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 is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

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, Pharoah D (eds.) and LTCcovid contributors. LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6

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

Overview

There is a shortage of workers in all countries including in this study and indeed for most countries around the world. At this pace of an ageing population, it is estimated that the need for LTC workers needs to increase by 40 – 100% if current ratios are to be maintained, which are largely deemed insufficient. The long-term care workforce ranges from specialized professionals (geriatricians, nurse case management workers, physiotherapists) to so-called low skilled care workers. This latter group can make up, up to 70% of the workforce that is responsible for ensuring older people’s activities of daily living (source: https://www.oecd.org/health/who-cares-attracting-and-retaining-elderly-care-workers). They are predominantly women and often middle-aged. Overall, the LTC workforce is ageing itself: in the EU in 2016, the median age of long-term care workers was 45 whilst the share of those aged 50 or over was close to 38 % in 2019. 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 (source: https://www.euro.who.int/healthy-ageing/publications/2019/country-assessment-framework-for-the-integrated-delivery-of-long-term-care-2019).

Limited career opportunities, lack of professionalization both for supporting the knowledge and rights of this workforce, as well as a lack of support and lack of research in this area, all exacerbate the challenges in attracting workers into the LTC sector. Across the OECD, about 45% of LTC workers are in part-time employment and need to work in multiple jobs  (source: https://www.oecd.org/health/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Where data is available it tends to identify the workforce working in institutions or suggest that larger portions of the workforce is working in institutions. This reflects a lack of visibility of home care workers but also the distinction between formal and informal workers (family carers) which is not as clear cut in long term care where informal carers provide a large proportion of the care to older people. Comprehensive policies are needed when it comes to the workforce and no single policy can be used to address workforce availability, the recruitment, retention and competencies of a sustainable supply of fit for purpose LTC workers. A range of approaches exist in addressing some of the key policy issues facing the LTC workforce (sources: https://www.euro.who.int/healthy-ageing/publications/2019/country-assessment-framework-for-the-integrated-delivery-of-long-term-care-2019; Employment, Social Affairs & Inclusion – European Commission (europa.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: January 6th, 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 (sources: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/; https://journal.ilpnetwork.org/articles/10.31389/jltc.51/).

Last updated: January 6th, 2022


In Belgium, the Wallonia region allows personal care workers to perform nursing tasks when the elderly person needs them and no other care options are available (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: January 6th, 2022


Excellence programmes established in LTC for nurses (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm). However, the country, alongside other Eastern European countries, experiences so called  “care drain’ where many long-term care workers are working in other EU countries, mostly for better salaries and working conditions (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: January 6th, 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: https://news.gov.bc.ca/files/1.25.2021_LTC_COVID-19_Response_Review.pdf).

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: https://www2.gov.bc.ca/gov/content/economic-recovery/work-in-health-care; https://www.choose2care.ca/hcap/).

 

Last updated: January 6th, 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.

Source:

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. https://doi.org/10.1080/01459740.2021.1927023

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


In addition to GPs, Nurses, Physiotherapists, Occupational Therapists there are two kinds of professionalized social care helpers. Social and health helpers and assistants represent most of the long-term care workforce. Physiotherapists and occupational therapists have grown in numbers and in influence during the past decade, especially after the reablement programme was implemented. In most residential settings, the number of personnel has stagnated or even declined while personnel employed in home help has increased by almost 10%. Between 2005-2015 there has been an increase in part-time working: 49% of practitioners employed in home care worked 30–35 hours per month in 2016 versus 21% in 2005. Greater professionalization of the workforce has also been observed, 46% of the practitioners in residential care facilities held relevant qualifications that require training of more than two years in 2016 versus 33% in 2005. As care needs of residents have increased, nursing home personnel also experienced an increase in health- and nursing-related tasks. Personnel also reported higher work intensity in both home and residential care, especially related to administrative workload. Although more than 75% of those interviewed perceived their work in long-term care as highly meaningful, about 40% have considered switching jobs because of deteriorating working conditions, especially less autonomy, less support from superiors and insufficient training (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

The Danish Health Authority provides accreditation and licensing services for practitioners, including physicians, nurses, dentists, clinical dental technicians, dental auxiliaries, social and health care assistants, physiotherapists, chiropractors, midwives and optometrists (source: https://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf).

Social and health helpers can become accredited after 1.5 years of training, including a basic course of 20 weeks and a period of alternating practical and theoretical courses. Social and health helpers can perform tasks related to support with personal care and hygiene as well as household chores. A further module of 32 weeks of theoretical training and 48 weeks of practice leads to the next level as social and health assistants. These can carry out nursing functions, including planning of activities. Social and health assistants may choose the traditional nursing education that encompasses 3.5 years for a university bachelor’s degree (source: https://pubmed.ncbi.nlm.nih.gov/20626496/). Modular training for personal carers is under development  for those seeking to access managerial roles or for nurse aides wanting to become nurses (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: January 6th, 2022


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 (source: Finlandltccovid.org). 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.

Last updated: January 6th, 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: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

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: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

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: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Last updated: January 6th, 2022


In 2019, the rate of LTC workers per 100 inhabitants 65 years and above in Germany was slightly above the OECD average, at 5.1 compared to 4.9. Of all LTC workers, about one third full-time equivalents was employed in home care and the remaining two thirds were employed in residential care. The workforce is predominantly female and works part-time (source: Germany_draft.pdf (who.int).

In 2019, approximately 976,500 (mostly qualified) people worked in residential care settings. Almost two thirds (more than 85% women) were employed part-time (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_page?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=406&p_ansnr=61388070&p_version=3&D.499=1000529&D.993=1000518&D.991=23746).

The creation of an additional 13,000 additional 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 came was prepared in 2018 and came into effect in large parts in 2019 (source: Gesundheitspolitik – Gesetze und Verordnungen 19. Wahlperiode: seit 2017 (vdek.com). 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. (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

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 (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).

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. This can lead to reduced working ethic and lower quality of care. A comparison of psychological burden of LTC workers in comparison with other jobs showed that burden was higher in a number of the aspects compared. The report also showed that while the majority of care workers felt their job was important, 53% of care workers reported that they felt their work was socially recognised.

In 2019, LTC workers earned a median gross salary of €2146- 3032 per month (FTE-adjusted) depending on their level of qualification, although salaries in residential care tend to be higher than in homecare. Salaries in LTC sector have increased by about 28% from 2012 to 2019, however the salaries are considerably below the median salary of nurses working in hospitals, and Germany might see a drift of the LTC workforce from the LTC sector to the inpatient sector (source: Germany_draft.pdf (who.int). 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 care 53% report having difficulty to live off their income. Among LTC workers, 52% think that their retirement pay will not be sufficient (source: https://www.barmer.de/blob/278006/6b0313d72f48b2bf136d92113ee56374/data/barmer-pflegereport-2020.pdf).

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-Wuerttemberg do not expect to experience the same challenges.

On 2 June 2021 the German government has passed a new care reform (Pflegereform 2021) that sets out that all LTC workers in care homes need to pay their staff according to 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 (source: Pflegereform – Altenpflege wird besser bezahlt und der Beruf attraktiver – Bundesgesundheitsministerium).

 

Last updated: January 6th, 2022


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 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 (€11/hour vs €15/hours respectively)
  • The care worker/persone 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 nurse. Plus, 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 in Italy, but estimates claim that only 40% are employed under a fully regular contract. The trend to rely on home-based migrant carers has been supported by different measures and policies at local, regional and national level, including training and accreditation programmes for such carers, though with scarce success in promoting regular contracts (source: Italy Country Report (filesusr.com).

Source:

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

Barbarella F, Casanova G, Chiatti C and Laura G (2018) Italy: emerging policy developments in the long-term care sector. CEQUA LTC network 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: January 6th, 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 (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan; https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf).

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 (source: https://www.researchgate.net/publication/231843369_Rationale_Design_and_Sustainability_of_Long-Term_Care_Insurance_in_Japan_-_In_Retrospect).

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 (https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

 

Last updated: January 6th, 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: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: January 6th, 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 Netherlands has developed stress management/coaching programmes on healthier work environment and prevention of work-place accidents for LTC centres to help decrease absenteeism  (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: January 6th, 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: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

Last updated: January 6th, 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: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

Last updated: January 6th, 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; https://www.oecd-ilibrary.org; 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: Employment, Social Affairs & Inclusion – European Commission).

Last updated: January 6th, 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 (ltccovid.org).

Last updated: January 6th, 2022


The number of LTC workers per 100 people aged 65 and over is 1.5 worker, representing less than half the EU-27 average. Care provided by family members remains 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 of education, including upper secondary education and post-secondary, non-tertiary education. Non-standard employment is not very widespread in the LTC sector, e.g. the share of temporary employment is less than 10 %. Shift work is experienced by less than 40 % of the LTC workforce, far below the EU-27 average (source: Employment, Social Affairs & Inclusion – European Commission).

Last updated: January 6th, 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.

Sources:

https://www.who.int/publications/i/item/9789241513388

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. https://doi.org/10.1016/j.ijans.2021.100288

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


Low public spending on LTC, is related to low wages in the sector. The monthly cost per member of staff in the sector is 67% of the average wage per worker 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 (LTCcovid-Spain-country-report-28-May-1.pdf).

Last updated: January 6th, 2022


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: https://www.who.int/publications/i/item/9789241513388).

Last updated: January 6th, 2022


Ninety percent of LTC workforce is personal support workforce (source: https://www.oecd-ilibrary.org/sites/b768405f-en). Approximately a quarter [reports vary from 25% to between 30-40% in different sources) of LTC workers in care homes and in homecare are on hourly and/or temporary employment contracts.  It has been reported that this may have been an additional risk factor in the care sector during the pandemic as such workers often cannot afford to stay home if they get sick, they are not covered by the Swedish health insurance, and they may infect older persons and colleagues. Moreover, temporary staff works across different care settings, which, during the pandemic increased the risk of passing on the infection.  One in five care workers in care homes lacks formal training. On average, there are three care workers and 0.4 registered nurses per ten residents in a care home (sources: Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf; The-COVID-19-Long-Term-Care-situation-in-Sweden-22-July-2020-1.pdf).

Last updated: January 6th, 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 (adb.org).

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: https://www.mdpi.com/2071-1050/13/11/6306/htm).

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.

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. Care providers continue to report difficulty recruiting and retaining workers, particularly to the roles of care worker, registered manager and nurse.

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.

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. 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. 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.

Last updated: January 6th, 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: January 6th, 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: January 6th, 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:

this list is regularly updated to reflect contributions to the report, if you’d like to contribute please email a.comas@lse.ac.uk

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Jorge 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, Stefania Ilinca, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, 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, 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.