Centering Equity in LTSS: Policy & Job Quality

Lessons from Germany, Japan, and Sweden  

 

Motivation

“The existing long-term services and supports (LTSS) system exacerbates the pervasive racial and gender disparities in American society. It is designed to rely upon both the exploitation of a care workforce, comprised primarily of women of color, and the undervaluation of family caregivers; all while forcing people with disabilities and older adults to impoverish themselves in order to receive the services they need through Medicaid coverage.”¹

For this reason, the Mel King Community Fellows Program, carried out by the Just Urban Economies Program within MIT’s Community Innovators Lab (CoLab), “which seeks to accelerate social innovation in and from marginalized communities in the United States”, is currently on the mission of envisioning an equitable LTSS system that will bring justice to both caregivers and care-seekers alike. In bringing together interdisciplinary academics, researchers, and “key leaders from California, New York, Massachusetts, and national organizations committed to advancing policy and investment strategies”, the 2022-2023 Class (“Centering Equity in Long-Term Care”) aims to identify specific aspects of our current system that contribute to injustice and on such grounds, actualize a quality LTSS system that places equity at the forefront of its mission.

 

\[\textbf{Through an improved LTSS system, we may improve job quality for care workers} \\ \textbf{and thus, improve the quality of the care they deliver.}\]

 

Where injustice within our systems has impeded economic growth within marginalized communities and prevented minorities from living dignified lives, an improved LTSS system must be one that builds wealth for its workers and preserves wealth for its consumers (and their families). Thus, our vision and the mission to which this work is dedicated, is: to improve the conditions for caregivers and care-seekers, by making care-giving a quality job that makes quality care accessible for all.

 

Research

LTSS systems around the world offer valuable lessons for the U.S. in years ahead. The primary aim of this work has been to identify and address specific aspects of three different LTC systems that may have significant impacts on job quality for the care workforce in an attempt to inspire future policy research in this space.

Specifically, we highlight key findings on care workers in Germany, Japan, and Sweden, which may be of particular interest to U.S. policymakers, while demonstrating the relevance and importance of this kind of work in cultivating a more sustainable and equitable care system.

 

Long-Term Services & Supports (LTSS)

According to the Paraprofessional Healthcare Institute (PHI), LTSS, often referred to as long-term care (LTC), comprises a wide range of health and social services provided to individuals who require assistance with general and instrumental activities of daily living (ADLs and IADLs)². These services are either provided at private homes or (community-based) institutions including nursing/residential homes, assisted living facilities, and adult day services. For more information on LTSS, please visit PHI.

LTSS systems around the world differ primarily with regards to the financing model (or models) they embody. Policymakers in charge of enacting such models (at a state or federal level) have the moral obligation to explore those which will create an equitable LTSS system “while meeting the political realities of their environments”. Generally, these financing models can take one or a combination of the following forms:

 

1. “Private LTSS Insurance: Private insurance companies provide coverage to individuals who pay premiums. This model tends to exclude lower-income individuals who cannot afford the premiums.

2. Safety Net: The government provides LTSS coverage to individuals who fall below a certain income and asset level (as is done through the Medicaid program). This model can force those of moderate means who would not otherwise qualify to impoverish themselves to meet qualification thresholds.

3. Social Insurance: Individuals contribute taxes toward a government-run program through which they can access benefits as needed. While this model can work well for older adults who have had time to pay into the program, it does not always meet the needs of younger people with disabilities.

4. Universal Coverage: The government provides LTSS coverage to all who need it. Generally financed through general revenues and taxes, this model is the most expensive to maintain but also tends to be the most equitable.”³

 

\[\textbf{What is the level of (positive) impact that these LTSS financing models have on equity?}\]

 

	Access & Affordability	Inclusion	Wealth Inequities
Private LTSS Insurance	minimal	minimal	minimal
Safety Net	moderate-high	moderate	variable
Social Insurance	moderate-high	moderate	moderate-high
Universal Coverage	high	high	high

 

Presently, the LTSS system in the U.S. operates under a combined form of the safety net model and private LTSS insurance. For more information on the current financing model implemented in the U.S. and the impact it has on equity, please refer to MIT CoLab Report 2, or MIT CoLab Report 1 for more on financing models broadly.

 

Germany

SYSTEM RELIES PRIMARILY ON FAMILY CAREGIVERS & INFORMAL CARE

“Germany has a social insurance program that provides coverage for a portion of LTSS costs to nearly all who require services. One of the longest-standing LTSS social insurance programs, it is fully funded through mandatory enrollee contributions. While this program has a deep focus on financial sustainability, it is structured to rely on caregiving and financial contributions of families in order to cover the remaining LTSS needs; thereby moderating its impact on equity.”⁵ For more information on the current LTSS financing system implemented in Germany and its impact on equity, please refer to MIT CoLab Report 3.

• By 2019, the number of people requiring long-term care was roughly 4.1 million.¹⁰
• By 2050, this number is projected to increase to around 6.5 million.¹⁰

The majority of individuals in need of care either receive a care allowance or professional care directly at home, what Germans often refer to as home care in-kind¹¹, in line with the principle, \[\textbf{“care at home prior to residential care”}.\]

• By the end of 2019, nearly 80% of those in need of long-term care were cared for at home, while 20% were cared for in nursing homes.¹⁰

“Today, caregiving for the old and disabled in Germany is a sector worth billions of euros, and one rife with reports of abuse: middlemen lining their pockets; families exploiting their caregivers or treating them like modern slaves; care workers who steal or just vanish overnight.”¹²

 

Japan

SYSTEM FOCUSES PRIMARILY ON PROMOTING COMMMUNITY-BASED CARE

“Japan, the country with the fastest-aging population, has a social insurance program that provides more comprehensive LTSS coverage than Germany’s program. Half of its funding comes through enrollee contributions and the other half via government taxes. It provides more comprehensive benefits but excludes most younger individuals with disabilities.”⁵ For more information on the current LTSS financing system implemented in Japan and its impact on equity, please refer to MIT CoLab Report 3.

• In 2020, close to 6.7 million people were in need of long-term care, demonstrating an increase of around 5 million from 2011.¹³
• By 2050, approximately one in four Japanese citizens will be over 75, and those aged 65 and over will represent 27% of Japan’s total population.⁶

Significantly more elders receive care at home as opposed to institution-based care. This is reflected in the comparatively large number of LTC workers that engage in hope-visit helper services, rather than daycare services at nursing facilities. Notably, while it is estimated that across OECD countries more than 50% of LTC workers are based in institutions, Japan exhibits a share below 25%.⁶ This may, in part, be due to the fact that,

\[\textbf{“Japan actively promotes community-based disability prevention and healthy aging.”}\]

In 2015, the Japanese government reformed the Long-term Care Insurance Act by “changing its primary strategy for long-term disability prevention from a high-risk strategy to a community-based population strategy”.¹⁴ As one study points out, this shift in strategies, having involved multidisciplinary community collaborations, has been very successful. Still however,

“To minimize the negative effect and maximize the positive effect of aging and to achieve healthy longevity, it is pivotal to increase the quality of a community-based integrated healthcare system and accumulate further evidence on disability prevention in Japan.”

In this light, the government has proposed “the establishment of a ‘Community-based Integrated Care System’ by 2025, when baby boomers will be 75 years or older”, its main purpose being to “comprehensively ensure the provision of healthcare, nursing care, preventive care, housing, and livelihood support in each community”.¹⁴

 

Sweden

SYSTEM PRIMARILY SERVES MUCH OLDER INDIVIDUALS & RELIES ON PART-TIME WORK

“Sweden has a comprehensive universal LTSS financing system with very minimal costs to beneficiaries. All who require services are able to access them, regardless of age or disability type, and the program is funded primarily through income taxes. It has a high impact on equity, but also has high costs to administer, with Sweden spending a larger portion of its GDP on LTSS than many other countries.⁵” For more information on the current LTSS financing system implemented in Sweden and its impact on equity, please refer to MIT CoLab Report 3.

• In 2019, the number of people in potential need of long-term care was roughly 412,600, corresponding to roughly 4% of the total population.¹⁰
• By 2050, this number is projected to increase to around 570,200.¹⁰

Over half of present LTC consumers are aged 80 or above, meaning that services are heavily concentrated on this particular age group. Despite representing a relatively small share of Sweden’s overall population however, the country’s public expenditure on LTC is still among the highest in the EU, having reached approximately 3.3% of the GDP in 2019.¹⁰

Even so, the system remains plagued with arduous working conditions and diminishing quality of care. These being among the reasons for which,

\[\textbf{“The sustainability of the Swedish LTC system is a challenge.”}\]

In the 2021 Long-term Care Report, jointly prepared by the European Commission and the Social Protection Committee, it was argued that,

“The public LTC for older people is not a cost, it is a precondition for high levels of women’s participation in the labor market, and thereby a precondition for economic growth and high standards of living.”¹⁰

 

Care Workforce

 

\[\textbf{Individuals who provide the laborious service of long-term care are classified}\\ \textbf{as either }\textit{formal }\textbf{or }\textit{informal }\textbf{caregivers, or “carers”.}\]

Informal

Informal caregivers tend to be close family friends and relatives that deliver, often unpaid, care services within informal contexts. Although, informal long-term care can also be provided by volunteer organizations, or paid but unregistered workers.⁸

As the Organization for Economic Cooperation and Development (OECD) points out, despite dwindling family care capacities, informal carers account for a considerably large portion of the care provided to older people in all OECD countries.⁷

Germany

As long-term care insurance (LTCI) allows older German people to receive cash benefits to cover their LTC needs as opposed to receiving care directly, today, more than 50% of all LTCI beneficiaries rely on informal care only.¹⁵

Family Caregivers:

• Of the 3.31 million people receiving care in their homes by the end of 2019, 64% were cared for strictly by relatives, while 30% received care services from a combination of relatives and outpatient care.¹⁰

Aside from spouses, most of these family caregivers were women, especially daughters and daughters-in-law, around 60% of whom had jobs.¹⁰ According to a EUROFAMCARE study however, the number of male caregivers is increasing. Particularly, data from the German Socioeconomic Panel suggests that in 2008 the proportion of primary male caregivers rose to approximately 35% from what used to be a mere 17% in 1991. Furthermore,

“As most male caregivers tend to be caring for their elderly wives, they themselves are already advanced in age at the time of caregiving, an age which statistically far surpasses the average age of female caregivers.”²⁰

Non-Family Carers:

Despite the growing number of family members providing long-term care for Germany’s care-dependent population, migrant workers, primarily women from Central and Eastern European countries, continue to play a significant role in informal care provision—“a setting unquestionably promoted and upheld by LTCI cash benefits.”¹⁵

This however, is not a new phenomenon. For decades, German households have privately hired migrants, often as live-ins, to provide around-the-clock care and perform standard household chores through informal work arrangements.¹⁵ In short, “the informal deal”¹² is this,

\[\textbf{“Germans needing care pay foreign workers on average about €1,600 a month net.”}\]

“This type of care provision, the so called ‘migrant-in-the-family’ model, can be seen as an unexpected policy outcome, triggered by households’ unanswered care needs and the supply of migrant care workers facilitated by European Union (EU) accession of Eastern European countries.”¹⁵

• Typically, two or more migrants will work in rotation for a single household, alternating after several weeks or months.¹⁵
• Due to the fact that payments are often in cash and unaccounted for, they are not taxed—“an attractive prospect for many in Poland, Romania, or Bulgaria.”¹²

Although this type of arrangement appears mutually beneficial on the surface, it also allows for, and often results in, poor working conditions for migrant workers that “are at odds with legal regulations on minimum wages and working hours”¹⁵, as well as inadequate or unethical treatment of care recipients¹² that are overlooked and limit the collection of administrative data on the matter.

“Peter Müller recounts how his wife once called out all night for her caregiver, who was simply no longer there.”¹²

A decade ago, there were approximately 200,000 migrants that worked in households, but more recent estimates suggest that there are now as many as 500,000.¹⁵

 

Japan

Family Caregivers:

Being home to the world’s oldest population¹⁶,

\[\textbf{“Japan has a term for the stress and exhaustion of family caregivers:} \\ \textit{kaigo jigoku}\textbf{, or ‘caregiving hell’.”}\]

In 2019¹³:

• It was estimated that around 24% of caregivers in Japan were spouses and almost 21% were the children of those in need of long-term care.
• Roughly 57% of caregivers in households with level-five care recipients spent nearly all day on nursing care, with the overall average of 19% having used the whole day.

“A survey in 2020 revealed that the majority of households with care recipients were nuclear family or one-person households, indicating a high demand for external caregivers.”¹³

 

Sweden

Family Caregivers:

There are two types of cash benefits available for family caregivers in Sweden. Namely, attendance allowance and carer’s allowance. However, due to the fact that municipalities independently determine the level of payment, who is eligible, and whether or not to offer payments at all, few family caregivers actually benefit from them (as municipalities seldom do).¹⁰

“It is important to understand that at present, these kinds of support play a very minor role in the Swedish system as services in kind are prioritized.”

In 2016, it was estimated that 22% of the total Swedish population provided informal care, 5.4% of which spent over 20 hours weekly delivering care.¹⁰ As noted more recently by the Swedish National Board of Health and Welfare (NBHW),

• The share of the adult population providing informal care on a regular basis remains at around 20%.
• Roughly “40-50% of all informal care is given by older people”.
• Care recipients tend to be those with more extensive care needs; for example, spouses with dementia.

Unfortunately,

\[\textbf{“There is neither a system for documentation nor any official statistics on carers and their support.”}\]

As a result, figures may not always capture the sheer magnitude of informal care provision, however evidence suggests that family care has increased over the last few decades—primarily due to “the more recent reduction of residential care”, its (residential care) “relatively high eligibility criteria”, and “the fact that a larger proportion of older people today have a partner or children compared to previous years.”¹⁰

 

Formal

OECD classifies formal LTC workers as

\[\textbf{“paid staff, typically nurses and personal carers.”}\]

The latter group, being synonymous with direct care workers (the more commonly used term in the U.S.), are characterized by OECD as those “providing care and/or assistance to people limited in their daily activities at home or in institutions, excluding hospitals”. Specifically, personal care workers or carers, can take on the titles of “nursing aides”, or “health assistants in institutions or home-based care”.⁷

On the other hand, PHI defines direct care workers as those who “assist older adults and people with disabilities with daily tasks and activities across LTSS settings”, and formally classifies them as “personal care aides”, “home health aides”, and “nursing assistants”.²

“On average, around 30% of LTC workers in OECD countries are nurses and the other 70% are personal care workers.”⁷

From this, we gather that the formal care workforce can be broken up into the “nurse” category and the broader category of “personal” or “direct care workers”. Based on available data and observations made throughout this research, we have found that vocabulary frequently used in reference to the care workforce includes, but is not limited to the following list:

• Nurses:
  • Registered Nurses (RNs), Licensed Practical/Vocational Nurses (LPNs/LVNs), Geriatric/Senior Nurses

• Personal/Direct Care Workers:
  • (Certified) Nursing Assistants (CNAs/NAs), Assistant Nurses (ANs), Nurse/Nursing Aides
  • Health Assistants/Aides
    • Home Health Aides (HHAs), Heath Assistants in Home-Based Care
    • Heath Assistants in Institutions
  • Personal Care Assistants/Aides (PCAs)

NOTE: The majority of care workers in the “nurse” category require a license, additional education and/or training, and typically receive higher pay. Additionally, all care staff can hold either part-time of full-time positions and be based in either a home or an institution setting.

 

Tasks

OECD claims that

\[\textbf{“While many tasks are low skilled, LTC jobs are more complex than often portrayed.”}^6\]

Although, as is the case with many aspects of the care workforce in international settings, “little is known about what LTC workers do across OECD countries when they provide care to elderly people”.⁶

Given that the role of nurses in LTC across OECD countries is more homogeneous in nature than that of personal care workers, OECD generally describes that

“Nurses in LTC are in charge of four main functions: health care provision, health care monitoring, care co-ordination and communication with families. The bulk of nurses’ tasks involve providing health care, including medication administration and health status monitoring”.

Yet, research suggests that the range of tasks performed by (some even unlicensed) personal care workers may include some of these nursing tasks as well. This is especially the case in countries, like Japan and Sweden, where personal care workers “play a more comprehensive role”.⁶

 

Personal Care Worker Tasks by Country

	Germany	Japan	Sweden	United States
Positioning, lifting, and turning elderly people	yes	yes	yes	yes
Transporting elderly people (via wheelchairs, movable beds and/or motor vehicles)	yes	yes	yes	yes
Assisting care recipients with personal hygiene, feeding, and dressing	yes	yes	yes	yes
Maintaining elderly people’s environmental hygiene standards	yes	yes	yes	yes
Planning, purchasing, preparing, or serving meals	no	yes	yes	yes
Scheduling and accompanying elderly people on errands	yes	yes	yes	yes
Preparing care recipients for examination or treatment	yes	yes	yes	yes
Providing oral medications to care recipients	no	yes	yes	no
Providing psychological support through conversation and reading aloud	yes	yes	yes	yes
Managing interactions between family caregivers and health practitioners	no	yes	yes	no
Maintaining records of care and changes in condition or behavior	yes	yes	yes	yes
Maintaining records of responses to care and treatment	yes	yes	yes	yes
Reporting concerns or providing referrals to health or social services	yes	yes	yes	yes
Implementing care plans established by health professionals	yes	yes	yes	yes
Source:
Information is based on Table 3.1 of OECD’s Who Cares? Attracting and Retaining Care Workers for the Elderly\(^6\), which itself corresponds to the OECD LTC Workforce Survey (2018).

 

Although job responsibilities may be similar among these workers—especially in countries where categories may be more broad, licensing requirements seldom imposed, and care workers required to fulfill a wider range of tasks—it is important to note that specific terminology for formal care workers varies considerably.

This is primarily true for the direct care workforce, where terms may differ with regards to the country or region in question; education and training requirements or certifications held; the scope of the practice, that is, the types of services provided and the populations served; and the predominant place of work (i.e., private homes, residential care facilities, etc.).

Even terminology associated with LTSS settings can be wide-ranging and often difficult to compare between countries. As one study points out,

“In the course of this study, it was often difficult to differentiate medically oriented from nonmedical residential long-term care settings. It was also difficult, in some instances, to decide which nonmedical residential facilities should be counted as institutions and which as sheltered housing. This was particularly the case for Sweden, where many elderly persons are being deinstitutionalized in place as older homes for the aged are converted into service flats with supportive services. Swedish officials insist that, unlike the older homes for the aged, the service flats are not institutions. The distinction between institutional and noninstitutional housing often is a matter of interpretation.”⁹

For this reason, synthesizing comparable information on formal care workers across different countries has been a particular challenge and readers should be mindful of these limitations as they review this kind of work.

With this in mind, the following table includes specific titles and care-related terminology frequently used and seen in the literature with regards to LTC/LTSS in our countries of interest.

 

Country-Specific Terminology

	Germany	Japan	Sweden	United States
LTC/LTSS	LTC\(^a\), Elderly Care, Geriatric Care, Day Care Services, (In-Kind) Home Care Services, Residential LTC	LTC, Helper Services, Home-Visit Care, Facility Care, Community-Based Care	LTC, Elderly Care, Eldercare Services, Day Care Services, Home Care Services, Home Health Care, Residential Care	LTC, LTSS, Home- or Community-Based Care (HCBC)
Nurses	Nursing Personnel, Geriatric Nurses, Senior Nurses	Registered Nurses (RNs)	Registered Nurses (RNs)	Registered Nurses (RNs), Licensed Practical/Vocational Nurses (LPNs/LVNs)
Direct Care Workers	Nursing Assistants (NAs), Healthcare Assistants, Health Aides, Senior Caregivers, Caregiver Assistants	Nurse/Nursing Assistants/Aides (NAs), Personal Care Workers, Care Workers (Certified/Not Certified)	LTC Assistant Nurses (ANs), Care Aides	Certified Nursing Assistants (CNAs), Personal Care Aides, Home Health Aides, Skilled Care Providers

 

The following numbered sections (I-VI), strictly regard the formal LTC/LTSS workforce.

 

I. Demographics

In this section, we will cover the following demographic categories:

• Gerneral
• Age
• Gender
• Foreign Workers

 

General

As the world’s population continues to age, most countries expect significant shortages of LTC workers, even those like Germany, Japan, and the U.S., “where the supply is higher than the OECD average”.⁶

Moreover, as previously mentioned, while “a few countries strictly limit the range of personal care workers’ tasks”, the majority report that personal care workers engage a more extensive set of responsibilities.⁶

Thus, it is not shocking to see that these workers make up the vast majority of the formal care workforce in countries where this is the case. The second set of figures (2.a and 2.b) of the four sets of graphs below—all of which are based on OECD’s most recent data on long-term care resources and utilization^a—confirms this.

 

Breakdown of Formal LTC Workforce

 

 

Note: Faint lines represent country-specific FTEs per 100 population aged 65 years and over.

 

 

 

 

Note: Percentages are relative to country-specific totals of formal LTC workers.

 

Germany

According to the Federal Statistical Office of Germany^e, there were 421,550 “mostly qualified” workers employed in home care services and 796,489 “mostly qualified” workers employed in residential homes for older people in 2019, reflecting increases of around 8% and 4.2% from 2017, respectively. This indicates that home care staff made up roughly 34.6% of the LTC workforce—an estimate not far from the one shown in Figure 3 above (39%). We assume this difference may be the result of OECD’s omission of “unqualified” workers from their data, but it is possible for other factors to have also played a role.

Moreover, as demonstrated in the last set of graphs, Germany’s LTC workforce, unlike the rest, is pretty evenly split between nurses and personal carers in both LTC settings. Notably, as was previously shown in the table of common personal care worker tasks, Germany prohibits direct care workers from “planning, purchasing, preparing, or serving meals”; “providing oral medications to care recipients”; “and managing interactions between family caregivers and health practitioners”. And, given that these tasks represent such significant aspects of effective delivery of care, it is not surprising that the German care workforce contains a larger share of nursing personnel.

“Fully qualified nurses have been a key component of the German LTC workforce since the early 2000s. However, this situation may change in the future and nurses may be lacking, as Germany faces two main challenges associated with the difficulty of attracting highly qualified nurses into the LTC workforce and the ageing of the reservoir of nurses (fully qualified geriatric nurses).”⁶

 

Japan

As demonstrated in the third and fourth figures above, Japan has a comparatively large home-based LTC workforce supply, with less than a quarter of total LTC workers being based in institutions.¹³

Still however, while the average jobs-to-applicants ratio as of 2019 was 4.2:1 for the entire LTC workforce, the average ratio for home visit staff in particular was 15:1 according to the Subcommittee on Long-Term Care Benefits. And, although “there are large regional differences in these ratios”, given that the corresponding average ratio for all industries was 1.5:1 in comparison, these figures highlight the additional need for recruitment and retention strategies in the care sector as staffing shortages become a growing concern in the coming years.²¹

Moreover, the majority of workers, namely 83-85% are personal carers, while 15-17% are nurses.^a,17 As mentioned previously, it is common for direct care workers in Japan to provide medications “and even act (and be considered) case managers: professionals able to aggregate all the micro-services gravitating around elderly people (such as transportation, meals-on-wheels, and so on)”.⁶ Thus, unlike in Germany, it seems fitting for the Japanese care workforce to be predominantly direct-care-focused.

 

Sweden

Sweden’s largely home-based “geriatric health care” workforce is almost entirely comprised of personal carers—a fact reflected in the second set of graphs above. More specifically, around 46% of care workers are care aides (Vardbiträdes) and 44% are assistant nurses (Undersköterskas).¹⁸ Similarly, according to a large 2003 survey from eight Swedish municipalities regarding employees in residential care facilities—a sector primarily reserved for those with the most critical of care needs—less than 6% were registered nurses, while 54% were assistant nurses and about 33% were care aides.¹⁹

Moreover, the first graph above not only shows that the number of Swedish LTC workers per 100 individuals aged 65 and older has remained considerably large compared to our other countries of interest (as well as all other OECD member states more broadly⁶), but that it has also been steadily decreasing for decades.

As argued by OECD, this decrease in LTC supply per 100 people aged 65 and older may be less of a problem in Sweden, “where healthy life expectancy among elderly people is among the highest in OECD countries”.⁶ However, the European Commission finds this conclusion “problematic from several perspectives”. In their 2021 report on long-term care they point out that, as it pertains to Sweden, LTC supply in relation to the population aged 65 and older is a suboptimal indicator given the fact that, as mentioned earlier, care is predominantly centered around folks aged 80 and above—a group that is not only “growing more quickly than others”, but one that, despite living longer, suffers from an increased risk of health complications and disability.¹⁰ In short,

\[\textbf{“...the fact that healthy life expectancy has increased in recent years does not} \\ \textbf{mean that the number of unhealthy years has dropped.”}\]

“This is exemplified in a study of life expectancy in Sweden, showing that although years free from disability increased in both men and women, the main part of men’s increased life expectancy featured disability problems.”¹⁰

 

Age

According to OECD,

\[\textbf{“Young workers comprise a relatively small share of the LTC workforce.”}\]

In particular,

• Individuals under the age of 26 represent just 13% of the LTC workforce in all EU countries.
• The proportion of workers aged 50 years or older is not only higher in LTC than in other sectors, but has been increasing for over a decade. Specifically, the share of care workers aged 50+ in the EU went from 28% in 2009 to 38% in 2019.²⁸

“The two main age-related issues in the LTC workforce are that attracting young workers is difficult and retaining workers aged 50+ is challenging. Indeed, young female workers tend to be attracted by sectors that have a better image than LTC, such as childcare or hospital care. Moreover, the oldest workers are likely to experience health issues (such as back problems) and can face increasing difficulties with carrying out LTC tasks like transporting and moving elderly people; this reduces the probability of staying into the workforce after a certain age.”⁶

Germany

 

In 2016, the median age of care workers was roughly between 43-45, reflecting a minor increase from 2011.⁶

 

The following graph depicts age-related demographics gathered from the Federal Statistical Office of Germany^e regarding the LTC workforce.

Note: Percentages are relative to industry membership.

 

Japan

 

In 2016, the average age of care workers was roughly between 46-48.⁶

 

• In Japan, 42% of LTC workers were aged 50 and over.⁶

One study using Japan’s Employment Status Survey observed that between 2002 and 2017, LTC workers aged considerably—this being particularly the case for the female care staff. It was noted specifically that, in this time period, both “the number of female facility LTC workers aged 60 and older increased 12-fold”, and “the main reason for females leaving LTC was ‘old age’”.²¹

\[\textbf{“The shortage in the supply of LTC workers may become more serious} \\ \textbf{as aging female LTC workers retire.”}\]

Thus, in an attempt to increase recruitment in LTC,

“Japan has introduced basic LTC training courses targeting middle-aged and older workers to prepare themselves to return to work after a long break.”⁶

 

Sweden

 

In 2016, the median age of care workers was roughly between 43-45, showing no change from 2011.⁶

 

\[\textbf{“In Sweden there is a lack of junior health professionals.} \\ \textbf{This shortage also affects }\textit{Undersköterskas }\textbf{and } \textit{Vardbiträdes}\textbf{.”}^{18}\]

 

Gender

According to OECD,

\[\textbf{“Most LTC workers are middle-aged women.”}\]

• Representing more than 90% of the entire LTC workforce, it stands to reason that the burden of long-term care falls primarily on the shoulders of women across all forms of care provision.
• The large proportion of women among care workers stands in contrasts to the share of women in “more skilled health occupations such as physicians, where under half are female across OECD countries”.

“LTC jobs are traditionally considered to be feminine and, while this perception may be changing slowly, stigma is still attached to men performing them.”⁶

The following graph is based on Figure 2.5 of OECD’s Who Cares? Attracting and Retaining Care Workers for the Elderly⁶, which itself corresponds to the EU-Labour Force Survey (2018).

 

 

Germany

“Historically, the female-dominated jobs in nursing, childcare and long-term care in Germany have been characterized by semi-professionalism; lacking established institutions of self-governance; and central state regulation regarding training standards, access, remuneration, and interest representation, which are typical for male-dominated core professions such as medicine and law.”²²

The following graph, similar to the one in the previous section, reflects information obtained from the Federal Statistical Office of Germany^e regarding gender in the LTC workforce.

Note: Percentages are relative to industry membership.

 

Japan

Despite the fact that women represent the majority of the LTC workforce, out of 26 OECD countries surveyed, Japan had the smallest fraction of female care workers$mdash;namely, around 80%, as shown in the graph above.⁶

The 2002-2017 study previously referenced, which found that the main reason for women leaving the LTC workforce was “old age”, also noted that the main reason for men leaving the care sector was “low wages”.²¹ Consequently, it was argued that

\[\textbf{To replace aging and retiring female LTC workers, wages must be raised to promote} \\ \textbf{male LTC labor supply and to reduce their turnover rate.”}\]

Additionally, the following gender-related observations were made regarding surveyed LTC workers in Japan during the course of the study:

• The share of male long-term care workers increased significantly, having reached 20% in 2017. And, although this figure is no different from the one observed in the previous year (depicted in the graph above), it remains the highest among all OECD countries who currently average less than 10%.
• More specifically, while the total number of LTC workers doubled in this time period, the number of male care workers tripled.
• Most men employed in formal LTC worked regularly (or full-time) in care facilities. Particularly, male residential care staff accounted for 17% of all formal LTC workers in 2017, demonstrating an increase of around 4 percentage points since 2002. It is important to note however, that it is not known whether these workers belonged to the public or the private care sector.

 

Sweden

In line with the fact that work-related injuries and health complications are more common in LTC than in most other industries, an article published by LTCCovid mentioned that “female eldercare workers have 50% more sick days than women in the rest of the workforce”.²³ The author, Marta Szebehely, a professor in social work at Stockholm University, remarks:

“All over the world, care workers, of which the vast majority are women, have increasingly problematic working conditions. Institutional recognition of the skills of care workers is weak, reflecting the gendered undervaluation of care work.”

Additionally, despite the fact that “in 2017, it was estimated that 272,700 persons were employed in formal home care and residential care services, out of which around 86% were women”¹⁰, the proportion of Swedish women in the formal LTC workforce has been decreasing for decades. This phenomenon is reflected in OECD’s most recent data on long-term care resources and utilization^a&mdash, which was used to create the visual below.

 

 

Foreign Workers

“Increased demand for long-term care (LTC) services alongside precarious working conditions has resulted in labour shortages in the LTC sector, which has led to an increasing share of workers of migrant origin filling these jobs.”²⁶

According to OECD,

\[\textbf{“On average, foreign-born workers represent over 20% of the OECD countries’ LTC workforce...They are}\\ \textbf{important contributors: they stay longer and work more hours than natives.”}^6\]

Yet, most countries either don’t encourage the recruitment of migrant care workers through channeled migration strategies or direct their initiatives towards nurses instead of personal carers.⁶

OECD claims that although cross-country variation often plays a role in the overall share of foreign-born people in the population, foreign-born workers tend to be particularly over-represented in the LTC sector compared to others across OECD countries.⁶

Additionally, “the size of the foreign-born workforce remains rather constant across LTC professions”, with the share of foreign-born workers among nurses being roughly the same among personal carers for the majority of OECD countries. However, the share of foreign-born workers tends to be greater among institution-based workers than among home-based carers in most European countries—a fact likely related to high degrees of institutionalization present within LTC systems. At the same time, it is important to note that “these statistics often fail to include live-in home care work, where foreign-born workers might be over-represented in some countries”.

• Notably however, it has been found that in the United States, unlike in most OECD countries, the share of foreign-born workers is both greater in home-based care as opposed to in institutions, and greater among personal care workers than among nurses.⁶

Moreover, as OECD suggests, it is common for foreign-born care workers to be both young and highly skilled professionals in their home countries—often migrating due to geographical proximity, language, culture, and/or wealth of their host countries. In spite of this, research shows that these workers often hold positions in their host countries that are at lower levels than those for which they are qualified.

• In particular, “the share of migrants reporting that they are overqualified for the work they do is greater in the LTC sector than any other” in most European countries.⁶

“The overqualification of foreign-born workers has been documented in recent work for countries like Canada, Spain, the United Kingdom and the United States.”⁶

As was mentioned in the same OECD report, LTC workers tend to follow common migration routes between lower- and higher-income countries. Specifically, the following countries were identified to be the primary sources of outflows:

\[\textbf{Bulgaria, India, Kenya, Liberia, Mexico, Nigeria, the Philippines, Poland, and Romania.}\]

“Among these, the Philippines, Mexico, Romania, Poland and Bulgaria were in the top 20 countries of origin of new immigrants to OECD countries in 2015, and a proportion of these flows were driven by demand for LTC workers.”⁶

 

Germany

As previously mentioned and confirmed by OECD, many families in Germany rely on migrant care workers due to the fact that formal care alternatives are generally far more costly. Hence, limiting these arrangements through policy interventions is a particularly delicate matter.¹⁵

However, we also see an increasing dependency of the formal care sector on migrants in Germany as well as in several other countries. To quote the authors of Dependencies of Long-Term Care Policy on East–West Migration: The Case of Germany,

“While the establishment and salience of a ‘migrant-in-the-family’ model for providing LTC can be seen as an unexpected policy outcome, the increasing presence of a migrant workforce in formal care seems more driven by explicit policies.”

Particularly, specific reforms to improve working conditions, wages, and training for formal care workers have given rise to a “mixed type of care provision”—namely, “migrants in the family and migrants in formal care”.

• In 2013, employment regulations were updated to allow for non-EU citizens with vocational credentials to obtain residence permits—subject to approval by employment services—as a way of increasing the supply of workers in professions, such as LTC, that are facing significant staffing shortages.¹⁵
• In the same vein, similar measures led to the 2019 establishment of a federal agency dedicated solely to the recruitment of skilled workers within the health and care sectors.¹⁵
• Moreover, the German government has established bilateral agreements with non-EU countries such as Bosnia-Herzegovina, Serbia, and the Philippines, in efforts to recruit skilled care workers as well as individuals seeking care apprenticeships in Germany.¹⁵

From 2013 to 2019, the number of migrant workers in formal care work nearly doubled.¹⁵

• Whereas only 5.3% of all care workers in 2013 were foreign-born, this share reached 10% by 2019—a difference that becomes even more pronounced for “elder care” workers; having increased from 6.8% in 2013 to 13.6% in 2019.
  • Top countries of origin for migrant workers in 2019 happened to be: Bosnia-Herzegovina, Poland, Turkey, and Romania.¹⁵
• Currently, around 11% of nurses in Germany are foreign-born—a share that has risen from 7% in 2013, according to OECD.⁶

These data, in part, reflect

\[\textbf{“Germany’s increased efforts to promote recruitment of skilled care} \\ \textbf{workers from abroad since the early 2010’s.”}^{15}\]

 

Japan

While not specifically targeting LTC workers, Japan is among the few countries to “have implemented initiatives to encourage foreign-born workers to get training and certification”.⁶

Specifically, the Japanese government introduced a system for training and recruiting foreign nurses and care workers under bilateral economic partnership agreements (EPAs), through which candidates for certified care workers from three countries in the region (Indonesia, the Philippines, and Vietnam) can get a visa for a total duration of stay of four years. Conditional on passing the national board caregiver examination during their period of stay—in which they receive Japanese language training and professional training at a medical or care facility—their residence status can be renewed very three years without restriction, making them eligible to work in Japan indefinitely.^6,24

In her 2017 article, Foreign Care Workers in Japan: A Policy Without a Vision, graduate school professor at Nagasaki University, Hirano Yūko, comments on this program²⁴—

\[\textbf{“Launched in 2008 with great fanfare, [it] offers important lessons for us going forward.”}\]

As she points out,

“Candidates invest a great deal of time and effort to complete their training and earn their license, as do the facilities that take charge of their training. We must ask why, then, 16%–38% of those who passed the national board examination have returned home instead of staying on in Japan.”

Particularly, many of the nurses and care workers who left Japan cite their reasons for leaving as being related to either poor working conditions that often proved injurious to their health, or having to work long hours which “made it impossible to balance work and family”—the same reasons Yūko claims Japanese LTC workers give for leaving the profession.²⁴

“In other words, Southeast Asian trainees are deterred by the same extreme conditions that drive Japanese women and men out of the profession. This tells us that the most important prerequisite for securing adequate care-work personnel in Japan, regardless of nationality, is to improve working conditions.”²⁴

 

Sweden

According to OECD, foreign-born workers made up roughly 28% of the Swedish LTC workforce in 2015.⁶ Moreover, recent Swedish statistics, published by the European Commision in March of 2020²⁵, show that:

• While 12% of all nurses in Sweden are migrants, of the approximate 183,000 assistant nurses, 26% (precisely, 48,329) were born abroad.
• With the inclusion of the Middle East, “the most common region of origin of assistant nurses was Asia”.

Notably, one study found that:

“Country of origin also plays a paramount role in the differences in working conditions experienced by migrants compared to native care workers, with non-European migrants being more likely to face a number of precarious working conditions.”²⁶

Consequently,

\[\textbf{“Apart from improving working situations Sweden is eager to employ} \\ \textbf{an increasing number of migrant health care workers.”}^{18}\]

 

II. Requirements

As mentioned in almost every initiative, few data on the education and qualification of Health Care Aides/Assistants (HCAs) in Europe are available. Many of the existing studies refer to the education of Registered Nurses (RNs).¹⁸

Although, research suggests that as much as 63% of LTC workers across OECD countries hold the equivalent of upper secondary educational qualifications—what OECD considers a “medium education level” and typically equates to a high school diploma or attendance at a vocational school.⁶

Nonetheless, the fact that personal care workers maintain much lower education levels, meanwhile representing the largest component of LTC workers in most countries, drives down the overall average of the LTC workforce’s education level across OECD countries. This can be attributed to the phenomenon that,

\[\textbf{“Education and initial training requirements are low for personal care workers across OECD countries.”}\]

Specifically, the table below gives the known minimal educational and training requirements identified by OECD with respect to our countries of interest.

Minimum Requirements for Personal Carers by Country

	Germany	Japan	Sweden	United States
No minimum education level	no	yes	no	yes
High school diploma	no	no	yes	no
Technical degree after high school	no	no	no	no
Primary or intermediate vocational training	no	no	no	no
Other	yes*	no	no	no
Note:
* “In Germany, provided that the training for nursing assistants meets the mutually agreed minimum requirements of the federal states, a secondary school leaving certificate (nine-year general education) is a prerequisite for admission.”
Information is based on Table 3.3 of OECD’s Who Cares? Attracting and Retaining Care Workers for the Elderly\(^6\), which itself corresponds to data obtained from the OECD LTC workforce survey (2018).

The following graph reflects OCED data collected from 2016 and 2019 surveys on levels of education among care workers. It is important to note that this data is representative of the entire formal LTC workforce, including both nurses and direct care staff—all of whom may also hold either full-time or part-time positions and work within a variety of LTSS settings.

 

 

Germany

Germany is among the few countries that, in addition to providing funds for education, “have developed a career structure for LTC workers”.⁶

Nurses:²⁷

• Typically obtain their education in a three-year vocational program at a higher nursing school attached to a hospital.
• More recently, nurses have also begun receiving their education in colleges where they obtain a B.Sc. in nursing.
• In either case, they must pass an official standardized exam “to be registered with the health authority of the corresponding federal state as a ‘general’ nurse”.
• Although not required, several nurses “further their education by taking up specialist courses”, such as psychiatry, intensive care, oncology, home care, hygiene, etc.

\[\textbf{“Unlike a nurse, a nursing assistant is not a regulated profession in Germany.”}^{27}\]

Nursing Assistants:²⁷

• Also known as healthcare assistants, generally complete a one-year vocational program at a higher nursing school along with prospective nurses.
• Some universities have recently launched courses designed for students that hold a secondary education in a non-healthcare related field.
• Unlike nurses, they do not need to pass any official exam. However, they must “demonstrate their fitness for the job to the local health authority of the federal state in order to be allowed to practice their profession”.

Foreign Nurses:²⁷

• Like nursing assistants, they must “demonstrate professional qualifications and skills equivalent to those of their German colleagues”. This typically involves having had working experience for a minimum of two years in the field.
• In addition to passing a German language proficiency exam at a B2 level, they must also have a clean criminal record and be in a good physical condition.

 

Japan

Highlights from the 2013 book, A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care—written jointly by OECD and the European Commission—point out that¹⁷

\[\textbf{“Japan has emphasized educational and workforce standards as the}\\ \textbf{principal quality-assurance mechanism in LTC.”}\]

The fact that Japan has no minimum educational requirements for care staff can be seen as concerning when their tasks often involve providing oral medications, maintaining records of treatment and care, as well as implementing care plans.⁶ However, the country’s LTC quality assurance “centers around ensuring skill levels of LTC workers”.¹⁷ Thus, in addition to offering “financial incentives for providers to provide care workers with continuous training opportunities”, the fact that “Japan is one of a few OECD countries imposing high skill requirements for LTC workers” may help explain why the share of LTC workers with high levels of education remains particularly high—approximately 40% or more⁶—in Japan compared to other OECD countries.¹⁷

Like Germany, Japan has also “sponsored access to LTC education with the introduction of scholarships”. Particularly,⁶

• Japan provides financial support to students applying for certified nursing and beginners seeking LTC training.
• As a result of this—in tandem with the aforementioned incentives which target middle-aged and older workers—the LTC workforce has seen an increase of around 320,000 new employees between the years of 2011 and 2015, further accelerating the supply growth within the LTC market.

Although educational requirements are not enforced, given that “workforce standards are higher than in most OECD countries”, Japan requires care workers to pass a state exam to become certified in the field. Specifically,¹⁷

• The training required to take the “State Examination” can consist of:
  • 1,190 hours in a high school training program;
  • 1,650 hours in a two-year program at a training facility; or
  • more than 3 years of experience in a personal care-related occupation.
• The exam is usually taken by care workers after having completed either a combination of theoretical and practical training for 2-4 years, or a college education in a care-related field.
• Upon passing the examination, certified entry level care workers must undergo a minimum of 130 hours of additional training, “compared to two weeks for home health aides in the United States”.

As of September 2021, roughly 1.8 million certified care workers were registered in Japan, reflecting a continuous increase over the past decade.^f

 

Sweden

According to the European Commission’s 2021 Long-term Care Report, “Sweden has high ambitions when it comes to educational qualifications within the LTC system.”¹⁰ Yet, as Stockholm University professor, Marta Szebehely, points out,

\[\textbf{“One in five care workers in care homes lack formal training.”}^{23}\]

One study showed that, in a sample of \(n=292\) Swedish care workers,¹⁹

• Just over 75% of Swedish care workers had at least one year of formal training.
  • This was particularly the case for 91% of assistant nurses, and 41% of care aides.
• Conversely, 43% of care aides had little to no formal training.

Moreover, Szebehely adds in her article, published by LTCCovid, that

“An inspection of more than 1,000 LTC units (care homes and home care) by the Swedish Work Environment Authority in 2017-2019, found health and safety deviations in almost 90% of the cases. Regular inspections of how the mandatory hygiene routines are followed in health and social care show that compliance with the routines is much lower in LTC than in hospitals. In one third of the situations inspected, there were deviations from the routines, especially among care workers with no or shorter formal training.”²³

Nurses: While nurses in LTC are required to have at least a bachelor’s degree in roughly half of OECD countries, Sweden is among the few that either already include geriatric care training in the general curriculum or require students to follow such training when working in the care sector.⁶

Nursing Assistants: After having completed the mandatory nine years of primary education within the Swedish school system, qualifications for assistant nurses can be achieved through a chosen three-year vocationally-oriented program or via in-service training for adults.¹⁸

Health Care Aides: On the other hand, education and training for care aides—the more common profession in geriatric the health care sector—generally takes one year in a corresponding vocational program.¹⁸

 

III. Wages

Alarming, but well-known, is the fact that

\[\textbf{“Current wages in the LTC workforce are low, especially for personal care} \\ \textbf{workers, who often have lower salaries than nurses.”}^{6}\]

Specifically, while 15% of direct care workers in the U.S. live in poverty², according to the European Foundation for the Improvement of Living and Working Conditions (Eurofound),

New data from the EU Structure of Earnings Survey (SES) show that, on average, EU Member States paid their social services workers 21% less than the average national hourly earnings in 2018: this compares with 19% less than the average in 2010 and 20% less in 2014. The majority of social services workers (69.3%) work in the long-term care sector.²⁸

Given the scarcity and inconstancy of international wage data for the LTC workforce however, especially within national data sources, compiling information for a comparative assessment of care worker salaries has been another particularly challenging aspect of this research. Thus, in light of the corresponding concerns involving accuracy and issues that may arise from expected between- and within-country differences, the information presented in this section should be considered with a great deal of caution.

In this context, we appeal to SalaryExpert’s salary calculator—which, in addition to being powered by the Economic Research Institute (ERI), uses regularly updated international compensation and cost of living data to provide users with reliable salary estimates for a wide range of professions in specified locations—for the purpose of comparing existing salary estimates of various LTC staff among our countries of interest in a way that aims to preserve some level of homogeneity in the available data.

The following table contains job descriptions used by SalaryExpert to distinguish LTC staff whose wage data were used to produce the subsequent graphs.

Salary Expert’s Job Descriptions for LTC Workers

	Title(s)	Job Description
RN	Registered Nurse	‘Treats and provides general nursing care to patients in hospital, nursing home, infirmary, or similar health care facility. Administers prescribed medications and treatments in accordance with approved nursing techniques. Readies equipment and aids physician during treatments and examinations of patients. Observes patient, records significant conditions and reactions, and notifies supervisor or physician of patient’s condition and reaction to drugs, treatments, and significant incidents. Requires RN license.’
RN-HC	Registered Nurse (Home Care), Home Care Nurse	‘Treats and provides professional nursing care to assigned patients in their home. Evaluates patient and plans and makes appropriate changes to the home care nursing process. Contacts physician and hospital to arrange for further medical treatment when needed. Requires RN license.’
RN-LTC	Registered Nurse (LTC)	‘Assess patient health problems and needs, develop and implement nursing care plans, and maintain medical records. Administer nursing care to ill, injured, convalescent, or disabled patients. May advise patients on health maintenance and disease prevention or provide case management. Licensing or registration required. Includes Clinical Nurse Specialists. Excludes Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners.’
AN	Assistant Nurse, Nursing Assistant, Nurse Aide	Helps patients in hospital, nursing home, or other medical facility, performing a variety of uncomplicated tasks, under direction of nursing and medical staff. Responds to signal lights, bells, or intercom system to determine patients’ needs. Bathes, dresses, and undresses patients. Serves and collects food trays and feeds patients requiring help. Transports patients, using wheelchair or wheeled cart, or assists patients to walk
HHA	Home Health Aide, Home Care Aide	Assists in providing simple or uncomplicated patient care in caring for elderly, convalescent, or disabled people in patient’s home. Changes bed linens, washes and irons patient’s laundry, and cleans patient’s quarters. Buys, prepares, and serves food for patient and other members of family, following special prescribed diets. Assists patients into and out of bed, automobile, or wheelchair, to lavatory, and up and down stairs. Assists patient to dress, bathe, and groom self
CA	Care Aide, LTC Aide	Provide routine individualized healthcare such as changing bandages and dressing wounds, and applying topical medications to the elderly, convalescents, or persons with disabilities at the patient’s home or in a care facility. Monitor or report changes in health status. May also provide personal care such as bathing, dressing, and grooming of patient.
CG	Caregiver	Cares for elderly, disabled, or convalescent persons. Supports employer, attending to personal needs. Transacts social or business affairs. Consorts with employer on trips and outings.

For more information on SalaryExpert’s tools and data-collection processes, please refer to SalaryExpert.com.

 

Average Annual Salaries of LTC Workers by Title and Country

 

Average Annual Salaries of Entry Level LTC Workers by Title and Country

 

Average Annual Salaries of Average Level LTC Workers by Title and Country

 

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NOTE:

• Values obtained from SalaryExpert, originally in national currency units (NCU), were converted to USD via Google Finance.
• Boxplots reflect average annual salaries for entry level (1-3 years of experience), average level (3-8 years of experience), and senior level (8+ years of experience) workers.
• Dashed lines in all plots give each country’s median household income for specified years.
• Percentages displayed on bar graphs give the percent changes of average salaries from country-specific median incomes; with “+” and “\(-\)” indicating percent increases and decreases, respectively.

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Provided that tenure tends to be relatively low for care workers, as we shall see in the coming section, we include bar graphs for entry and average level wages with corresponding percent changes from median incomes to emphasize the figures that we believe are most representative of the entire LTC workforce.

These graphs, in tandem, suggest a few things.

1. Nursing personnel earn higher wages than direct care workers. As noted by OECD, care workers in the nurse category earn significantly more than direct care workers. In particular, although salaries appear to be uniform for all personal care staff in Sweden—which could be due to similarities in roles, terminology issues, or insufficient wage data to differentiate care staff salaries among other factors—we notice that the highest earners, by SalaryExpert’s terms, tend to be RN (LTC), followed by RN, RN (Home Care), care aides, caregivers, assistant nurses, and home health aides, in that order. Not only do nursing personnel receive higher pay however, but they also see the greatest salary increases when transitioning from entry level workers to average level workers. That is, according to this data, while nurses see significant growths in their yearly earnings, positively setting them apart from from the median income line with just a few years of experience, direct care workers remain deprived of career-advancement opportunities in the LTC sector and the prospect of building wealth for their families and their communities. This undervaluation of care staff, particularly direct care workers, reinforces their exceedingly high turnovers.

2. LTC workers in Japan experience the largest salary increases after gaining experience. For all LTC staff, Japan sees the largest salary increases between entry level and average level workers. That is, care workers in Japan, irrelevant of title, experience greater increases in their wages than American, German, and Swedish equals after three years of experience. This may not be so relevant if, for example, tenure tends to be low among these workers. Particularly, in the case that the majority of Japanese care staff leave the sector before becoming average level workers, salary increases would then be practically impalpable. Notably, the magnitude of wage increases between entry and average workers for the remaining countries stayed fairly consistent across all categories of LTC workers, with Germany having shown the greatest leap after Japan, followed by the U.S. and then Sweden—the only exceptions to this being for caregivers in the U.S. and Sweden who showed the same wage increases relative to their median incomes, and for home care as well as LTC RNs, who displayed the same increases in salary for Germany and the U.S. As with Japan, we could argue that in Sweden, gaining experience in the care sector doesn’t seem to yield the financial reward associated with working up to an average level care worker in other countries. We ought to however, examine a greater pool of circumstances. Namely, aside from tenure being a significant factor to consider when evaluating experience-based raises, starting wages for entry level workers (relative to median household income in our case) are another key factor for determining whether changes in salary are in fact pertinent. For example, if Japanese care workers earn significantly less than their Swedish counterparts—who, in contrast, see considerably smaller increases in their earnings after having gained three years of experience; then a more drastic average increase in pay would seem critical for preserving equal standing between these workers. If on the other hand, care workers in Japan already earn much higher salaries in entry-level positions, then we would be forced to look at why care workers in Sweden, in addition to earning substantially less, have little prospects for financial growth in LTC.

3. Relevant to median household income, LTC workers earn the highest wages in Japan and the lowest wages in the U.S. On the surface, it appears that care staff in the U.S. earn appreciably higher wages than those in other countries discussed—and in absolute terms, this holds. However, we see that the converse is true when we account for median household incomes as a way of contextualizing these figures for suitable baseline comparisons. It is in this regard that we not only see nurses in Japan earning vastly higher salaries than their German, Swedish, and American equivalents, but that for all care workers, earnings remain, even if only marginally, higher in Japan than in all other countries depicted irrespective of experience level&mdahs;with the exception of home health aides, where those working in Japan earn slightly less than those in Germany and even less than those in Sweden, but still considerably more than those in the U.S. Strikingly, we observe that when it comes to direct care workers, still in the context of median household incomes, annual wages are lowest on average for those employed in the U.S. irrespective of experience level. This is particularly concerning for several reasons.

   • First, in that “low wages” is one of the primary reasons that care workers leave the LTC sector in Japan despite earning significantly more than those who perform the same work in other countries; this being especially true for male staff as was discussed previously. The fact that they have the highest earnings out of all depicted countries, does not however, indicate that care worker salaries in Japan are high, or even adequate by national working-class standards for that matter. Rather, it highlights the severity of the issues surrounding job quality and fair pay within the care sector, particularly for those in countries where LTC wages are exceedingly below the median income.
   • Second, the idea that care workers in Japan earn more than their German and Swedish counterparts is not immediately alarming, given the fact that working-class Germans and Swedes benefit from more comprehensive government systems and public policies that provide a wider range of services—meanwhile those in Japan must sacrifice a share of their earnings to provide themselves with these services, thereby justifying higher levels of pay. For instance, in benefiting from univesal healthcare, care workers in Germany and Sweden do not have the added expense of health insurance premiums that those in Japan do—typically in the form of payment cuts by employers to provide all workers with healthcare at a fixed cost. This does not, on the other hand, explain why average salaries for care workers in the U.S. are (in relative terms) so far below those for similar care staff in all three other countries. Indeed the model adopted by the American healthcare systems is comparable to that of Japan’s; in any case, more so than to that of Germany’s or Sweden’s. However, the most notable difference between them is that no care worker or employed individual under the Japanese healthcare system stands to go bankrupt from unrealistic healthcare costs like many do in the U.S. Particularly, Japan’s fixed fee schedule and provision of universal healthcare coverage limits individual spending and reduces the financial burden of health insurance, which many Americans, especially minorities, regularly endure. In this way, the American healthcare system—notorious for financially draining thousands of working-class people every year³⁹—would lead us to expect much higher care worker salaries, in relative terms, than we observe. This should of not only refect the coulntry’s severe neglect of those whose work drives the American economy, but of those whose lives depend on this work.
   • For this reason, international differences regarding employment laws and worker benefits, which often reflect broader political agendas and cultural values, is yet another matter to consider when evaluating cross-national wage comparisons.

It should be noted that our reasonings are based on 2018 German and Japanese median incomes as well as 2019 median incomes for Sweden and the U.S. Given that SalaryExpert’s data are expectedly more recent, these findings may be prone to some level of inaccuracy if median household incomes have since changed. Conducting a similar analysis, with updated median salaries or compensation data reflective of relevant time periods for median incomes, may reduce the chances of biased assumptions and provide more solid grounds for inference. However, provided that the years considered in this analysis are in close range, we anticipate that our observations are, at least, moderately idicative of the relative financial standings of LTC workers in the countries discussed.

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In addition to country-specific information on wages gathered for the purposes of this work, shown in the remainder of this section, we include graphs representative of the wage data provided by PHI and OECD as a way of corroborating some of our findings from SalaryExpert above.

Particularly, we present PHI’s data to substantiate our observations pertaining to the direct care workforce—which, by PHI’s definition, “comprises personal care aides, home health aides, and nursing assistants”.

 

 

Our immediate thoughts on PHI’s data—which specifically give 2019 median annual earnings of direct care workers in the U.S.—is that figures are rather low compared to those provided by SalaryExpert. However, there are a few things to consider regarding potential reasons for these discrepancies.

1. The more straight-forward reasons for variation in wage estimates include, but are not limited to, inherent differences in:

   • sample size;
   • sample design or data-collection process;
   • population and locations represented in the sample;
   • terminology or definitions used for direct care workers;
   • units/measurements, conversions/calculations, and data transformations;
   • result interpretation.

2. PHI’s data reflects median earnings, while SalaryExpert’s is based on averages. This difference in statistical measures is particularly relevant in cases where fewer individuals earn considerably higher wages since averages tend to be more drastically influenced by extreme values in the data. Thus, if factors other than experience (such as company-membership or variation in costs of living) contributed to higher wages for a small subset of individuals reflected in the samples, it would make sense for SalaryExpert’s estimates to have been pulled in that direction, making them appear much higher than PHI’s figures—that is, depending on the extremity of values present in the samples, which themselves are subject to influence by a range of factors such as those outlined above.

Nonetheless, after closer inspection, we notice that SalaryExpert’s estimates for entry level staff in the U.S.—roughly ranging between $16k-$30k for all care workers—are in fact comparable to PHI’s estimates, which more narrowly range between $18k-$24k. As discussed previously, this could be partially due to sampling and procedural differences, meanwhile reflective of specific measures used to represent population-level salaries—thereby explaining SalaryExpert’s display of a more drastic range of values as well. By and large, this suggests that Salary Expert’s data—at the very least, that which pertains to entry and average level direct care workers—are not so unparalleled that it should prevent us from making surface-level salary comparisons between countries.

With respect to SalaryExpert’s estimates regarding nursing staff in LTC, we appeal to OECD’s most recent Health care resources dataset which includes mean remunerations for health professionals over several years across a number OECD countries. Specifically, the graphs below provide salary trends for (registered) hospital nurses, measured in various terms, up to 2018 for Germany, Japan, and the U.S.

 

Average Annual Salary of Hospital Nurses by Country Over Time

 

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NOTE:

• “Average salaries for healthcare professionals are now converted to USD PPPs using PPPs for private consumption to bring them in line with average earnings calculations across the OECD.”

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Looking at these graphs, we notice that OECD’s salary estimates (in USD), despite being generally lower, are within the ranges of those displayed in SalaryExpert’s nurse-specific data, especially for “Registered Nurses”. More importantly, we identify that mean nurse salaries, particularly those in more recent years, are not only similarly arranged by country—higher in the U.S. than in Germany, and higher in Germany than in Japan, as was originally observed—but their relative differences are also comparable to those shown by SalaryExpert’s data. Conversely, remaining discrepancies, aside from having been potentially influenced by (one or a combination of) the aforementioned procedural varieties, could be explained by the following:

1. Existing time differences between estimates—a factor of particular importance if salary observations gathered by OECD in 2018 happen to be at significant odds with SalaryExpert’s undefined, yet presumably more up-to-date, wage data.

2. The fact that OECD’s data pertains to nurses working strictly in hospitals, while SalaryExpert’s regards nursing staff working within a range of LTC settings, which per their descriptions displayed above, includes, but need not be limited to, hospitals for all nursing types.

In this way, OECD gives a more restricted overview of salaries for nurses—one that does not necessarily contradict that of SalaryExpert’s, but like PHI’s, accentuates the variability within its estimates and limits the amount of validity it can provide.

Nonetheless, the striking parallels observed between all three datasets, supports the idea that a sizable portion of SalaryExpert’s figures and our corresponding findings are, at the very least, telling of a broader financial reality which calls attention to the profound undervaluation of LTC workers across nations; particularly those that take on direct care roles, and those that work within the American LTSS system.

Moreover, the graph below gives SalaryExpert’s projected yearly bonuses for all care workers discussed. As with the rest of SalaryExpert’s figures, we anticipate that these estimates are subject to influence by a range of possible factors and should therefore be considered with great caution.

 

 

Germany

In 2018, workers in residential and non-residential long-term care earned hourly wages that fell 18% and 16% below the national average according to data from the EU Structure of Earnings Survey (SES).²⁸

• The starting monthly salary of an entry level senior caregiver is approximately €2,400, but may increase to around €2,800 after ten years of experience—amounting to a yearly range of about $29-34k.²⁷
• Conversely, caregiver assistants earn an average monthly wage €2,000—amounting to a yearly average of approximately $24k.²⁷

According to the Federal Ministry for Labor and Social Affairs, on January 28th of 2020, the Nursing Commission agreed to raise minimum wages for caretaking personnel in elderly care²⁹:

• In July of that year, the hourly minimum wage for care assistants in western and eastern parts of Germany rose to €12.55.
• For the first time, the care commission set a minimum care wage for qualified nursing assistants and specialists, said to have taken effect on April 1st, 2022.
  • Nurses: The hourly minimum wage for qualified nurses was set to €15.40.
  • Nursing Assistants: The hourly minimum wage for qualified care workers was set to €13.20.
  • Additionally, nursing staff became entitled to paid leave aside from their statutory leave entitlement—amounting to to five days in 2020 and six days in 2021 and 2022 for employees with 5-day work weeks.
• Presently, around 1.2 million workers are employed in care facilities that fall under the minimum care wage.
• Non-residential care staff, for whom the minimum care wage does not apply, must be paid at least the general statutory minimum wage—currently standing at an hourly rate of €9.82 and expected to rise to €12 by October of 2022³⁰.

 

Japan

Despite being one of the world’s wealthiest countries, people working in Japan have long had some of the lowest wages among all residents in OECD countries. Specifically, in 2021, the average salary in Japan was approximately equal to $40,949, which according to OECD’s data, was the 11th lowest of all 38 OECD member states. ³¹

One possible reason for Japan’s traditionally stagnant wages relates to the “cultural importance of job security”.

“Historically, workers stick with their employers for many years and are willing to sacrifice bigger wage hikes in favor of greater employment stability.”³¹

• Japan’s government-mandated prefectural minimum wages—last changed in October of 2016—range between hourly rates of ¥714-932 for all workers; roughly amounting to $5.38-7.02 per hour.³²
  • Certain industries also have distinct minimum wages which are often set higher than prefectural ones. In the case that these differ however, the higher of two will apply.³²
  • Under Japan’s labor law, additional earnings—such as for working overtime or on holidays, commuting, bonuses, tips, etc.—must be paid in addition to, rather than as part of, the set minimum wage.³²
• Given the rising costs of living as a result of global inflation, “the Japanese government has released a proposal to increase its average minimum wage by a record 3.3% for the fiscal year ending in March 2023”—amounting to an overall average hourly rate of ¥961, or $7.30, compared to the current average of ¥930.³¹

Studies show that,

\[\textbf{“The relatively low wage levels of LTC workers increase their intention to leave the LTC sector.”}^{21}\]

However, according to the CEO of a Japanese nursing home, interviewed as part of the Lien Foundation’s Long Term Care Manpower Study³³,

“Promotion prospects are attractive. The average care worker salary is ¥3M/yr ($22,528.80/yr). With a license, good work ethics and some leadership skills, this will increase to ¥4-5M/yr ($30-38K/yr). As [around] 60% of our workforce moves from a different industry, this is quite attractive.”

Moreover, in efforts to improve the wages of LTC staff, the Japanese government has initiated “reforms of regional LTC unit prices for regions with high labor costs, and wage subsidies to help develop career paths, while restraining the average LTC fee schedule”—measures which studies have shown have had a positive impacts on care worker wages.²¹ Particularly,

• Some showed that negative revisions to the LTC fee schedule for the fiscal years of 2003 and 2006 may have caused wages of LTC workers to fall.
• While others concluded that revisions “which raised LTC unit prices in urban areas” for the fiscal years of 2009 and 2012 had no impact on care workers’ scheduled cash earnings—having only increased lump-sum payments and bonuses—in the fiscal year of 2015, these revisions were shown to have increased scheduled cash earnings for new job applicants.

Additional studies showed²¹:

• For care workers employed in less aged regions of Japan, particularly men, wages “are noticeably low compared to those of other industries”.
• “The older the prefecture, the higher the ratio of health and welfare industry workers, but the lower the wage rate overall.”
• Wage rate increases reduce working hours and have no impact on the number of LTC workers.
• “Even if increases in wages for LTC workers reduce turnover, they do not necessarily increase the supply of LTC workers.”

A welfare ministry survey covering 10,670 facilities (including special care homes) found that the average monthly salary, including basic pay, allowances, and bonuses, for regular workers at elderly nursing care facilities exceeded ¥300,000 “for the first time since the survey started in 2009”—standing at ¥300,970, or $2,260.16, “as of September 2018 among facilities receiving government support aimed at promoting pay increases for care workers, up by ¥10,850 from a year earlier”. On the other hand, the average basic pay alone amounted to a monthly ¥181,220, or $1,360.89; showing an increase of ¥3,230 from 2017—the equivalent of $24.26.³⁴ This is primarily the case for care workers in facilities “receiving government support aimed at promoting pay increases for care workers”. According to ministry officials,

\[\textbf{“The growth reflected not only a boost from the program but also upward pressure} \\ \textbf{on wages caused by manpower shortages at many facilities.”}^{34}\]

 

Sweden

In Sweden, wage rates are negotiated and set by workers’ unions and employers, “considering a fair rate for a decent living and other statistics from various unions regarding average salaries, as guidelines”.²⁸

• Although the country doesn’t have a set minimum wage established by law, data shows that gross minimum salaries hover around monthly rates of 18,000kr and hourly rates of 113kr—roughly amounting to $1,650-1,750 a month, or $10.5-11 an hour.²⁸
• As of 2018, workers in residential and non-residential long-term care earned hourly wages that fell 14% and 15% below the national average according to data from the EU Structure of Earnings Survey (SES).²⁸
• The European Commission’s 2021 report claims that the average monthly full-time salary for an assistant nurse within LTC is around 80% of the national average and lightly above 70% for care aides.¹⁰

It should be noted however, that part-time employment and shift work or “employment by the hour”, in addition to being common within the LTC sector, are particularly prevalent in Sweden. According to the European Commission’s report,

\[\textbf{“The stressful working conditions are further amplified by low pay} \\ \textbf{and uncertain employment contracts.”}^{10}\]

 

VI. Retention & Turnover

The majority of OECD countries face alarmingly high turnover rates in LTC—workers often leaving the sector entirely after only a few years. In particular, OECD states:

“In countries for which data are available, it is estimated that turnover issues affect between one-quarter and one-third of LTC workers. For instance, in the United States, turnover in the overall LTC workforce is a challenging issue: in 2013, 13% of LTC workers were entrants while 21% were LTC sector leavers.”⁶

In their recent report, Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD provides average tenures for care workers in 2016 and highlights that several OECD countries ranked retention as being a challenge of high importance within their LTC agendas as part of a 2018 survey.⁶ The first and second left-most graphs below, based on Figures 4.1 and 4.3, summarize this information. Additionally, the second right-most graph below illustrates the shares of part-time and temporary staff (not including shift-work) in LTC for our countries of interest in given years, as provided by OECD.^d

 

\[\textbf{“On a scale between 1 (low-level) and 5 (high-level), what is the challenge faced}\\ \textbf{to retain LTC workers into the LTC workforce in your country?”}\]

 

Germany

German official statistics suggest that around 1.218 million people were employed in LTC in 2019, with more than two thirds having been part-time workers.¹⁰ A 2021 study titled Workforce issues in home- and community-based long-term care in Germany similarly stated that approximately 80% of employees in Germany work part-time³⁶, while OECD additionally claims that more than 50% of home-based carers work shifts.

\[\textbf{“Nevertheless, LTC is characterized by a pronounced lack of LTC professionals.”}^{10}\]

In light of this, stakeholders agreed on setting goals and comprehensive measures in June of 2019 in a shared attempt to improve remuneration as well as working and training conditions for nursing and caretaking personnel within LTC. Five different working groups specified goals and measures to be adopted on topics such as training; personnel management; occupational health, safety, and health promotion; innovative approaches to care and digitization; recruitment of nursing staff from abroad; and remuneration conditions in care.^10,37

According to OECD, estimates based on the German Socio-economic Panel show that, on average, only 68% of German LTC staff “in a given year keep participating in the LTC workforce the following year”—a remarkable fact that “holds true for people who have recently completed their training, according to the German Institute for Employment Research”.⁶

Although, “the frequency and intensity of staff turnover varies greatly between provider organizations”. Authors of Workforce issues in home- and community-based long-term care in Germany mention the following as being the most likely reasons for the prevalence of staff turnovers among care organizations³⁶:

• Poor leadership and lack of professional human resources development.
• Unrealistic expectations of nurses working in home care.
• High identification with and awareness of one’s importance for the company.
• Stronger thoughts of giving notice.

 

Japan

“One of the factors contributing to the supply–demand gap for LTC workers is their shorter tenure and low wages compared to other industries and occupations…A series of empirical studies in Japan have repeatedly found that low wage levels have increased the turnover rate of LTC workers.”²¹

• As shown above, 18% of LTC workers in Japan held part-time positions in 2016. At the same time, 43% of care workers were on temporary contracts—the largest share compared to the 19 other OECD countries for which data were available.⁶
• Additionally, we observe that the average tenure for LTC workers in Japan was around 6.5 years in 2016, compared to 12 years for workers in all sectors. Notably, out of 21 OECD countries surveyed, Japan not only showed the highest average tenure among all working people, but the largest discrepancy between mean tenures in care and its entire workforce—highlighting the particularly high turnover associated with LTC by Japanese standards.⁶
• Although the median tenure among regular facility workers was 5 years in 2017, one study claims that “the proportion of care workers with more than 10 years of service is increasing, accounting for about 20–30% or more. While this is certainly lower than the all-industry average of 40%, the median length of tenure of LTC workers rose by about one year over every five years.”²¹

Among the countries that have implemented coaching and/or stress management programs, Japan has arranged for the provision of counseling services through professional agencies “to give advice on how to improve employment management in LTC”.⁶

Nonetheless, available data show that in 2014, 20% of LTC workers in Japan reported having had at least one work-related accident in the previous 12 months that resulted in injury.⁶ This is particularly concerning given the share of rapidly aging workers in LTC. Unsurprisingly, one study found that while the primary reason for male subjects leaving LTC was “low wages”, the main reason for women was “old age”.²¹ When compared to leavers in all industries, the results were as follows:

• Whereas 19% of male workers who left LTC in 2017 cited “low income” as their reason for leaving, the average share of all industry leavers who gave this response was 14%.
• Aside form “old age” being the primary reason for women leaving the care workforce, one in seven female care leavers cited “informal care”—such as caring for an elder or sick family member, caring for a child, childbearing, etc.—as their reason for leaving, while the corresponding proportion for all female leavers was only one in twenty.
• Roughly 10% of total LTC leavers in 2017 cited “illness” or “old age” as their main reason for leaving, while the average for all leavers was a mere 3%.

Moreover, when asked to provide reasons for wanting to change jobs, responses given by those working in LTC between 2007 and 2017 were summarized as follows:

• Compared to the average for all sectors, significantly more men in LTC cited “low wage or salary” as the primary reason for wanting to change jobs—32% higher than the 2007 all-industry average and nearly twice as high compared to female LTC workers in 2017.
• As much as 44% of the female care staff cited “long working hours” or “heavy physical strain” as a reason for wanting to change jobs—almost two times the average for all industries in both years.

Thus, authors argue that, as discussed previously in less detail, “to replace aging and retiring female LTC workers, wages must be raised to promote male LTC labor supply and to reduce their turnover rate”. Crucially, they also reason that

“To identify the factors behind the undersupply of LTC workers, it is necessary to identify those sectors from which, or to which, LTC workers are flowing…It would then be possible to argue that the wage level of LTC workers should be set more appropriately, by referring to wage levels in those sectors.”²¹

 

Sweden

“To have professionally trained staff, and—equally important—making them stay, is a key challenge within the Swedish LTC system.”¹⁰

According to the European Commission, a survey among care workers in Sweden showed that almost 50% of participants were “seriously considering quitting the job” at the time, especially those with higher educational credentials.¹⁰ Given the prevalence of foreign-born workers in Sweden, this makes sense as “the share of migrants reporting that they are overqualified for the work they do is greater in the LTC sector than any other” in most European countries.⁶

Moreover, reasons for LTC workers desire to quit were identified by the European Commision as being associated with a range of “problematic and hectic working conditions”—many involving work schedules that lead to “a work-life balance problem”.¹⁰ A trade union study, which found a smaller, but growing, proportion of possible quitters in LTC within a three-year period, noted that low pay and uncertain employment contracts further amplify the current stressful working conditions of care staff, as was previously mentioned.¹⁰

In particular, the overwhelming number of Swedish LTC workers that work part-time or in shifts reflects both the care market’s dependence on temporary and hourly work, as well as the level of job insecurity present among care employees.

• OECD states that more than 70% of LTC workers work shifts in Scandinavian and central European countries—a phenomenon which an overwhelming amount of evidence suggests is associated with a wide range of health risks including depressive syndromes, anxiety, and burnout.⁶
• Interestingly, individuals working in institutions are on average 80% more likely to work shifts compared to home-based carers. However, while 25% of all care workers are employed by the hour²³, as is the case in Germany, more than 50% of home-based carers work shifts in Sweden.⁶
• One study claimed that, based on 2008 Swedish statistics, 65% of direct care workers in Sweden work part-time. At the same time, authors pointed out that this kind of part-time work was much more common among care workers than among the entire female workforce in gerneral.¹⁹
• Crucially, it was argued that the prevalence of part-time work was to some extent involuntary as roughly 22% of surveyed workers said they’d worked shorter hours than they preferred and 7% held more than one job—“suggesting that there was both a need and a desire for full-time jobs”.¹⁹

Additionally,

“Work stress and low pay for many in the LTC workforce has constantly been a challenge and deteriorating working conditions over time has been reported, something that is also reflected in sick leave statistics.”¹⁰

• Particularly, the share of assistant nurses and other LTC employees on sick leave is two times higher than that of the entire labor force in Sweden—“a fact that is likely to decrease continuity and quality”.¹⁰
• As mentioned previously, “female eldercare workers have 50% more sick days than women in the rest of the workforce”.²³
• Not only are physical load injuries three times more common in the LTC sector than in the overall Swedish labor market, but occupational disease due to social and organizational factors increased by over 70% between the years 2010 and 2014.

Sweden’s largest labor union, Kommunal, announced in Mach of 2020 that

“40% of staff at nursing homes in Stockholm were unskilled workers employed on short-term contracts, with hourly wages and no job security, while 23% were temps.”³⁸

Thus, in light of Swedish care workers’ job insecurity and adverse working conditions, which have been amplified and exposed as a result of the more recent COVID-19 pandemic, the Swedish government, together with Kommunal, introduced the Elderly Care Lift Program (äldreomsorgslyftet). Expected to cost around SEK 4.5 billion between 2020 and 2023, this a LTC workforce reform is to³⁸:

• Offer paid education to LTC employees within their employment contract during paid working hours.
• Assure that those taking part in the program are offered permanent employment contracts.
• Give 10,000 new permanent employment contracts for assistant nurses and care aides.

 

Conclusion

In order to satisfy the growing care needs of our overpopulated and aging world, policymakers and national governments must elicit creative strategies to both retain and attract skilled professionals to the care sector in an effort to close the gap between the supply and demand of LTC workers.⁶ Importantly, this will require a widespread acknowledgement of the flaws within our care systems—particularly those with high impacts on job quality that have become increasingly more apparent with the global outbreak of COVID-19.

 

\[\textbf{The diminishing quality of care provision is but a mere reflection of the care} \\ \textbf{system's failure to provide workers with quality jobs.}\]

 

As we have continuously suggested throughout this work, care workers all over the world are not only excessively overworked as a result of widespread staff shortages, but also exceedingly subject to inadequate pay and a lack of career prospects among a range of adverse working conditions which often result in injury or poor mental and physical health more broadly. The ongoing neglect and undervaluation of a disproportionately aged, female, Black and Brown, migrant, and unskilled care workforce is thereby reflected in the abundance of worker dissatisfaction and turnover; the growing dependence on informal caregivers; and the diminishing quality of formal care provision.

In these circumstances, international approaches to strengthening and improving the LTC workforce provide valuable lessons for the U.S. going forward; particularly, as it pertains to the well-being of those who provide and those who receive care. In what follows, we discuss some notable ones.

 

Germany

Unmonitored cash benefits. By the end of 2019, nearly 80% of those in need of long-term care were cared for at home, while 20% were cared for in nursing homes.¹⁰ At the same time, home-based formal care workers represent under 40% of the LTC workforce, suggesting that over 60% of formal workers care for merely 1/5 of the total population requiring long-term care. This contextualizes not only the sheer prevalence of informal care in Germany, but also the magnitude of the care system’s dependence thereon—a phenomenon that can largely be attributed to the German subsidiarity principle, which saw a share of 48.3% of LTCI beneficiaries receiving benefits in the form of care allowances alone in 2018.¹⁰ Although these cash benefits provide a positive sense of autonomy for care-dependents in granting them the freedom to choose how they would like to have their care needs met, there are also several negative consequences to consider. Particularly, the fact that such care allowances are unregulated and unmonitored, prompts a more cost-effective and often preferred form of care provision—for both caregivers and care recipients—commonly known as the “migrant-in-the-family” model, which despite making care more affordable and work more appealing for foreigners, allows for the backdoor exploitation of migrant workers and the unacknowledged neglect of care-dependents, as previously mentioned. Indeed, it may be the case that positives in this case outweigh the negatives and that the U.S. could benefit from a similar, perhaps more restrictive, scheme—one that makes long-term care more needs-based and accessible, as well as care provision more recipient-focused. However, it is important for policymakers to understand and equally consider both positive and negative effects discussed here, as it is possible for them have different consequences for the U.S. population.

 

Japan

Shifts in care workers’ profiles. Japan’s care system, which sees the largest share of male workers in formal LTC across all OECD countries, sheds light on the significance of reshaping the culture around care provision; reaffirming the importance of attracting men into the LTC workforce as it relates to reducing the burden of care that largely falls on women. Specifically, the physical and emotional strain of LTC, which has more damning consequences for the aging majority of female care workers, makes worse the already existing problem of attracting young workers to the LTC sector. As mentioned previously, one study showed that, between 2002 and 2017, female facility workers aged considerably while the number of male facility workers increased—leading researchers to conclude that: since “the shortage in the supply of LTC workers may become more serious as the aging female LTC workers retire”, it follows that “male workers are key to the supply of LTC workers”. Moreover, given that “low wages” had the greatest effect on male workers’ intentions to leave the LTC sector in comparison to the average for all sectors, it was also suggested that wage increases, despite not having shown a direct increase in the supply of male care workers, otherwise had a positive impact on their retention.²¹ This not only demonstrates the positive effects that reforms relevant to sources of job dissatisfaction has on the retention of care workers, but also implies that there are other, some perhaps more intrinsic, aspects of the care sector that deter prospective male applicants. It is thus crucial for the supply of workers and the demographic expansion of the LTC workforce to recast the image of care work; making it, more than a secure and quality job, a growth-centered, skilled, and widely-respected profession.

Promotion prospects. As we’ve shown in our analysis of salaries in LTC, Japan offers attractive promotion prospects for care workers. More than being reflected in current wage data, this is something that is also verified by documented first-hand accounts of employers in the care sector, as noted previously.³³ Not only has the Japanese LTC system more recently seen the greatest increase in average monthly salaries for care workers in over a decade—“particularly among facilities receiving government support aimed at promoting pay increases for care workers”³⁴—but care workers, at least those working in nursing facilities, can expect substantial growth in their wages after becoming licensed, gaining-experience, and demonstrating strong leadership skills and good work ethics.³³ This is both appealing for men, who tend to be primarily driven by higher salaries and are hence, more likely to work in care facilities; as well as for the broader population of prospective workers who desperately seek job security. However, the fact that such reforms largely apply to facility-care only, this leaves little room to evaluate their potential effects on a greater scale, given that the bulk of the Japanese LTC workforce is home-based.

Quality assurance. Although no educational requirements are imposed in Japan, the country’s LTC quality assurance guarantees that care workers maintain high levels of skill through mandated examination, rigorous training, and certification, in addition to offering “financial incentives for providers to provide care workers with continuous training opportunities”¹⁷. It is likely that this framework, seldom seen across OECD countries, has largely contributed to the comparably high shares of educated care staff documented in Japan, incentivizing workers to seek higher education in care-related fields. Moreover, given that direct care workers in the Japanese LTC system are responsible for a wide range of tasks which demand considerable knowledge, training, and skill, sponsored access to LTC education⁶, has been another successful approach to increasing both the competence and the supply of care workers.

 

Sweden

Shift work. The fact that Sweden’s spending on LTC is among the highest in the world is not a problem. Rather, it is the fact its care system is lacking in quality—both in terms of care work and care provision—in spite of this level of spending, that has made its sustainability questionable. That is, not only do a large number of Swedish care staff lack formal training, raising a range of concerns considering their involved and multidimensional roles, but the majority also lack job security due to the care system’s profound dependence on shift and part-time work. In recognition of this, the Swedish government has taken immediate steps to ensure that care workers receive adequate training and are guaranteed permanent employment contracts, thus, motivating young people to seek care work and existing staff to remain in the sector. Given that this program remains in its infancy, we have yet to witness its positive effects on the system. However, the goals outlined by Swedish officials suggest drastic quality improvements to the LTC system as well as increases to the supply of workers. In this way, such reforms reveal the kind of drastic measures needed to bring forth notable changes to the nature of care systems everywhere—primarily in view of adhering to the needs of care workers as a way of ensuring the care needs of our aging populations are adequately met.

Systemic oppression in LTC. As we’ve vaguely alluded to, foreign-born workers of non-European origin face even more precarious working conditions than their Swedish and European counterparts, suggesting a more implicit racial issue within the nation’s historical, cultural, and political ideals which underlie Swedish systems of governance—a matter to which the United States is no stranger. Viewed in this way, not only will solutions (for both countries) require a hard look at the system’s injustices against racial minorities, but also involve a much more extensive collective effort to combat systemic oppression in LTC through fair, race-conscious policies. This is particularly relevant to the U.S. given the nation’s considerable population of Black, Brown, and foreign-born workers, who are not only overrepresented in the care workforce, but largely overqualified for the care jobs they are offered. In this way, POC and foreigners are increasingly subjected to higher degrees of injustice—receiving inferior wages to their white counterparts, which in turn contributes to widening the racial wealth gap. In addition to implementing more a structured means for recruiting foreign workers, as many other countries have done successfully, the U.S. must acknowledge their value by prioritizing their needs and ensuring that marginalized workers receive the respect, dignity, and fair treatment they deserve.

---

Future Work:

• Workforce mobility analysis. In Aging and Wages of Long-Term Care Workers: A Case Study of Japan, 2002–2017, Atsuhiro and Ishii provide invaluable insight into how we may “identify the factors behind the undersupply of LTC workers”; arguing that “it is necessary to identify those sectors from which, or to which, LTC workers are flowing”. Importantly, they suggest that comparing salaries within the LTC sector to those within sectors that tend to attract or deter care staff, would allow for a more meaningful assessment of current care worker wages and regional LTC unit prices, and consequently, a more grounded argument for percise changes we must see to ensure a continued supply of LTC workers.²¹ Thus, workforce mobility analysis, offers a key tool for quantifying inadequacy within the care system contributing to worker dissatisfaction more broadly, and hence, to high turnovers. In this way, this method may not only reveal to us the factors that deteriorate job quality, but also offer specific solutions to improve staff retention.

---

 

As we have come to learn throughout the course of this research, those who provide long-term care are faced with varying degrees of individual and group-level injustices.

 

\[\textbf{The unmet needs and unheard voices of caregivers, both formal and informal, is a global issue—not only} \\ \textbf{within the scope of public health (and policy), but within the orbit of social justice.}\]

 

In addition to bringing to light some of the successes and failures of international LTSS systems—identified and remarked in the literature—that offer important lessons for the U.S. going forward, this work should provide a glimpse into the profound undervaluation of care staff, and consequently, the severe exploitation of women of color in the world beyond our American borders. For this reason, the adverse working conditions of care staff is not only a global public health (and policy) issue, but a social justice issue that demands urgency, innovation, and mass interdisciplinary collaboration. As such, policy research within the context of LTSS couldn’t be of more crucial importance. It is in this light that we have devised this work and hope it will encourage and inspire future work in this space.

 

 

References

[1] “MIT Colab.” MIT CoLab.

[2] Campbell, Stephen, et al. “Caring for the Future: The Power and Potential of America’s Direct Care Workforce.” PHI, 15 Jan. 2021.

[3] Cook, Allison, and Grant Williams. “Centering Equity in Long-Term Services and Supports: A Primer on Financing Models.” MIT CoLab, MIT CoLab, 18 Mar. 2022.

[4] Cook, Allison, and Grant Williams. “Centering Equity in Long-Term Services and Supports: Case Studies & Lessons from the U.S.” MIT CoLab, MIT CoLab, 29 Apr. 2022.

[5] Cook, Allison, and Grant Williams. “Centering Equity in Long-Term Services: Lessons from Germany, Japan, and Sweden.” MIT CoLab, MIT CoLab, 25 May 2022.

[6] Who Cares?: Attracting and Retaining Care Workers for the Elderly. OECD Publishing, 2020.

[7] “Long-term care workers”, Health at a Glance 2015: OECD Indicators, OECD (2015), OECD Publishing, Paris.

[8] Simmons, Cassandra, et al. “Working Conditions in the Long‐Term Care Sector: A Comparative Study of Migrant and Native Workers in Austria and Sweden.” Health & Social Care in the Community, vol. 30, no. 5, 2021.

[9] Doty, Pamela. “Long-Term Care in International Perspective.” Health Care Financing Review, CENTERS for MEDICARE & MEDICAID SERVICES, Dec. 1988.

[10] “2021 Long-Term Care Report: Trends, Challenges and Opportunities in an Ageing Society.” Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG EMPL), vol. 1, 2021.

[11] “Towards Carer-Friendly Societies - Eurocarers Country Profiles - Germany.” Eurocarers.

[12] Pieper, Oliver. “How Germany Fails to Manage Care for the Elderly.” DW.COM, Deutsche Welle, 1 Aug. 2021.

[13] “Topic: Long-Term Care in Japan.” Statista, Statista Research Department.

[14] Yamada, Minoru, and Hidenori Arai. “Long-Term Care System in Japan.” Annals of Geriatric Medicine and Research, vol. 24, no. 3, 2020, pp. 174–180.

[15] Gottschall, Karin, et al. “Dependencies of Long-Term Care Policy on East–West Migration: The Case of Germany.” International Impacts on Social Policy, Springer International Publishing, 2022, pp. 515–529.

[16] Cottle, Michelle. “Who Will Take Care of America’s Caregivers?” The New York Times, The New York Times, 13 Aug. 2021.

[17] OECD, Japan.

[18] Eurodiaconia.

[19] Daly, Tamara, and Marta Szebehely. “Unheard Voices, Unmapped Terrain: Care Work in Long‐Term Residential Care for Older People in Canada and Sweden.” International Journal of Social Welfare, vol. 21, no. 2, 2011, pp. 139–148.

[20] Lüdecke, Daniel, et al. “The Impact of Sociodemographic Factors on the Utilisation of Support Services for Family Caregivers of Elderly Dependents - Results from the German Sample of the EUROFAMCARE Study.” Psycho-Social Medicine, German Medical Science GMS Publishing House, 2012.

[21] Yamada, Atsuhiro, and Kayoko Ishii. “Aging and Wages of Long-Term Care Workers: A Case Study of Japan, 2002–2017.” Economic and Social Research Institute (ESRI), Cabinet Office, Government of Japan, 2019-2020.

[22] SAME AS [15]

[23] Nicholls, Christine. “Covid-19 Reveals Serious Problems in Swedish Long-Term Care.” Resources to Support Community and Institutional Long-Term Care Responses to COVID-19, LTCCovid, 18 May 2020.

[24] Yūko, Hirano. “Foreign Care Workers in Japan: A Policy without A Vision.” Nippon.com, 13 Feb. 2017.

[25] “Immigrant Health Staff Indispensable in Sweden’s Response to COVID-19.” European Website on Integration, European Commission, 5 Mar. 2020.

[26] SAME AS [8]

[27] “Nursing Jobs and Senior Caregiver Jobs in Germany.” LearnGermanOnline.org, LearnGermanOnline.org.

[28] Eurofound.

[29] Stolzenberg, Margo. “Higher Minimum Wages for Workers in the Care of the Elderly in Germany.” INCLUSIVA, 8 Dec. 2020.

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