GRAY MATTERS: HOW DO THE WORLD BANK’S ENGAGEMENTS IN SOCIAL PROTECTION & JOBS STRENGTHEN LONG-TERM CARE? Rethink Social Protection and Jobs in an Actively Aging World What is Long Term Care (LTC)? LTC comprises a set of services that support people in developing and maintaining their functional abilities to perform daily activities, participate in social activities, and pursue what they value. How does population aging interact with LTC? The need for LTC increases with age. Population aging will increase the demand for LTC services, which, in turn, will strain resources, increase government spending, and impact the labor market. What is the World Bank doing on LTC? Support to countries on LTC is still developing. Analytical and operational work to date has included pilots of LTC models in aging countries, knowledge generation, development of tools for needs assessment, financial projections, and guidance on preparation of LTC strategies based on country context and best practices. This brief offers policymakers and practitioners a primer that includes key issues including why countries should care about LTC; the components of a dialogue on LTC; what the World Bank is doing on LTC (including the list of engagements in Annex 2); lessons learned from World Bank engagements; and priorities for future work. 2 Contents Gray Matters: How Do The World Bank’s Engagements In Social Protection & Jobs Strengthen Long-Term Care? 1 THE CARE AGENDA 1 WHY CARE ABOUT LONG-TERM CARE? 2 COMPONENTS OF A DIALOGUE ON LTC 4 IMPACT: WHAT THE WORLD BANK IS DOING ON LONG-TERM CARE 14 LESSONS FROM WORLD BANK ENGAGEMENTS 16 MORE AND BETTER LTC WORK AT SPJ 17 ANNEX I. Definitions 19 ANNEX II. List of World Bank Activities Discussed in the Brief 21 References 25 GRAY MATTERS: HOW DO THE WORLD BANK’S ENGAGEMENTS IN SOCIAL PROTECTION & JOBS STRENGTHEN LONG-TERM CARE?1 THE CARE AGENDA Caregiving is a fundamental aspect of the human experience and takes various forms depending on the needs and social risks faced by households throughout the lifecycle. These forms include childcare, caring for individuals who are ill or disabled, and caring for older individuals with functional limitations. With rapid urbanization, international migration, and aging populations, there is growing recognition of the need for countries to develop comprehensive care policies. A multisectoral effort addressing the care agenda can enhance the well-being of care receivers, their families, and caregivers. Well-organized care policies can boost labor force participation and productivity, especially for women who bear a disproportionate burden of care. This brief focuses on long-term care (LTC) for older persons, emphasizing the areas where social protection and jobs are key to building and strengthening this agenda.2 While LTC is sometimes perceived as part of the health agenda, social protection programs and policies are crucial for providing and financing social care-related services. Taking a multisectoral approach to LTC can ensure an integrated range of social and health care options which would be the foundation for efficient and cost-effective provision of LTC for all older adults. 1 This brief was authored by Diego Wachs, and Andrey Tretyak. It is one of the three briefs of the Social Protection & Jobs, Aging working group’s tasks led by Himanshi Jain. The work was carried out under the guidance of Loli Arribas Banos, Practice Manager, Global Social Protection & Jobs team, and Gustavo Demarco, Pensions & SI lead. We thank the peer reviewers Prof. Shereen Hussein, Philip O’Keefe, Ali Hamandi for their feedback. We also thank Sarah Coll Black, Elena Glinskaya, and Gisela Garcia who guided the team and provided inputs to draft versions of the note. Deepika Davidar did the editing of the series. 2 To the extent possible, this brief concentrates on the areas where social protection and jobs can contribute to the LTC agenda. However, subsequent sections will elucidate that LTC is a multisectoral issue with fuzzy boundaries that extend across social protection and jobs, health, and other domains. 1 Adopting a social protection lens can help assess individuals’ care needs, considering not only their health requirements but also their familial and social contexts. Additionally, leveraging social protection delivery systems can help to efficiently identify and organize care services. Applying this perspective to the LTC dialogue in countries can uncover new entry points for policies such as developing a social services framework, implementing pension reforms, establishing LTC insurance, promoting the participation of informal workers as formal care providers, and providing social protection for caregivers. This brief covers five questions commonly asked by policymakers and practitioners: • Why is LTC important? • What are the key components in a dialogue on LTC? • How is the World Bank engaging on LTC? • What are the lessons learned? • What is the scope for future work? LTC embodies a multifaceted agenda, weaving through diverse sectors and engaging various stakeholders. Confronting this extensive and intricate agenda may seem formidable, especially for low- and middle-income countries (LMICs) constrained by resource limitations. Nonetheless, taking a foundational step toward developing a formal LTC system is imperative, considering the high costs of inaction and the potential gains from establishing such a system. This brief describes and provides examples of several areas for countries to explore in laying the initial groundwork for a resilient LTC system. WHY CARE ABOUT LONG-TERM CARE? The demand for LTC is rapidly increasing due to population aging, socioeconomic factors, and the diminishing availability of familial support. However, the rationale for developing robust LTC systems extends beyond the well-being of individuals in need of care and their caregivers; it encompasses reducing catastrophic costs, addressing market failures and gender inequalities, and creating employment opportunities. As people grow older, they are increasingly likely to lose the functional ability that enables them to care for themselves and stay active in their community (WHO 2015). Estimates by the World Health Organization (WHO) indicate that more than 142 million older people, or 14 percent of the world population aged 60 years and over, are currently unable to meet all of their basic daily needs due to functional limitations, measured through their capacity to perform activities of daily living (ADLs) such as eating, dressing, or toileting, and instrumental activities of daily living (IADLs) that include independent living skills such as housework, shopping, and medical management (WHO 2020; 2022b). As functionality decreases, people may find it challenging to stay active in their community by maintaining social relationships, participating in the labor market, or engaging in social activities such as attending a community club. People dependent on others often need ongoing medical care to manage chronic conditions and remain healthy (Kim et al. 2022). 2 LTC comprises a set of services that support people in developing and maintaining their functional abilities. It aids people in performing daily activities, participating in social activities, and pursuing what they value (WHO 2015). While there is no consensus across institutional definitions regarding the precise elements of LTC, there is agreement on several key aspects. LTC encompasses services that cater to individuals across various aspects of life over an extended period. It is commonly provided by families or trained caregivers and can be administered in diverse settings including private homes, communities, and institutional settings. LTC addresses both social and health care, necessitating coordination and integration across these domains (Glinskaya et al. 2023). Advances in life expectancy and falling fertility rates have led to a momentous time in history when all regions are experiencing a growth in the number and proportion of older persons (WHO 2022a). By 2050, 8 in 10 of the world’s population aged 65+ will live in developing regions. By 2060, the global population of persons aged 80+, the primary target group for LTC, will reach over 400 million. Given the strong correlation between care dependence and age, these dynamics are poised to rapidly increase the number of people requiring LTC. The challenge of meeting care needs in low- and middle-income (LMICs) is particularly acute given these countries’ low pension coverage and lack of robust healthcare systems (Glinskaya, Feng, and Suarez 2022; United Nations 2017). LMICs are aging faster and with fewer resources than high-income countries had at similar stages of the demographic transition. Simultaneously, other demographic and socioeconomic factors are reducing the availability of care. The traditional familial support for individuals in need of care is decreasing due to positive changes in gender norms, increasing female labor participation, and diminishing intergenerational co-residence rates (UN 2023). Additionally, international migration in search of job opportunities has led to the proliferation of skip-generation households, where grandparents raise children and parents are largely absent, further exacerbating inequalities in access to care between urban and remote areas (UN 2019). As aging unfolds, the state’s role in stewarding the development of LTC systems is increasingly recognized. Market failures and consumers’ myopia often limit the coverage that the private sector can attain on its own. Without government support to foster market development, a large care-dependent population may lack access to affordable LTC services. In some instances, this leaves individuals with no option but to rely solely on informal care provision. In other cases, it can result in financial burdens or expenses that become overwhelming and potentially catastrophic for individuals dependent on LTC support or their families. LTC systems can have positive spillover effects, notably on opportunities for migration, improved gender equality, and new avenues for job creation. International migration can help reduce the care gap when migrants are employed as caregivers. When done through formal agreements between two countries, recruiting can be particularly promising. However, origin and destination countries face several challenges, including the lack of necessary travel documents, training, or credentials. Migrant caregivers are, therefore, more likely to work in the informal sector, poorly remunerated, and often exposed to exploitative practices 3 (UN 2023). International migration may not be a panacea for addressing the care gap but, if managed strategically, it can help aging countries achieve a smoother demographic transition. Caregiving is more likely to be taken on by women and in unpaid roles, worsening gender inequalities. Informal caregivers work fewer hours in paid employment than non-caregivers and often withdraw from the labor force if care commitments are heavy (Lilly, Laporte, and Coyte 2007). Fewer paid hours results in lower income (Chari et al. 2015). While both women and men carers earn less because of unpaid care, literature has shown that women are more likely to take on familial care responsibilities, exacerbating gender imbalances in the labor market (Lee and Tang 2015; Ciccarelli and Van Soest 2018; Stampini et al. 2022). Women also face higher levels of caregiving stressors and have fewer social resources, leading to lower levels of psychological and physical health (Miller and Cafasso 1992; Pinquart and Sörensen 2006). Research across OECD countries has also identified gender inequalities in access to care, with older women being more likely to require LTC and less likely to afford it (OECD 2017). Formalizing LTC provides significant labor market opportunities. The enormity of unpaid care work, estimated at 16.4 billion hours daily in LTC, is equivalent to two billion people working eight hours per day without remuneration (UN 2023). But formalizing LTC requires a cautious approach due to associated risks, including increasing costs for care services and heightened access issues. It is also important to recognize the existing challenges for paid caregivers who typically receive low wages and face health risks such as anxiety, burnout, and depression (OECD 2020). COMPONENTS OF A DIALOGUE ON LTC The design of national LTC systems is an ongoing discussion. The optimal design of LTC for a country depends on various factors such as its stage of demographic transition, the rate at which its population is aging, cultural preferences, the available resources, and the level of development of its social and health care systems. When developing an LTC system, countries need to address these crucial questions: • Who should be beneficiaries of publicly financed LTC? • What are the different types of LTC services and benefits? • What role should the government play in facilitating these services and benefits? • How should LTC be financed? • How can quality of care by service providers be ensured? • How can the LTC workforce be developed and regulated? • How can LTC be integrated with health care? The selection and order of these questions are not entirely discretionary. They are consistently repeated in the gray literature and organized to facilitate the understanding of LTC systems.3 However, due to substantial variation across countries in LTC arrangements, alternative sets of questions are conceivable. Most important, the questions are closely interconnected and should not be viewed as isolated components (Figure 1). 3 See, for example, the LTC country diagnostics from the Asian Development Bank or the Inter-American Development Bank. 4 Figure 1: The components of a LTC system. Benefits and services Planning Access and Financing eligibility Families Governance system Private sector Improvements Integration Quality and adjustments Workforce Source: Adapted from Gray Matters: Building and Strengthening Long-Term Care Systems, by Elena Glinskaya, Ali Hamandi, Dwen Wang, and Sarah Coll-Black (Glinskaya et al. 2023). WHO ARE THE BENEFICIARIES OF LTC Countries can adopt a needs assessment methodology and choose eligibility criteria that maximize coverage based on budget resources while ensuring equity across needs and income. In practice, an individual with LTC needs typically requires assistance with ADLs and IADLs. Countries where data on difficulties with daily activities is scarce often use information about health issues like physical disabilities, dementia, impairments, and chronic diseases to estimate local LTC needs. While these health issues are often correlated with the likelihood of needing LTC, it’s crucial to note that having them doesn’t automatically imply a specific need for LTC support at the individual level (Glinskaya, Feng, and Suarez 2022; European Commission and OECD 2013). Older adults are more likely to need LTC as their capacity to perform ADLs and IADLs decreases with aging. In 2022, the prevalence of severe limitations to performing daily activities in the European Union (EU) was twice as high for individuals aged 85 and above than for those aged 65 and over (35 percent and 15.9 percent, respectively) (WHO 2015). World Bank regional studies shows similar results across LMICs, with examples from Latin America, South Asia and the Pacific, and Eastern Europe and Central Asia (Rofman and Apella 2020; Bussolo, Koettl, and Sinnott 2015; World Bank 2016). LTC services are also provided 5 to younger age groups, particularly those with disabilities, to prevent the development of severe functional limitations. Eligibility can be determined through several criteria, including the results of a care needs assessment, an individual’s age, financial resources, the availability of informal care, and social insurance contributions. A care needs assessment evaluates an individual’s functionality level and assesses limitations in performing ADLs and IADLs. The same assessment can be used to determine the care package for an eligible person, i.e., the type of services, number of hours, and level of public subsidy allocated to an individual. These assessments should be uniform and done regularly across the country. Countries can pilot a needs assessment toolkit and roll it out after adjusting based on feedback from the pilot. There are various models for conducting LTC need assessments. For example, they can be conducted by a multidisciplinary team comprising various type of professionals such as social workers and medical practitioners. In some countries, the responsibility for assessments does not rest on those directly involved in care provision to prevent potential bias towards severity. The assessments can account for the dynamic nature of needs, recognizing that they may intensify with age or be mitigated through early interventions. The assessments can be layered, with an initial assessment followed by more comprehensive geriatric needs assessments at a later stage, as necessary. Examples from LMICs highlight the diverse approaches to LTC assessments. In Thailand, tools are utilized to measure assistance required for basic daily tasks such as movement and self-care. Meanwhile, Vietnam relies on assessing disabling conditions that hinder a person’s ability to work. China’s assessment instruments vary across local authorities. Indonesia is experimenting with various methods, including assessments for ADLs and dementia evaluations. India employs a two-step process, first administering a community- based checklist focusing on basic activities, followed by a more comprehensive geriatric assessment, if issues are identified (O’Keefe and Yiengprugsawan 2023). Eligibility criteria determine the coverage of LTC services. Limited availability of public resources can force countries to set stringent eligibility criteria that may exclude individuals who need LTC services, resulting in a care gap. A minimum set of services has the potential to provide fair protection in a fiscally sustainable manner. For example, a system may define eligibility based on care needs and other factors such as age, income, and the availability of informal support to define a fiscally sustainable coverage. Some countries incorporate equity considerations when designing eligibility criteria assessments to prevent individuals from facing extreme financial costs, commonly referred to as catastrophic costs. Eligibility criteria should remain dynamic to adapt to changes in budget constraints across time. It is imperative that countries develop resources to systematically assess individuals’ needs to implement a targeted approach. WHAT ARE THE SERVICES AND BENEFITS OF LTC? Countries should aim to achieve a continuum of care options, providing for the diverse and evolving needs of beneficiaries, with a strong preference for “aging in place”. 6 Typically, LTC benefits can be delivered as in-kind direct service delivery, support for informal caregivers, or cash benefits for care recipients. These options entail trade-offs concerning effectiveness, user choice, and cost control. The generosity of benefits, alongside their coverage, influences the financial sustainability of a system. Consequently, most governments establish minimum and maximum limits for these benefits, and some provide a variety of benefits at different need levels. LTC services can be delivered in several settings, such as the home (home care), community centers (community care), and, when needed, through residential care. The different types of services are better suited to different contexts and levels of care dependence. Home care typically includes personal care (help with ADLs), basic nursing and medical services, rehabilitation, and palliative care. Community care supports people who live as independently as possible in their communities and includes temporary access to residencies such as daycare centers and specially designed assisted or adapted living arrangements. Residential services, such as nursing and care home facilities or supported housing arrangements, provide accommodation and LTC as a package and typically involve higher costs and levels of dependency. Residential services are usually provided when the beneficiary requires high medical support and organizing it at home is too costly. Cash benefits can be “restricted” or “unrestricted” to the purchase of specific services. Even when different modes of care provision are available, people prefer “aging in place”. Aging in place refers to a preference for services that allow people to remain in their homes or community, independently and comfortably, regardless of age, income, or capacity level. Home and community services are also, on average, cheaper than residential care. LTC services for aging in place include home care and integrated community health as well as social care services such as managing chronic geriatric conditions, rehabilitation, palliation, promotion, and preventative services (WHO 2020). A global trend promoting aging in place is evident across regions. In EU countries, it takes the form of a shift towards de-institutionalization (European Commission 2021). In Latin American and Caribbean, the Inter-American Development Bank strongly advocates for the development of home care services as a foundational step in building LTC systems (Cafagna et al. 2019). In various Asian countries, such as Cambodia, China, India, Indonesia, Nepal, Myanmar, Sri Lanka, and Viet Nam, the concept is supported by Older People’s Associations (OPAs). These membership organizations, led or managed by older individuals, play a crucial role in facilitating activities and delivering services for the elderly (Glinskaya, Feng, and Suarez 2022). WHAT IS THE ROLE OF THE GOVERNMENT IN LTC? Government policies and strategies should enable the creation of this continuum and its smooth functioning by playing a stewardship role of creating markets and intervening in instances of market failures. Historically, the state was seen as the last resort for providing LTC. However, with the increasing demand for LTC, it is imperative for the government to transition to a stewardship 7 role within the LTC sector to assure that the supply grows in line with the demand. In this role, the government must strategically allocate support to areas with the highest need, emphasizing both fairness and cost-effectiveness. Following this trend, private provision complemented by public financing is becoming the predominant modality in high-income countries. Meanwhile, private provision with private financing along with limited last-resort public provision for low-income groups is predominant in LMICs. The stewardship of LTC systems is primarily the responsibility of national governments, with local authorities sometimes tasked with its provision and (partial or total) financing. Within the government structure, the ministries of health and social welfare are typically the main players for the governance of LTC (Walker and Wyse 2021). In certain countries, specialized agencies, either independent or nested within these ministries, have been established to handle specific components of LTC, focusing notably on the development of strategies to support the implementation of associated laws and policies. These LTC strategies may be either standalone or integrated into broader policies, such as aging-related laws. In general, the strategies, laws, and policies set a legal framework and give shape to the system. Further, policymakers, particularly in emerging LTC systems, need to consider whether to establish a standalone LTC system or incorporate LTC within existing public healthcare frameworks (Glinskaya, Feng, and Suarez 2022). The stewardship role involves interventions at three distinct levels. At the macro-level, governments are tasked with developing a national policy, crafting a vision or strategy for long- term care (LTC), determining the financing source, and defining the institutions responsible for regulating the system. Moving to the meso-level, governments should establish a national LTC program based on the national policy. This program should encompass mechanisms for contracting private providers, regulating quality, directing resources for LTC to ensure value for money, and coordinating across different sectors and government levels. At the micro-level, governments must ensure the effectiveness of systems in place for determining eligibility and enduring the quality of services at the individual level. Governments can also actively participate by providing benefits through supply-side subsidies, vouchers for services, cash benefits, in-kind benefits, and other forms of support, such as assistive devices and training for formal and informal caregivers (Glinskaya et al. 2023). Government involvement in LTC can often start with laws that specifically address the needs of older people, with subsequent national policies and plans building upon these foundational laws. This approach is exemplified in Asian countries like Mongolia, Singapore, and Indonesia. In Sub-Saharan Africa, LTC policy development is not as advanced as in other regions, but progress is evident. Countries in this region have initiated policy frameworks that encompass LTC, both directly and indirectly. This includes integrating older person- focused conditions in policies or constitutions, introducing dedicated bills on older adults, and implementing national strategies on healthy aging, as seen in Tanzania and Zimbabwe. In Central and South America, aging policy evolution has shifted from a charity-based to a rights-based approach. Notable progress in developing pensions and an increased focus on older people’s rights, particularly in Argentina, Chile, and Costa Rica, have led to the gradual elevation of aging policy on the broader policy agenda (Glinskaya, Feng, and Suarez 2022). 8 HOW IS LTC FINANCED? As populations age, LTC expenditures will increase, requiring government stewardship to establish markets that ensure affordable access to quality care. A mix of public and private financing combined with changes to the living environment will be needed to sustain short- to medium-term LTC expenditures. As longevity increases, expenditure on LTC, all else being constant, will grow. The 2021 EU Aging Working Group report estimates that, on average, LTC spending for EU countries will double over the next 50 years in the reference scenario. Spending on LTC varies greatly across countries. Even within European countries, the combined health and social sector LTC spending in 2013 averaged 1.8 percent of GDP and ranged from 0.2 percent in Cyprus to 4.5 percent in Denmark. Addressing the fiscal pressures of the increasing demand for LTC will be particularly challenging in LMICs where the population is projected to age rapidly and fiscal resources are often far more constrained. Discussions on the sustainability of LTC must also consider the need to influence the demand side (i.e., the needs of an aging population) through prevention, rehabilitation, and adaptations to the living environment. While demographics is a key driver of LTC spending, parameters such as eligibility and the mix of services also influence spending. In general, residential services have higher costs per beneficiary (unit costs) than home care or community-based services. Therefore, countries attempt to control LTC costs by regulating the supply of LTC arrangements or encouraging home care and community-based care utilization. In addition to looking for systematic financing for LTC, it is critical to improve the allocation and targeting of public financing for LTC. For example, a classic tradeoff is between subsidies for construction of residential care facilities versus investments in home and community-based services. LTC financing arrangements can be broadly categorized into social insurance (payroll financed), general revenue financed, or out-of-pocket payments. Furthermore, public financing can come from central or subnational governments. There is no optimal combination of financing sources for LTC. The objective should be to precisely map financing sources against LTC provision and develop a sustainable system that enables access and promotes equity. Each financing option comes with its tradeoffs and countries typically choose based on the local economic and political context and institutions, paying particular attention to levels of informality, inequality, and historical preferences. How the health system is financed will also have implications for policy choices. Publicly funded LTC is scarce in LMICs, leaving older individuals and their families to primarily finance care out-of-pocket. When public financing is available, LMICs showcase a diverse array of funding combinations. In Kenya, a private nursing agency provides in-home care for those who can afford it or have insurance coverage (Glinskaya, Feng, and Suarez 2022). China initially funded LTC through a combination of general revenues and a portion earmarked from national welfare lottery receipts. However, recent efforts have expanded LTC insurance pilots. In Costa Rica, the system relies on centralized general tax revenues as local governments are not involved in design or financing. In Ghana, donors fund services like geriatric training and medical supplies through cash or in-kind donations. Volunteer workers receive free health care in return for their service (Glinskaya, Feng, and Suarez 2022). 9 Scarce resources for LTC results in many individuals resorting to informal care without access to subsidized public services. The costs are prohibitive for most people. OECD estimates indicate that without public financial support, the total costs of LTC would be higher than median incomes among older people in most OECD countries. Costs rise even more when the “opportunity costs” of informal care (the impact on labor market and productivity) and the effects of informal LTC provision on the health of caregivers are included. In addition, the availability of affordable and well-regulated LTC services can directly reduce both primary and secondary health care costs, particularly by minimizing unnecessary hospitalizations, which can be costly. Policy making would be greatly aided by an earmarked source of financing, clear and comprehensive reporting of expenditures, and long-term cost projections. An earmarked budget source with clarity on what the budget will cover can ensure predictability in resources and that they reach their target audience. In recent years, countries, particularly OECD countries, have made progress in improving the general comparability of LTC spending. However, more needs to be done to reconcile variation in reporting practices between different components of some LTC activities and capture privately funded LTC expenditure. Lack of reliable data also limits the ability to gauge and forecast care needs. National surveys could be conducted to project costs by estimating the demand and costs of public LTC provision under a baseline scenario, i.e., no changes to the current model of LTC provision and financing. The World Bank has developed a toolkit for countries and it can also be used to assess the impact of reforms by changing the eligibility rules, distribution of financing across different benefits, and/or unit costs. HOW CAN THE QUALITY OF LTC SERVICES BE ENSURED? Governments have a vital stewardship role to play in developing the LTC market to ensure that regulations are applied, providers are accredited, and service standards are monitored. Effective regulatory oversight and monitoring the quality of care is part of the stewardship role of the state and should be applied to all types of providers. This can be accomplished through regulation, accreditation for service providers, and robust monitoring and evaluation. These standards can be reinforced by modern quality management practices for social services provision based on international best practices. When setting these standards, it is useful to adopt a participatory approach that involves beneficiaries, social workers, service providers and supervising bodies. Feedback from beneficiaries can be incorporated on a regular basis. The government plays a critical role in quality assurance and grievance redressal because LTC consumers and their families are typically too vulnerable to change providers when they receive suboptimal care. Specific mechanisms should be established to prevent abuse (such as negligence, domestic violence, emotional, financial, and legal abuse) of beneficiaries by LTC workers. The implementation of quality regulation in LTC is contingent on developing effective systems and practices for quality management. In Indonesia, with no single body overseeing 10 LTC quality management, adherence to standards relies on local fiscal capacity, lacking systematic monitoring or oversight. Similarly, Mongolia grapples with aligning policy intentions with practical quality management (ADB 2022). The absence of a comprehensive registry of providers is another factor hindering oversight of compliance with quality measures, as seen in Uruguay, Argentina, and Chile (PAHO 2023). The shortage of a qualified workforce also impacts care quality, as demonstrated in China, where direct-care workers in senior care facilities often lack proper training and face low wages (World Bank 2016). WHAT IS NEEDED TO DEVELOP AND REGULATE A CARE WORKFORCE? Skills shortages and burnout within the care workforce are acute issues and can be addressed with improvements in work conditions, better pay, training and coaching, and enforcement of job descriptions. The care workforce encompasses those who provide care and support to those requiring LTC. Definitions of the care workforce vary with respect to the time, intensity, and activities performed (WHO 2015). For policy purposes, carers are typically distinguished by their level of professionalization and remuneration. Professionalization commonly refers to caregivers with professional training, and paid care relates to receiving compensation for the service provided. Formal LTC workers, as defined by the World Health Organization (WHO), are individuals who have received professional training; however, the term is often used to refer to those who are paid for their services (WHO 2022b). Due to the labor-intensive nature of LTC services, the availability of formal LTC workers typically acts as a bottleneck in the development of formal provision for LTC. Persistent shortages of formal LTC workers exist even in countries with more advanced LTC systems. For example, in most OECD countries, the formal LTC workforce has shown a slower increase than the number of individuals aged over 65 (OECD 2020). On top of budget restrictions, low recruitment and retention rates are largely the concequence of the hardships associated with care work. Caregivers frequently express dissatisfaction with their compensation, working conditions, and career opportunities, which adds to their job’s physical and mental stress. As crucial as the quantity of caregivers is ensuring that they acquire the skills required for their diverse functions in both social and health care (OECD 2020). For example, surveys across LAC countries reveal that almost half of caregivers lack training (Aldaz Arroyo et al. 2023). There is also an increasing demand for IT and computer skills due to technological advancements in the care ecosystem that was accelerated during the COVID-19 pandemic (Socha-Dietrich 2021). Training not only enhances care quality but reduces turnover by improving job satisfaction and alleviating caregiver stress (Aldaz Arroyo et al. 2023). Nevertheless, considering the persistent shortages of LTC workers and the speed of population aging, the prospect of having a fully trained staff capable of meeting the entire LTC demand seems unlikely. A pragmatic approach for countries considering quantity and skills could involve the pursuit of training, recruitment, and retention policies to achieve a good enough human resource capacity. 11 Globally LTC is largely provided by informal caregivers. Informal caregivers are individuals who provide care without formal training and are typically (but not always) unpaid (WHO 2022b). They often support a family member, friend, or neighbor. Like formal care workers, informal carers are a critical asset to society and require support to maintain a sound LTC system. Even in high-income countries with well-developed care systems, informal care is extensively relied upon to meet the demand for LTC in private homes. In Europe, for instance, informal caregivers provide up to 80 percent of all LTC (UN 2023). In many cases, this context is influenced by social norms. Some countries, including Algeria, Argentina, Brazil, Chile, China, India, Mexico, Russia, and Turkey, have gone as far as legalizing and mandating adult children’s responsibility for taking care of their elderly parents (Glinskaya, Feng, and Suarez 2022). When setting a robust care system, it is important to develop specific measures to support and protect formal and informal caregivers. Several countries have explored various measures to attract and protect workers, such as LTC training programs, public image campaigns, increased compensation, use of telecare, and promoting a healthier work environment (OECD 2020). Official recognition of informal care, provison of specific trainings and respite services can significantely improve the quality of care. It is also important to recognize that both formal and informal LTC are primarily provided by women. This leads to a disproportionate burden on women, impacting their economic opportunities and overall well-being, and reinforcing gender roles. HOW CAN LTC BE INTEGRATED WITH HEALTH CARE? Integrating LTC with health care is important to provide comprehensive care to older adults and reduce costs. Health and long-term care are closely intertwined, particularly for individuals with chronic health issues. Strong evidence indicates that integrating LTC and health care can enhance service outcomes, decrease service utilization, and reduce costs. A flagship example of inadequate integration is the prolonged stay in health care facilities after acute interventions due to delays in the assessment of post-discharge long-term care needs and eligibility. Integration is needed at both the systems and program level. In practice, this means sharing information across agencies through interoperable systems and developing care plans that address both health and LTC needs. These should be done with the main objective of developing person-centered care and quality holistic care. Integration is also important for reducing inefficiencies, making the best use of limited public resources, and crowding in private investment where appropriate. At a program level, this will require a multisectoral effort between social protection and health teams, including, at the implementation level, multidisciplinary task teams such as geriatricians, nurses, therapists, social workers, and LTC facility administrators. Care coordination is a driver for care integration. Care coordination is generally viewed as provider-centric, with the goal of helping individuals navigate different providers in a disjointed system. Understanding the entirety of available services to older adults is a cruical first step. This process can commence by mapping the fundamental components of long- 12 term care systems. The inventory can reveal services available with or without government support and identify the key players involved in provision (private entities, civil society, and local governments). Conducting a landscape assessment or diagnostic study will pave the way for care coordination among health care providers, LTC providers, and other stakeholders to ensure seamless transitions and continuity of care. UNDERSTANDING LONG-TERM CARE At least 142 million older persons worldwide are unable to meet their basic needs without support. Age is correlated with an increase in physical and cognitive limitations that require LTC support. 1 in 6 people will be 65 or older in 2050 compared to1 in10 today. LTC can be provided at home, in the community, or at specialized facilities. In an optimal system, LTC is provided through a continuum and according to the needs of bene ciaries. Most LTC is provided by informal carers. In Europe, informal carers provide up to 80 percent of all LTC. Caregiving can a ect labor participation, income, access to pensions, and physical and mental health. There are also gender inequalities in care needs and access. 9 in 10 LTC workers in OECD countries are women. The state can regulate prices, quality and other market characteristics as well as participate in the provision of certain services. Sources: WHO Decade of healthy ageing: baseline report. UN (2023) World Social Report 2023: Leaving No One Behind In An Ageing World. 1/ Based on a WHO study covering people aged 60+ in 37 countries and between 2013 and 2019 and extrapolated to the world population aged 60+. The gures do not include older people living in long-term care facilities or other institutions. 13 IMPACT: WHAT THE WORLD BANK IS DOING ON LONG-TERM CARE The World Bank has established itself as a partner of choice in this area, with work on LTC continuing to grow following demand from clients. Under the aging agenda, LTC stands out as an area in which World Bank teams have published analytical work and implemented innovative projects. The World Bank’s multisectoral structure is key to its ability to advance LTC’s cross-cutting agenda as it brings together expertise across health, migration, delivery systems, private sector partnerships, labor, and social protection. Engagements on LTC have allowed World Bank teams to build internal capacity and strengthen the evidence base for policy engagement. To date, most activities have entailed technical advisory and analytical engagements and, in some cases, have led to pilot projects or opportunities for in-country investments. A thorough analysis of engagements (see Annex 2) reveals that most include support to middle- and high-income countries to strengthen their LTC strategy or implement new care programs. The World Bank has also conducted knowledge activities related to LTC, including issuing aging-related regional and country- level reports and developing products to analyze cross-cutting LTC issues such as gender inequality or fiscal sustainability. The following sections provide details of these activities. PUBLISHING REGIONAL AND COUNTRY REPORTS Regional and country reports by the World Bank include an extensive discussion of LTC policy questions that are tailored to specific regions. Three regional reports (East Asia and Pacific, Latin America, and Europe and Central Asia) cover in depth topics of LTC financing, estimations of demand and dependency, projections of expenditure, and a summary of the state of LTC and related policies in each region, to name a few. All three regional reports mention the scarcity of data and the utilization of OECD statistics and case studies as benchmarks, albeit always considering the local contexts. DEVELOPING ANALYTICAL TOOLS FOR LTC ENGAGEMENTS The World Bank has, through its engagements, developed analytical tools for LTC activities with the objective of assisting client countries in policymaking. An example is the development of the Long-Term Care Assessment Toolkit to evaluate the state of care for older people. The forthcoming toolkit includes a questionnaire designed to assess LTC policy, service delivery, and household and gender-related issues. The methodology is being tested through case studies across several countries. Through the same activity, the World Bank is quantifying unpaid care’s impact on caregivers’ income in Indonesia. In addition, an LTC Fiscal Projections Model was prepared through technical assistance provided to Belarus. The model was prepared following international best practices and will be used in future client engagements. 14 SUPPORTING COUNTRIES IN ROLLING OUT NEW CARE SERVICES Three recent engagements supported governments with the implementation of new LTC components. The World Bank strengthened each government’s capacity to develop policies and institutional arrangements. Financing was also provided in some cases. The activities in Chile facilitated the rollout of the National Support and Care Subsystem (SNAC) which provides support and care services for older adults with functional limitations. In Colombia, the World Bank is providing technical assistance to the District of Bogota to improve service delivery and support for caregivers through the Manzanas de Cuidados (“care blocks”) program. Two projects in the Chinese provinces of Anhui and Guizhou provided financing for the development of care services and strengthening of the quality and management of services. The Bank’s strong analytical capacity and international experience guided Bank participation in these engagements. The Bank’s participation included activities such as identifying the beneficiary population using national household surveys, analyzing coverage and budgetary restrictions, and facilitating the design and piloting of functional ability and needs assessment methodologies. One of the challenges encountered in these activities was dealing with a diverse set of government stakeholders (from various sectors), hierarchical administrative levels (ranging from central to local), and procedures (including administrative, financial, operational, and technical aspects). Going forward, it will be important to document both challenges and success stories of multisectoral implementation. SUPPORTING COUNTRIES IN DEVELOPING LTC STRATEGIES The World Bank has supported countries in their efforts to strengthen their LTC strategies and make them more comprehensive. Besides working alongside countries to develop LTC strategies, the Bank has helped them determine beneficiary groups and services packages, analyze financing options for LTC, estimate fiscal cost scenarios, address inequalities in access to care, and provided advice on making the delivery of LTC more efficient. Often, these engagements focused on healthy or active aging strategies where LTC was a key element. For example, in Seychelles, the World Bank provided technical advice toward developing an updated health sector strategy that could meet new challenges such as the rise of non-communicable diseases and an aging population. In Malaysia, the government has engaged the Bank as the lead technical advisor on the development of the country’s National Aging Blueprint in which LTC is a key pillar. Likewise, in Romania, technical activities addressed the state of LTC services as part of a broader engagement that covered health services for older people and pension systems. Similar activities were implemented in Estonia, Greece, Latvia, and Macedonia. 15 LESSONS FROM WORLD BANK ENGAGEMENTS LTC engagements have led to the building of internal capacity, meeting of client expectations to deliver cutting edge thinking on difficult policy problems, and positioning the World Bank as the partner of choice in the LTC dialogue across regions and country income levels. There are six key lessons learned to date from LTC engagements: The efficient functioning of an integrated LTC requires clarity in the roles and responsibilities of the national government, local authorities, households, and market players. The government should play a strong stewardship role in facilitating the development of a LTC market and defining its rules. These rules should encourage LTC providers—private non-profit, profit-oriented services, or public institutions—to offer a variety of transparent services based on best practices and priorities set by the government. Public agencies should also monitor providers to ensure that they fulfill quality service standards while respecting beneficiaries’ rights. Financing discussions need to focus on identifying sources of financing, efficient resource allocation or targeting of finances, and influencing demand. Key questions to consider are what resources need to be raised and how should they be spent keeping in mind need, equity and efficiency? LTC insurance mechanisms have emerged in several countries; however, even in rich countries, the financial burden of LTC is usually shared between society and family. Specific support can be, and often is, made available for poor and vulnerable families. But there is no simple solution and innovative financing methods are needed to develop a sound and sustainable LTC system. In raising resources, care should be taken to avoid introducing distortions. Aging in place is a cost-effective, efficient and a preferred option for many countries and individuals. While many countries have established residential services for the elderly who require more extensive LTC support, an increasingly common approach is to prioritize LTC services which promote aging in place, enabling elderly individuals to remain in their homes and communities for as long as possible. A formal system of efficient home- and community- based care is also compatible with the high co-residence rates and cultural preferences in many LMICs. Governments stimulating markets can dedicate resources on promoting “aging in place” as it provides value for limited public resources. This strategy can benefit from complementary approaches such as mobilizing self-care, prevention, preparedness for future needs, and home and environmental adaptations. Effective coordination of care requires collaboration across multiple dimensions—between health and social protection agencies, between national and local levels, and between delivery and financing. Establishing formal aged care systems is crucial to ensure robust coordination between LTC and health care. Care coordination is fundamental for the quality, appropriateness and efficiency of care, as it reduces over-reliance on extended hospitalization. In this regard, the skills of both social protection and health professionals in case management are valuable but require clarity on roles, responsibilities, and financing. The COVID-19 pandemic and its disproportionate impact on older individuals have further highlighted the significance of enhancing coordination between the health, social protection, and employment sectors. 16 National and local agencies need to agree on roles and responsibilities. While delivery and financing can be separate discussions in the context of LTC, they are nonetheless closely intertwined. Achieving coordination across multiple dimensions is important for seamless, efficient, and cost-effective LTC that meets the diverse needs of older adults. Using a decentralized and bottom-up approach to improve coordination is a promising strategy. The IEG (2021) report noted that the “decentralized and bottom-up approach” adopted by the World Bank was particularly promising (Independent Evaluation Group 2021). The approach involved expanding and adapting the services and programs already present in each community. It focused on improving the coordination across municipalities and institutionalizing initiatives that were already happening at the local level in an uncoordinated and fragmented way. While this approach did not fully succeed in achieving strong coordination between local and central governments, leveraging the existing local initiatives was an innovative strategy. LTC is gaining visibility in many countries and there is a substantial need for capacity building, including measurement, modelling and monitoring of expenditures. Two important technical contributions from recent engagements are the Long-Term Care Assessment Methodology and the LTC Fiscal Projections Model. These tools will be part of the Bank´s toolkit for future client engagements. In particular, the Projections Model has been used to help Romania’s Ministry of Social Protection develop a National Strategy on LTC by estimating the fiscal impact of policies that affect the mix, coverage, and intensity of services. The lack of a standard definition of LTC across countries or a clear demarcation of what constitutes LTC expenditures makes it difficult to monitor the expenses that countries incur. World Bank focus areas could include developing guidance on how to measure, model, and monitor the growth of LTC expenditures. As demand for LTC grows across countries it will be important to track their growth, similar to pensions, so that policy action specific to LTC can be supported through World Bank engagements. MORE AND BETTER LTC WORK AT SPJ The demand for analytical and lending activities related to LTC is expected to increase in the coming years. As part of the “Decade of Healthy Aging” action plan (2021–2030), WHO aims to achieve measurable improvements in the lives of older people in all WHO and UN member states, including the acceleration of LTC system development (WHO 2020). Countries will continue seeking technical and lending instruments from the World Bank to meet these objectives. To develop its technical capacity and build on lessons learned, the institution could advance on several areas described below. Strengthen collaboration across global practices given the multidimensional nature of LTC. The engagements reviewed for this brief have shown that capturing the demand for LTC- related activities requires perspectives that go beyond the scope of the SPJ practice. The Bank could reinforce coordination on analytical and lending activities with other practices, 17 particularly Health, Nutrition and Population, Urban, Governance, private sector, to address activities related to healthy aging, longevity, and the development of formal LTC systems. Streamline approaches that assess functional limitations in older people and estimate LTC needs. A common thread across several engagements has been client demand for assessment methodologies that will help them assign LTC entitlements and estimate the demand for LTC. Once developed, these approaches should be made consistent with standardized disability and needs assessments. Streamlining such assessments will make them more efficient to deploy and replicate in different countries with minimal tailoring based on the context. Explore global solutions via migration. The LTC sector is highly labor-intensive and meeting the growing demand for services will depend on countries’ ability to recruit and retain sufficient numbers of caregivers. Many countries have reacted to this challenge by employing a considerable number of caregivers from other countries. While this is an important avenue to explore, some caution is warranted. Although migrant workers may benefit from employment opportunities and sending remittances to their country of origin, formal agreements between countries may not always translate into equitable working conditions for them. Destination countries must address this issue by implementing appropriate employment policies and ensuring adequate immigration regulations to protect migrant caregivers while ensuring quality of care. Source countries must also ensure that they have sufficient carers to support their own citizens. Support countries in addressing gender inequalities related to LTC. The World Bank has demonstrated a strong commitment to tackling gender inequalities, and this includes addressing gender issues related to LTC. Promoting formalized LTC, providing dedicated carer benefits, and labor market policies such as flexible work arrangements are common approaches for addressing gender inequalities in the labor market. Nevertheless, inequalities can persist even in highly formalized settings, as paid care workers often receive low wages, limited job security, and a physically and mentally demanding work environment. Invest in data collection efforts for a better understanding of population aging and LTC demand and supply. Using harmonized information is a necessary condition to facilitate comparability across studies. This can be achieved by utilizing specialized surveys such as the Survey of Health, Ageing and Retirement in Europe (SHARE), and WHO’s Study on global AGEing and adult health (SAGE). 18 ANNEX I. Definitions WHAT IS THE TYPOLOGY OF CARE WORKERS? Carers are typically distinguished by their level of professionalization and remuneration. Professionalization is commonly understood as a caregiver that received professional training while paid care relates to the receipt of remuneration for the service provided. The matrix below shows how these categories separate typologies of carers according to a recent WHO publication (Figure 2). It is important to note that these categories may not align with the context in some countries. For instance, personal assistants may receive a minimum level of training in some cases. Figure 2: Classification of caregivers REMUNERATION Paid Unpaid Voluntary Formal PROFESSIONALIZATION Care worker care professional Informal Live-in carers Informal / & personal family assistants caregivers Source: WHO (2022) WHAT ARE SOME OF THE LONG-TERM CARE SERVICES? Long-term care services are the set of activities available for those who need care and can be provided at home, in the community, or at specialized institutions. At-home services are services provided at the residence of the beneficiary and can include personal care (help with ADLs), basic nursing and medical services, rehabilitation, and palliative care. Community services are designed to support people living as independently as possible in their communities and include temporary access to institutions like daycare centers and specially designed assisted or adapted living arrangements. Residential services, such as nursing and care home facilities or supported housing arrangements, provide accommodation and long-term care as a package and typically involve higher costs and levels of dependency (European Commission and OECD 2013). 19 WHO REQUIRES CARE? The loss of capacity or care needs among older adults is typically measured through an assessment of functional status (capacity to perform physical or cognitive functions). Typically, the functional status is defined as a person’s ability to perform activities of daily living (ADLs, such as bathing, dressing, and using the toilet) or instrumental activities of daily living (IADLs, such as shopping, preparing meals, performing housework, and managing medications). 20 ANNEX II. List of World Bank Activities Discussed in the Brief ANALYTICAL TOOLS FOR LTC ENGAGEMENTS East and South Asia. Elder Care and Female Employment in Asia (P173533). Analytical work is underway in East and South Asia to develop a toolkit that will provide an assessment methodology and template for diagnostics of the state of older age care and monitoring their changes over time at the policy, service delivery, and household levels. Several case studies of LTC systems in LMICs are used to test the toolkit. Through the same engagement, the World Bank is quantifying the impact that unpaid care has on the income of caregivers in Indonesia. Belarus. Belarus Long-Term Care ASA (P172595). This activity focused on the identification of the existing main state and local interventions related to LTC for the elderly, an analysis of the existing regional data, service utilization, and main cost of LTC, as well as identification of the main selected elderly group needs and gaps in the LTC provision. Importantly, a prediction model of LTC expenditures was prepared for the activity that followed international best practices, and it is now available for future client engagements. SUPPORTING COUNTRIES ROLLING OUT NEW CARE SERVICES China (Anhui). Anhui Aged Care System Demonstration Project (P154716). The investment lending operation has supported the Government of Anhui province to develop and manage a diversified, three-tiered aged care service delivery system for the elderly, particularly those with limited functional ability. The project will concentrate most of its resources on expanding service provision in municipalities but will also devote resources to strengthening the government’s stewardship capacity over the public and private segments of service provision. This includes building an information system that would serve the government, the private providers, and the consumers; improving the government institutions responsible for the assessment of elderly people’s functional ability; and strengthening quality standards and human resource training to improve efficiency and quality of provision and consumer satisfaction. China (Guizhou). Guizhou Aged Care System Development Program (P162349). The program’s development objective is to increase equitable access to a basic package of aged care services and to strengthen the quality of services and the efficiency of the aged care system. The program will expand the coverage of basic aged care services by providing subsidies for services. Other activities to achieve this objective include the development of a needs assessment toolkit, defining packages of services, and eligibility criteria. The activities will also address questions related to: (i) providing incentives for active and healthy aging, (ii) promoting autonomy and independence in old age, (iii) reducing the over burden of 21 health institutions in caring for the elderly; and (iv) for those who require care, delivering relevant services and support needed from the appropriate channels. Colombia. Closing the post-pandemic economic and social gender gap in Bogotá (P176408). In Colombia, the District of Bogotá is piloting Manzanas de Cuidados (“care blocks”), a program with a neighborhood approach to supporting caregivers, particularly those providing care for the elderly and persons with disabilities. The pilot is arranged through Manzanas—“squares of care”—located throughout the city to enable easy access to care. The World Bank is providing technical assistance to the District of Bogotá to improve the delivery of services through the Manzanas. This involves defining the ideal urban design for the Manzanas and supporting the expansion of the pilot. Chile. Technical Assistance for phased implementation of National System for Social Care (P159331). The World Bank supported the country with the creation and roll-out of a new subsystem within the Inter-sectoral Social Protection System in Chile. Among others, the main activities of the engagement included (i) developing a methodology to identify the localities for the initial implementation of the services based on LTC needs criteria; (ii) supporting the use of administrative records and direct data collection; (iii) organizing workshops to troubleshoot potential issues encountered during the roll-out, and extract lessons for the next phase of the implementation; and (iv) providing technical quality control services on ongoing and new studies. SUPPORTING COUNTRIES IN DEVELOPING LTC STRATEGIES Estonia. Long Term Care RAS (P158968). In Estonia, the engagement focused on the promotion of an effective, equitable, and financially sustainable LTC strategy. The activities included a first stage that assessed the LTC system in place in Estonia, gave policy recommendations for the future development of the system, produced a review based on international experiences, and facilitated regional workshops on the topic. The second stage focused on implementation issues such as developing a standardized care assessment tool, creating a strategy for developing care for the workforce, and monitoring and quality assurance. Greece. Development of a strategy for the reform of social care services for the elderly in Greece (P174500). The engagement with the Greek Ministry of Labor and Social Affairs produced a technical report with an assessment of the demand and supply of elderly care in Greece; a “mapping” report outlining processes, resources, and actors involved in delivering services by the publicly funded programs providing aged LTC in the country and a policy note outlining the proposed key elements of a proposed strategy for the implementation of the reform of aged LTC services for the elderly in Greece. Macedonia. Promoting Jobs and the Care Economy in the Western Balkans (P180684). The proposed activities will support operationalizing the aging and care agenda across several dimensions. While reports focused on aging do exist, including for the Europe and Central Asia region, they offer general recommendations. The activities proposed go a step further in understanding the system and the overall policy and institutional environment, to provide the analytical basis for potential operations to be financed. Activities also complement ongoing 22 engagements in the Western Balkans, notably the Second Social Services Improvement Project in North Macedonia which, among others, provides home care support to selected poor older people. Latvia. Active aging (P149711). The Government of Latvia accessed funding from the EU to develop an active aging strategy. As part of this engagement, it was agreed that an international organization would conduct a review focused on recommendations to improve active aging outcomes. The World Bank provided a background analysis for the Government of Latvia in preparing its active aging strategy for the population aged 50 and over. The focus was on labor market participation and the productivity of the labor force. Malaysia. A National Ageing Blueprint for Malaysia (P149711). The engagement’s development objective is to support the Government of Malaysia’s development of a comprehensive national aging blueprint and action plan, to tackle the challenges and realize opportunities from rapid societal ageing. LTC is included as a crucial pillar of the wider strategy. Romania. Strategy for the Elderly and Active Ageing RAS (P147650). The objectives of the advisory services agreement are to (i) provide analysis of the current situation in the areas related to active aging and the elderly; (ii) increase technical capacity of the government; (iii) assist the government in preparing Draft National Strategy for Active Aging and the Elderly for 2014-2020; and (iv) help the government to raise public awareness around the issue of active aging and the elderly and build support for the government’s strategy. Romania. Supporting the operationalization of social protection reforms in the National Recovery and Resilience plan (P178551). The development objective is to support the implementation readiness of key Social Reforms in the National Recovery and Resilience Plan of the Government of Romania to improve the living conditions, care, and opportunities of poor and vulnerable groups. Seychelles. Social Sectors and SOE RAS 6 (P157794). In Seychelles, the engagement was tasked with providing technical advice toward the development of an updated health sector strategy to meet new challenges, including the rise of non-communicable diseases and an aging population. The Bank also supported the government’s strategic plan for social assistance through the sharing of international experience on home care programs to improve services to beneficiaries while containing costs. Seychelles. Strengthening quality of the social protection system (P168993). The development objective is to strengthen the efficiency and effectiveness of social protection programs in the Seychelles. The Program for Results is supporting the adoption of the WHO Disability Assessment Standards to evaluate the functionable capability of participants and the adoption of a revised means-testing scheme which will funnel government financing for care to those who need it. The engagement is also supporting the establishment of a new Home Care Agency which will hire, train, and supervise home caregivers and ensure that at least all high needs recipients receive appropriate care from trained caregivers. 23 REGIONAL AND COUNTRY REPORTS ON AGING THAT COVER LTC AS A SUBCOMPONENT Latin America. Rofman, Rafael; Apella, Ignacio. 2020. When We’re Sixty-Four: Opportunities and Challenges for Public Policies in a Population-Aging Context in Latin America. International Development in Focus. Washington, DC. World Bank. https://openknowledge.worldbank.org/ handle/10986/34562. Europe and Central Asia. Bussolo, Maurizio; Koettl, Johannes; Sinnott, Emily. 2015. Golden Aging: Prospects for Healthy, Active, and Prosperous Aging in Europe and Central Asia. Washington, DC. World Bank. https://openknowledge.worldbank.org/handle/10986/22018. East Asia and Pacific. World Bank. 2016. Live Long and Prosper: Aging in East Asia and Pacific. World Bank East Asia and Pacific Regional Report. Washington, DC. World Bank. https://openknowledge.worldbank.org/handle/10986/23133. Chile. Apella, Ignacio, Truman Packard, Clement Joubert, and Melissa Zumaeta. 2019. “Retos y oportunidades del envejecimiento en Chile.” World Bank, Washington, DC. Argentina. Gragnolati, Michele, Rafael Rofman, Ignacio Apella, and Sara Troiano. 2015. As Time Goes by in Argentina: Economic Opportunities and Challenges of the Demographic Transition. Washington, DC: World Bank. Brazil. World Bank. 2011b. Growing Old in an Older Brazil: Implications of Population Aging on Growth, Poverty, Public Finance, and Service Delivery. Washington, DC: World Bank. Bulgaria. World Bank. 2013. “Mitigating the Economic Impact of an Aging Population: Options for Bulgaria.” Social Analysis Paper 78979, Poverty Reduction and Economic Management Unit, Europe and Central Asia Region, World Bank, Washington, DC. China. Glinskaya, Elena; Feng, Zhanlian. Options for Aged Care in China: Building an Efficient and Sustainable Aged Care System. Directions in development, human development Washington, D.C.: World Bank Group. Latvia. World Bank. 2015a. “The Active Aging Challenge for Longer Working Lives in Latvia.” World Bank, Washington, DC. Malaysia. Schmillen, Achim Daniel et al. 2021. A Silver Lining - Productive and Inclusive Aging for Malaysia (English). The Malaysia Development Experience Series. Washington, D.C.: World Bank Group. Thailand. Glinskaya, Elena et al. 2021. Caring for Thailand’s Aging Population. Washington, D.C.: World Bank Group. Vietnam. Glinskaya, Elena et al. 2020. Vietnam - Adapting to an Aging Society. Washington, D.C.: World Bank Group. 24 REFERENCES ADB. 2022. ‘The Road to Better Long-Term Care in Asia and the Pacific’. Manila, Philippines. https://doi.org/10.22617/TCS220199-2. Aldaz Arroyo, Erkuden, Elisa Berrios Prieto, Laura Fernández Cordero, Mónica Leiva Marín, Laura C. López Franco, Alejandro López Gómez, Fiorella Benedetti, and Pura Díaz-Veiga. 2023. ‘Hacia La Profesionalización de Las Personas Cuidadoras: Formación y Competencias Necesarias Para El Cuidado de Largo Plazo’. Washington, D. C. https://doi.org/10.18235/0005055. Bei, Lu. 2023. ‘China Long-Term Care Programs’. In Shaping Long-Term Care in Emerging Asia: Policy and Country Experiences. https://doi.org/10.4324/9781003131373-3. Bussolo, Maurizio, Johannes Koettl, and Emily Sinnott. 2015. Golden Aging. Prospects for Healthy, Active, and Prosperous Aging in Europe and Central Asia. Edited by World Bank Group. Washington, DC. Cafagna, Gianluca, Natalia Aranco, Pablo Ibarrarán, Nadin Medellín, María Laura Oliveri, and Marco Stampini. 2019. Envejecer Con Cuidado: Atención a La Dependencia En América Latina y El Caribe. Inter-American Development Bank. https://doi.org/10.18235/0001972. Chari, Amalavoyal V, John Engberg, Kristin N Ray, and Ateev Mehrotra. 2015. ‘The Opportunity Costs of Informal Elder-Care in the United States: New Estimates from the American Time Use Survey.’ Health Services Research 50 (3): 871–82. https://doi.org/10.1111/1475-6773.12238. Ciccarelli, Nicola, and Arthur Van Soest. 2018. ‘Informal Caregiving, Employment Status and Work Hours of the 50+ Population in Europe’. De Economist 166 (3): 363–96. Colombo, Francesca, Ana Llena-Nozal, Jérôme Mercier, and Frits Tjadens. 2011. Help Wanted? OECD. https://doi.org/10.1787/9789264097759-en. European Commission. 2021. ‘Long-Term Care Report. Trends, Challenges and Opportunities in an Ageing Society. Volume 1’. Vol. 1. Luxembourg. https://doi.org/10.2767/183997. European Commission, and OECD. 2013. A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care. OECD Publishing. https://doi.org/https://doi.org/10.1787/2074319x. Glinskaya, Elena, Zhanlian Feng, and Guadalupe Suarez. 2022. ‘Understanding the “State of Play” of Long-Term Care Provision in Low- and Middle-Income Countries’. International Social Security Review 75 (3–4): 71–101. https://doi.org/https://doi.org/10.1111/issr.12308. Glinskaya, Elena, Ali Hamandi, Dwen Wang, and Sarah Coll-Black. 2023. ‘Gray Matters: Strengthening Long-Term Care System’. 2023. https://thedocs.worldbank.org/en/doc/ d7cf7eef526395677d1c13e02a7b8e9c-0140022024/original/Aging-and-Longevity-Seminars- Gray-Matters.pdf. Independent Evaluation Group. 2021. ‘World Bank Support to Aging Countries: An Independent Evaluation’. https://ieg.worldbankgroup.org/sites/default/files/Data/Evaluation/files/ AgingCountries.pdf. Kim, Hongsoo, Boyoung Jeon, Lorraine Frisina Doetter, Nanako Tamiya, and Hideki Hashimoto. 2022. ‘Same Same but Different? Comparing Institutional Performance in the Long-term Care Systems of Japan and South Korea’. Social Policy & Administration 56 (1): 148–62. https://doi.org/10.1111/spol.12761. 25 Lee, Yeonjung, and Fengyan Tang. 2015. ‘More Caregiving, Less Working: Caregiving Roles and Gender Difference’. Journal of Applied Gerontology 34 (4): 465–83. Lilly, Meredith B, Audrey Laporte, and Peter C Coyte. 2007. ‘Labor Market Work and Home Care’s Unpaid Caregivers: A Systematic Review of Labor Force Participation Rates, Predictors of Labor Market Withdrawal, and Hours of Work’. The Milbank Quarterly 85 (4): 641–90. Miller, Baila, and Lynda Cafasso. 1992. ‘Gender Differences in Caregiving: Fact or Artifact?’ The Gerontologist 32 (4): 498–507. OECD. 2017. The Pursuit of Gender Equality: An Uphill Battle. Paris: OECD Publishing. https://doi.org/https://doi.org/10.1787/9789264281318-en. ———. 2020. Who Cares? Attracting and Retaining Care Workers for the Elderly. https://doi.org/ https://doi.org/https://doi.org/10.1787/92c0ef68-en. O’Keefe, Philip, and Vasoontara Sbirakos Yiengprugsawan. 2023. ‘Aged Care in Emerging Asia: New Demands, Evolving Responses, and Future Directions’. In Handbook of Aging, Health and Public Policy. https://doi.org/10.1007/978-981-16-1914-4_150-1. PAHO. 2023. Long-Term Care in Latin America and the Caribbean. PAHO and IDB. https://doi.org/10.37774/9789275127155. Pinquart, Martin, and Silvia Sörensen. 2006. ‘Gender Differences in Caregiver Stressors, Social Resources, and Health: An Updated Meta-Analysis’. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 61 (1): P33–45. Rofman, Rafael, and Ignacio Apella. 2020. ‘When We’re Sixty-Four : Opportunities and Challenges for Public Policies in a Population-Aging Context in Latin America’. Washington, D.C. https://openknowledge.worldbank.org/handle/10986/34562. Socha-Dietrich, K. 2021. ‘Empowering the Health Workforce to Make the Most of the Digital Revolution’. No. 129. OECD Health Working Papers. Paris. Stampini, Marco, Maria Laura Oliveri, Pablo Ibarraran, and Carlos Flores. 2022. ‘Who Works Less When a Parent Needs Long-Term Care? Gender Disparities in Labor Market Effects in Mexico’. Journal of Long-Term Care. UN. 2019. ‘Living Arrangements of Older Persons around the World’. https://www.un.org/ development/desa/pd/content/publications. ———. 2023. ‘World Social Report 2023: Leaving No One Behind in An Ageing World’. https://desapublications.un.org/publications/world-social-report-2023-leaving-no-one- behind-ageing-world. United Nations. 2017. World Population Ageing [Highlights]. https://doi.org/10.1007/s10916-012- 9888-1. Walker, Wendy, and Meredith Wyse. 2021. ‘Leadership and Governance of Long-Term Care Systems in Asia and the Pacific’. WHO. 2015. The World Report on Ageing and Health. World Health Organization. ———. 2020. Decade of Healthy Ageing: Baseline Report. Geneva. Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/9789240017900. ———. 2022a. ‘Ageing and Health’. 2022. https://www.who.int/news-room/fact-sheets/detail/ ageing-and-health. 26 ———. 2022b. ‘Rebuilding for Sustainability and Resilience: Strengthening the Integrated Delivery of Long-Term Care in the European Region’. Copenhagen: WHO Regional Office for Europe. https://apps.who.int/iris/handle/10665/353912. World Bank. 2016. ‘Live Long and Prosper: Aging in East Asia and Pacific’. Washington, D.C. https:// openknowledge.worldbank.org/handle/10986/23133. ———. 2021. ‘Making It Work for Women: What SPJ Projects Are Doing in the Care Space’.