are feminized and poorly qualified jobs, converted into a labour niche for foreign migrants with little recognition. Domestic workers have the worst working conditions and suffer from an evident lack of rights (Comas-d’Argemir and Martínez-Buján, 2021).

Female care workers face various obstacles to professionalization. One of them is related to the persistence of a family model of care that links care to the home (preference to grow old at home), where an individualizing logic predominates and where the figure of the family caregiver extends into that of the paid caregiver (Moreno-Colom et al., 2016). The other obstacle is that little or no qualifications are required to do this job, based on the naturalisation of expertise considered unique to women, which justifies the low salaries (Recio Cáceres et al., 2015). That weakens the capacity for collective action and increases the insecurity and vulnerability of these workers (Cañada, 2021). Job insecurity is the enemy of quality care. Low wages, part-time work and temporary employment generate a high turnover of female workers, especially the youngest, who can access more qualified qualifications and easily leave the sector searching for better-paid jobs. Or they go to the health sector, where there are better salaries. The lack of specific training to treat certain pathologies also affects the quality of care (Comas-d’Argemir and Martínez-Buján, 2021). The dichotomy is clear: either the costs of care are assumed socially so that it is carried out in decent conditions, or women continue to be exploited, either as unpaid family caregivers or as cheap labour. That is the current model in the Spanish context (Comas-d’Argemir and Martínez-Buján, 2021).


Cañada, Ernest (2021) Cuidadoras. Historias de trabajadoras del hogar, del servicio de atención domiciliaria y de residencias, Barcelona, Icaria.

Comas-d’Argemir, Dolors y Martínez-Buján, Raquel (2021), Hacia un modelo alternativo de cuidados, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas.

Martínez-Buján, Raquel (2011) La reorganización de los cuidados familiares en un contexto de migración internacional, Cuadernos de Relaciones Laborales, 29, 1, 93–123.

Moré, Paloma (2015) Cuidados a personas mayores en Madrid y París: la trastienda de la investigación, Sociología del Trabajo, 84, 85-105.

Moreno-Colom, Sara; Recio Cáceres, Carolina; Borràs Català, Vincent y Torns Martín, Teresa (2016) Significados e imaginarios de los cuidados de larga duración en España. Una aproximación cualitativa desde el discurso de las cuidadoras, Papeles del CEIC, 145, 1-28.

Roca, Mireia (2017): Tensiones y ambivalencias durante el trabajo de cuidados. Estudio de caso de un Servicio de Ayuda a Domicilio en la provincia de Barcelona, Cuadernos de Relaciones Laborales, 35, 2, 371-391.

Roca, Mireia, Bañéz, Tomasa y Hernández, Ana Lucía (2021), Trabajadoras en servicios de cuidado. Servicios sociales básicos, centros de día, asistencia domiciliaria y asistencia personal, en Comas-d’Argemir, Dolors y Bofill-Poch, Sílvia (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españ

Recio Cáceres, Carolina; Moreno-Colom, Sara; Borràs Català, Vincent y Torns Martín, Teresa (2015) La profesionalización del sector de los cuidados, Zerbitzuan, 60, 179-193.

Zalakain, J. Davey, V. & Suárez-González, A. (2020). ‘The COVID-19 on users of Long-Term Care services in Spain’. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Last updated: March 10th, 2022   Contributors: Joanna Marczak  |  Carlos Chirinos  |  

Most family caregivers are left to provide support with little or no guidance on how to address complex issues that sometimes arise. Dementia is a key example: few caregivers understand the nature of the condition, the ways it can influence behaviour and what responses can ease the burden and enhance the lives of care recipients. Unpaid family caregivers also pay a price in terms of foregone education and/or income-earning opportunities. Study findings further highlight adverse effects on caregivers’ physical health, including fewer opportunities for self-care, and their mental health, including depression. Some evidence documents the considerable financial costs of caregiving borne by families, particularly in households with dependent children (source:

Last updated: January 6th, 2022

Organisational reforms aiming to contain costs and increase efficiency introduced since the 1980s have involved the introduction of market oriented models that have resulted in worsening working conditions (Szebehely, 2020 and Strandell, 2019). Approximately 25% of LTC workers are employed by the hour and, of those who work in care homes, one in five lack formal training (Szebehely, 2020).

There are roughly 17,000 registered nurses in social care in Sweden, and about 200,000 care workers (assistant nurses/ care aids). Around 60% of this workforce work in care homes; on average, there are 0.4 registered nurses and three care workers for each ten residents (Szebehely, 2020).

A study analysing changes in the job content and working conditions of Swedish home care workers between 2005 and 2015 found that working conditions worsened during that period, with respondents in 2015 reporting higher workloads (both in intensity of tasks and number of clients per day), less support from supervisors, less interactions with colleagues and less scope to plan their daily work. They also reported being more mentally exhausted (Strandell, 2019).


Strandell R. (2019) Care workers under pressure – A comparison of the work situation in Swedish home care 2005 and 2015. Health and Social Care in the Community 28(1): 137-147.

Szebehely M (2020) The impact of COVID-19 on long-term care in Sweden., Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.



Last updated: February 13th, 2022

In general, care for older persons in Thailand is provided by informal caregivers. After informal caregivers, volunteers are the next most important group providing LTC, Volunteers are usually officially trained in the basics of caring for older persons. Although they work without pay, those who volunteer for government projects receive transport allowances. The roughly 1 million village health volunteers (VHVs) in
Thailand play an important role in the country’s care system, but they do not have any specific responsibility or training for LTC.

The two main government programs that utilize volunteer caregivers are: 1) the Home Care Volunteers for the Elderly (HCVE); 2) the Community-Based Long-Term Care Program, under the National Health Security Office (NHSO), which uses volunteer caregivers in
about 75% of the participating districts and paid caregivers in the other 25%. The HCVE volunteers are trained for 3 days, for a total of 18 hours, in basic personal care of older persons, the role of the volunteer, welfare and social services for older persons, and health promotion for older persons. The caregivers involved in the Community- Based Long-Term Care Program receive 70 hours of training whether they are
volunteers or paid caregivers.

Professional care personnel  encompasses professionals who work in the health and social professions, including doctors, nurses,  physiotherapists, occupational therapists, and other health personnel who receive payment for the provision of care services.

Nonprofessional care personnel encompasses people who actually provide private care for older persons, especially at home and in the community. They do not necessarily have formal training, but use past experience in caring for their own family members or their own knowledge and skills to provide care for others. This group includes care assistants, trained paid caregivers, untrained paid care givers, domestic workers (source: Country Diagnostic Study on Long-Term Care in Thailand (

Last updated: January 6th, 2022

When LTC is provided formally within care settings, women remain the primary providers. With low female labour participation rates, LTC is seen as a potentially suitable sector to enhance women’s training and employability. Recent evidence highlights the role of informally employed domestic and migrant live-in care workers to provide LTC at home when the family cannot meet such needs, funded either through cash-for care schemes or out-of-pocket by the private households (source:

Last updated: January 6th, 2022


Currently, there is no national workforce strategy for the adult social care workforce – the last strategy was published by government over a decade ago in 2009. Proposals on workforce reforms are expected to be outlined in two forthcoming white papers, on adult social care reform and health and social care integration, respectively (Source: Build Back Better: Our Plan for Health and Social Care).

Social care vacancies

On average in 2020/21, 6.8% of posts were vacant in the English social care sector, equivalent to 105,000 at any one time (Skill for Care, 2021). Overall, data indicate that the staff vacancy rate in social care in  2020/21 was much higher compared to 2014/15 and that pay could be a factor, as although pay has increased in the same period of time, the increase has not kept pace with other sectors (Bottery et al., 2022).

Working conditions and pay

Data indicate that the sector suffers from high staff turnover, poor working terms and conditions, and 24% of the workforce are on zero-hours contracts. Pay levels are low compared to other competing sectors such as retail and hospitality. The national minimum wage has increased in recent years and is set to rise to £9.50 per hour as of April 2022. While this is positive for entry-level staff, there has been no parallel action to boost the pay of more experienced staff with 5 or more years of experience. As a result, the pay differential between junior and more senior care workers has narrowed to an average of 6 pence per hour by March 2021. There are few opportunities for training and progression, with data on qualification levels indicating only 45% of direct care-providing staff in 2020/21 held a relevant adult social care qualification (Bottery et al., 2022).

The adult social care workforce is reliant on migrant labour. It was reported that in total, an estimated 98,710 migrant workers joined the formal care workforce between 2009 and 2019, with 9% from EU and 11% from non-EU countries (Dayan et al., 2019).  In London, more than two in five care workers are from abroad. However, under the new points-based immigration system introduced on 1st January 2021, care workers have not been recognised as eligible for the ‘skilled worker’ route (Source: UK points-based immigration system: further details statement). As a result, the number of new entrants to the social care sector from abroad fell from 5% in 2019 to fewer than 2% in the spring of 2021 (Skills for Care, 2021). To release the recruitment pressures, in December 2021, the government  announced that care workers, care assistants and home care workers will be added to the Shortage Occupation List as part of the health and care visa to make it quicker, cheaper and easier for social care employers to recruit eligible workers to fill employment gaps (see section 3.06 of this report for more details).


Bottery, S., Ward, D. (2022). Social Care 360. The King’s Fund.

Dayan, M., Palmer, B. (2019). Stopping the staff we need? Migration choices in the 2019 general election. Nuffield Trust Election briefing

Skills for Care (2021). The state of the adult social care sector and workforce in England 2021.

Last updated: March 8th, 2022   Contributors: Joanna Marczak  |  Nina Hemmings  |  Chris Hatton  |  

The Scottish Social Service Council (SSSC) has a statutory duty to keep a register of workers in social services including care homes, care at home and housing support services. It is possible for an individual to appear in more than one category covered in the SSSC register but the most recent data suggests there were 36,661 non-managerial registrants working in care homes, 58,016 non-managerial registrants working in the care at home sector, and 49,295 non-managerial registrants working in the housing support sector.

Last updated: March 10th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

According to data published by the US Department of Health and Human Services, in 2015-2016 there were almost 1.5 million nursing employee full-time equivalents (FTEs) working across the five sectors of long-term care in the United States. This includes registered nurses (RNs), licensed practical or vocational nurses (LPNs or LVNs), and healthcare aides, as well as approximately 35,000 social work FTEs. The majority (63.3%, or 945,700 FTEs) work in nursing homes, 20.0% are residential care community employees, 9.7% are employed by home health agencies, 5.7% are employed by hospices, and 1.3% are adult day services centre employees. Employment conditions and required qualifications vary a great deal across the sectors; a breakdown of employment rates in each sector can be found beginning on page 18 of the CDC report.

Nursing home workforce

The nursing home workforce is composed of nursing assistants, licensed practical/vocational nurses, and registered nurses. Nursing assistants provide hands-on care with daily activities such as eating, toileting, dressing, and toileting. Licensed practical or vocational nurses administer medications or wound treatments while registered nurses oversee the overall nursing care of nursing home residents.

According to a report, 9 out of 10 nursing assistants who work in nursing homes are women. One in three has a child under the age of 18  at home and about 15% have a child under the age of five. Less than half of nursing assistants have completed education beyond high school. Approximately 54% of all nursing assistants in nursing homes are people of color, 36% of which are Black of African American. Additionally, 20% of nursing assistants are immigrants.

Last updated: February 11th, 2022   Contributors: William Byrd  |  Nerina Girasol  |  

Vietnam faces a shortage of qualified nursing care staff for the elderly population. Most are cared for by family or domestic workers, who usually have no training in care or medical expertise (source: Vietnam Investment Review). They also do not normally receive any financial support from the government for their informal caring duties (source: UNDP report).

Staff in formal nursing homes do not have to be formally trained. Their salaries are low due to limited funding, which results in difficulty with recruitment and difficulty reaching staffing quota levels (source: UNDP report). Staffing levels in social protection facilities are mandated by The Ministry of Labour, Invalids and Social Affairs. The ratio of care staff to recipients is 1:8-10 for low-level care needs and 1:3-4 for higher level care. The ratio for nutrition staff (preparers and purchasers of food) is 1:20 (source: Royal Commission into Aged Care Quality and Safety).

Last updated: January 6th, 2022   Contributors: Daisy Pharoah  |  

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.