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Challenges for financing and providing long-term-care in Eastern Europe
Johannes Koettl and Sarbani ChakrabortyEurope and Central Asia Regions – Human Development Sector
BackgroundWorld Bank prepared report on LTC challenges
for the New Member States of the EU and Croatia
Focus onDemographic transition in Eastern Europe and
implications for LTCCurrent LTC systems (financing, provision of
services, regulations) in Bulgaria, Croatia, Latvia, and Poland
Lessons learned from OECD countries (Austria, Germany, France, United States)
Key messages1. LTC sector has to prepare for future demographic
“shocks”
2. Substantial future fiscal pressure from LTC expenditures in ECA countries
3. Policy implicationsi) Urgent need to mobilize financing for future LTC
expenditures nowii) Control demand and costs for formal LTC services: From health to social services From institutional to community-based care From care fragmentation to care coordination From producing to purchasing LTC services From in-kind to cash benefits
1. Prepare for demographic shocks
Population is aging rapidly, yet not at a constant rate, but in waves
These waves will lead to sudden increases in the number of dependent people
There will be much less healthy people, and more and more dependent people
Who will then care for the dependent?
There will be much less young people, and more and more old people
Who will then pay the care for the dependent?
Example: PolandPolish society is aging rapidly, yet not at a
constant rate, but in waves: 2010
Source: Eurostat
Example: PolandPolish society is aging rapidly, yet not at a
constant rate, but in waves: 2020
Source: Eurostat
Example: PolandPolish society is aging rapidly, yet not at a
constant rate, but in waves: 2030
Source: Eurostat
Example: PolandPolish society is aging rapidly, yet not at a
constant rate, but in waves: 2040
Source: Eurostat
Example: PolandPolish society is aging rapidly, yet not at a
constant rate, but in waves: 2050
Source: Eurostat
Example: PolandPolish society is aging rapidly, yet not at a
constant rate, but in waves: 2060
Source: Eurostat
Sudden increase of 75+ age group during 2020s and after
2045 Annual population growth rate by age group
Source: Eurostat
Dependency level is highest among older age groups…
Dependency level by age group for Poland
Source: SILC
…so demographic waves will lead to sudden increases in the number of dependent
people…
Projected annual population growth rates by dependency level in Poland
Source: World Bank staff calculations
…while the healthy population is constantly decreasing (green line)
Projected annual population growth rates by dependency level in Poland
Source: World Bank staff calculations
Who will care and who will pay?
There will be much less healthy people, and more and more dependent people
Who will then care for the dependent?
There will be much less people in working age, and more and more retired people
Who will then pay the care for the dependent?
Today: 11 healthy per severely dependent2060: 5 healthy per severely dependent
Projected inverse dependency ratios for Poland
Source: World Bank staff calculations
Today: 5 aged 15-64 per 65+2060: less than 2
Projected inverse dependency ratios for Poland
Source: World Bank staff calculations
Key messages1. LTC sector has to prepare for future demographic
“shocks”
2. Substantial future fiscal pressure from LTC expenditures in ECA countries
3. Policy implicationsi) Urgent need to mobilize financing for future LTC
expenditures nowii) Control demand and costs for formal LTC services: From health to social services From institutional to community-based care From care fragmentation to care coordination From producing to purchasing LTC services From in-kind to cash benefits
2. Substantial future fiscal pressure from LTC expenditures in ECA
countries
Combination ofSteep expenditure increases per beneficiary in the
past (quality improvements)Expansion of formal services (larger share of
elderly consume formal services)Overall increase in number of elderly
Strong expenditure growth dynamic
Example: PolandTwo scenarios:
If expenditures per beneficiary continue to grow like between 2006 and 2008, cost explosion (pessimistic scenario)
If expenditures per beneficiary grow with GDP per capita, still considerable increase in spending (optimistic scenario)
Public expenditures per beneficiary increase strongly…
Public expenditures per beneficiary by benefit type and sector in Poland (current PLZ, 2005 to 2008)
Source: Wieckowska (2009) and own calculations
…on average more than 8% annually for in-patient LTC
Annual real growth rates of public expenditures per beneficiary by benefit type and sector in Poland (percent, 2006 to 2008)
Source: Wieckowska (2009) and own calculations
The pessimistic scenario Projected public expenditures on LTC (as share of
GDP)
Source: World Bank staff calculations
Example: PolandWhat are assumptions in optimistic scenario?
Return to strong GDP growth Likely to happen, but what if not?Expenditures per beneficiary (costs) increase with
GDP per capita UnlikelyShare of population who demand formal services
stays constant Very unlikely
Optimistic scenario seems more like minimum increase in public expenditures (over-optimistic)
Share of dependents who receive NO care in Poland more than 80 percent=> most likely to decrease strongly
Share of dependents with no or informal care, 2005
Source: EC
The optimistic scenario Projected public expenditures on LTC (as share of
GDP)
Source: World Bank staff calculations
Example: PolandWhere will Poland end up? Somewhere in
between….
In any case, sharp increase in spending during “shock” years (2020s and after 2050)
Key messages1. LTC sector has to prepare for future demographic
“shocks”
2. Substantial future fiscal pressure from LTC expenditures in ECA countries
3. Policy implicationsi) Urgent need to mobilize financing for future LTC
expenditures nowii) Control demand and costs for formal LTC services: From health to social services From institutional to community-based care From care fragmentation to care coordination From producing to purchasing LTC services From in-kind to cash benefits
3.i) Urgent need to mobilize financing for future LTC expenditures now
Risk-pooling is essential to avoid old-age poverty
Private LTC insurance has not been very successfulMarket failures (adverse selection, risk selection)Unpredictability of costs lead to high mark-ups
Large role for public sectorTax-financed (cash benefits, social assistance)Contribution financed (social security) Both are pay-as-you-go mechanisms Who will pay?
Who will pay?Today’s young can pay for tomorrow’s old…
Source: Eurostat
…but who will pay for today’s young when they are old?
Source: Eurostat
?
Increase private savings for retirement and dependency
nowIncrease savings of current working age
population for their own retirement and dependency needs
Private financial products (not LTC insurance for in-kind benefits) to insure against poverty in case of dependencyExample of FranceEnhanced annuity (life insurance payments
increases in case of dependency)Reversed mortgage
3.ii) Control demand and costs for formal LTC services
Promote healthy life-styles
From health to social services and from institutional to community-based care Channel future demand for formal LTC to more adequate and less
expensive services Away from medical care and hospital care Toward social care, especially community-based care Resist converting hospital infrastructure into inpatient LTC
infrastructure Rather, invest in community care centers that offer a wide variety
of (outpatient) care services (daycare and home-based care)
From care fragmentation to care coordination Especially between health and social sector to avoid cost shifting
at the expense of patients Joint needs assessments by inter-disciplinary teams (GP and social
worker) Scaled benefits
3.ii) Control demand and costs for formal LTC services
From producing to purchasing LTC services In the future, a much larger share of the economy will evolve
around providing care Cannot be done by public sector alone Define core competencies of the public sector The rest, buy from private market Proper regulation, accreditation, standards of care, and quality
control mechanisms Institutions and mechanisms might take time to develop In the meantime, explore potential of public-private
partnerships
From in-kind to cash benefits Puts consumer in charge Main vehicle to support (cheap) informal care Maybe easier to control public expenditures on cash benefits Explore potential of vouchers