1. Introduction
The phenomenon of an ageing society is perceived as a potential threat to public expenditure in Europe (European Commission, 2003, p. 4, 2012, pp. 45–46), and has raised questions about how to respond to the present and future financial challenges it poses. Increasing demand for LTC for the elderly, especially formal care, is perceived as a relatively new social risk in Lithuania. Until recently, most of the elderly were taken care of informally in their families (Reference Lazutka, Poviliunas and ZalimieneLazutka, Poviliunas, & Zalimiene, 2015, p. 8; Reference MarcinkowskaMarcinkowska, 2010, p. 8). Changing family structure (there are fewer families living in households of several generations, fewer children per family) and demographic factors (lower birth rates, ageing society) has led to calls for solutions to be identified to the problem of how to care for the elderly. Indeed, the share of the elderly within society is increasing rapidly in Lithuania, and is expected to continue to grow (see Table 1 below).
The social investment paradigm in academic and European Union (EU) policy debates is treated as an argument in favour of social policies which later result in economic and social returns for a society. Thus welfare expenditure is seen not as a burden on national economies. Rather, it is seen as holding the potential to improve economic and human capital, which in turn leads to a strengthening of the current and future capacities of individuals (Bouget, Frazer, Marlier, Sabato, & Vanhercke, Reference Bouget, Frazer, Marlier, Sabato and Vanhercke2015; European Commission, 2013). The concept of social investment is not an unknown term in Lithuanian social policy debates. However, this topic has not received a significant amount of coverage within national social or economic policy documents to date. The context in which the term ‘social investment’ is mentioned usually relates to family and labour market policies (Lazutka et al., Reference Lazutka, Poviliunas and Zalimiene2015, p. 13). Care for the elderly or even broader issues of ageing society are not mentioned.
Social investment in long-term care has not been easily measured or quantified so far in other EU countries either. Long-term care for older people has been seen as a cost rather than part of social capital. The SPRINT projectFootnote 1 under Horizon 2020 financing framework aims to give meaning to the concept of social investment as applied to long-term care provision. The project among the other objectives, means to assess the social costs and benefits of various ways of providing long-term care for the frail elderly, present examples of approaches that do facilitate provision in a way that social benefits are achieved, and articulate in more detail the aspirations of the Commission's Social Investment Package.
Consultations with stakeholders of long-term care for the elderly on their views on care systems in their respective countries were on-going during the project. The stakeholders were consulted about their perceptions on success in care, their understanding of social investment principles and its applicability to the ageing of society.
This article presents an analysis of primary qualitative data from a study on perceptions of LTC stakeholders along several dimensions in relation to care for the elderly in Lithuania. Interviewed policy makers and regulators, care providers, subject-matter experts, and elderly individuals were asked questions about how they evaluate current LTC for the elderly in Lithuania; what they consider to be an LTC success and the factors that contribute to this; and what the main challenges and opportunities are in relation to LTC. In addition, the interviews explored stakeholder familiarity with the concept of social investment, and sought to tease out whether they perceived this to be relevant to ageing society and long-term care for the elderly in particular. The hypothesis of the study was that the LTC stakeholders would not relate the social investment concept with long-term care for the elderly . This hypothesis was grounded in statistical data (Statistics Lithuania, 2015, p. 30) and Lazutka et al. (Reference Lazutka, Poviliunas and Zalimiene2015) the report on social investment in Lithuania which states that family members, mostly women, typically provide long-term care of children or other family members who need constant care in Lithuania. This restricts their participation in the labour market.
Thus, the article proceeds with a short depiction of the current state of LTC for the elderly in Lithuania in section 1. Section 2 provides current debates in the literature and documents on social investment in LTC context. Section 3 presents methodological aspects of the study and data collection information. Section 4 of the article discusses the results of the study, before the article ends with some concluding remarks.
2. LTC for the elderly in Lithuania
Responsibility for care for the elderly is divided between two sectors in Lithuania: health and social. The health sector mostly provides inpatient care either in special nursing institutions or in nursing departments in general hospitals (Health Statistics of Lithuania, 2014, 2015). Elderly patients (65 years of age or older) represent 33% of all hospitalisation in all hospitals (EU, 2014). A patient can receive inpatient nursing care under coverage from the National Health Insurance Fund for a maximum of four months. After this period the person in care is transferred to a social care institution within the social sector's responsibility. Primary health institutions also provide nursing services at home.
The social sector provides a variety of services for the elderly: social attendance and social care at home, social care in day care centres and residential care. Social sector services are financed mostly from the state budget channelled to municipal budgets. Care and attendance at home is provided by various specialists such as social workers, social worker assistants or other specialists. The elderly can receive help with household tasks or personal care. Day care centres provide the elderly with care from several hours per day to 5 days a week. Residential care is provided by specialised social care homes, old age homes or independent living homes.
Public spending on LTC was 0.8% of GDP in 2013 in Lithuania, below the average EU level of 1% of GDP (European Commission, 2016a). Statistical data and the Report of National Audit (2015) indicate that the system is not functioning well. There are many issues to be solved: starting from provision of the information on availability of social services in different municipalities to unsatisfied demand for various LTC services for the elderly. Thus, in spite of on-going reforms (of the health care system and institutional care], there are a lot of issues to improve.
Most of the care for the elderly is still provided informally by family members in Lithuania (Lazutka et al., Reference Lazutka, Poviliunas and Zalimiene2015, p. 8; Reference MarcinkowskaMarcinkowska, 2010, p. 8). This form of care is perceived as the most reliable and acceptable by older Lithuanians as the survey by the Lithuanian Social Research CentreFootnote 2 indicates. The survey on the expectations for care at older age was performed with representative sample of the population aged 50–65 in Lithuania. The results of the survey showed that 90.7% of the respondents indicate that closest family members are the most trusted care providers at older age, 70.1% mentioned other relatives and 50.6% of the respondents – acquaintances and neighbours. Public/municipal institutions representing formal care providers are mentioned by 44.2% of the respondents, while private care institutions were considered as reliable by 49.9%. Church/parish institutions are mentioned by 35.3% and non-governmental by 34.4% of the respondents. Care by closest members of family is indicated as most desirable by 66.6% of the respondents. Institutional care for the older population is not a desirable choice: public/municipal care institutions are mentioned by 10.4%, private institutional care providers are considered desirable only by 8.7% of respondents.
As for the perceptions within the society about children's responsibilities towards their older parents, it seems that just under three-fifths (58%) of the older population in Lithuania believe that their children should care for them in old age. Around one fifth (22%) believe that children should take care of their elderly parents only if there is financial support for the children, and just 13% think that children do not have to take care of their older parents.
Older Lithuanians indicate that monetary support is the preferred form of care support in older age (more than 70%) rather than direct social services. Only one in five respondents would like to receive services directly. Only one in four of the respondents of the survey (27%) agree that they would like to receive some of the services electronicallyFootnote 3 (rather younger in the respondent group, receiving higher income or residents of bigger cities). Ten percent of the respondents indicate that such services would not be accessible to them since they do not know how to use computers. When asked who should finance care in older age, 46.1% of the respondents indicated that all the services should be financed by the state, only one in five (20.9%) would agree to pay part of the services themselves, one in four (26.3%) would agree to pay only for better quality of services additionally.
To summarise, primary responsibility for LTC for the elderly still rests with family members and should continue to do so according to the perceptions of the older members of Lithuanian society. Formal LTC is still perceived as the last source for care.
3. Social investment in the context of LTC
Social investment as a paradigm is gaining more and more attention in the latest discussions on transformations of the welfare state (see Esping-Andersen, Gallie, Hemerijck, & Myles, Reference Esping-Andersen, Gallie, Hemerijck and Myles2002; Hemerijck, Reference Hemerijck2013, Reference Hemerijck2015; Reference LeoniLeoni, 2016; Reference Morel, Palier and PalmeMorel, Palier, & Palme, 2012; Reference Nicaise and ShepersNicaise & Shepers, 2013). The social investment approach to welfare state policies shifts emphasis from social expenditure as not only a cost factor in the economy to an approach treating at least part of social expenditure as a factor potentially enhancing development of society as more equal and inclusive. Thus social investment as a social policy paradigm focuses on the welfare state not only as a burden, but as an investment in the future. However, there is no clear agreement on a single definition of social investment in the academic debates.
Social investment as a welfare policy approach has not only received attention from the academic community but also from the International Labour Office (2005) and European institutions (Bouget et al., Reference Bouget, Frazer, Marlier, Sabato and Vanhercke2015; European Commission, 2013).
The European Commission (2013) definesFootnote 4:
Social investment is about investing in people. It means policies designed to strengthen people's skills and capacities and support them to participate fully in employment and social life. Key policy areas include education, quality childcare, healthcare, training, job-search assistance and rehabilitation.
However, it remains unclear what social investment means in relation to long-term care for the elderly or even broader policies related to the ageing of societies. For the purposes of this article the definition by Lopes (Reference Lopes2017, p. 1) of social investment within the context of LTC will be used:
Social Investment within the context of long-term care is defined as welfare expenditure and policies that generate equitable access to care to meet the needs of ageing populations, improve quality of care and quality of life, increase capacities to participate in society and the economy, and promote sustainable and efficient resource allocation.
The concept of social investment itself is not completely new within the Lithuanian social policy context. However, most public discussions interpret social investment as an investment that provides ‘return’ in future and can be evaluated financially. Usually the concept is associated with investment in younger people or the working population who after such an ‘investment’ will re-pay (provide a return) in various forms to society. For example, after the investment the younger generation would integrate better into a society, the working generation would stay in employment or would be more qualified and efficient, etc. (Lazutka et al., Reference Lazutka, Poviliunas and Zalimiene2015).
4. Methodology and data
This article analyses perceptions of long-term care stakeholders on care for the elderly and social investment in Lithuania. As mentioned above, stakeholders in various countries representing very different welfare traditions were consulted within the SPRINT project. Lithuania represents the Eastern European welfare tradition following classical social policy analysis with low formal care and an almost exclusive informal care orientation, as identified by the European Commission (2016b, p. 173). On the other hand, according to Greve (Reference Greve2017b), Lithuania represents an extreme case with primary reliance on civil society in resourcing care for the elderly.
The article is based upon an analysis of national and international documentation, academic literature, and primary data. National statistical data (Health Statistics of Lithuania, 2014, 2015; Statistics Lithuania, 2015) alongside with the national documentation on the situation on long-term care for the elderly (Valstybės kontrolė, 2015) provide background information for further analysis of the situation concerning care for older people in Lithuania. International documentation (European Commission, 2003, 2012, 2013, 2016a, 2016b; European Union, 2014; ILO, 2005) enables analysis of the Lithuanian situation in a broader European context. Academic literature on long-term care (Reference GreveGreve, 2017a, Reference Greve2017b; Reference MarcinkowskaMarcinkowska, 2010; Reference Poskute and GrevePoskute, 2017; Reference Poskute and GrevePoskute & Greve, 2017) and social investment (Bouget et al., Reference Bouget, Frazer, Marlier, Sabato and Vanhercke2015, Reference Bouget, Spasova and Vanhercke2016; Reference HemerijckHemerijck, 2013, Reference Hemerijck2015; Lazutka et al., Reference Lazutka, Poviliunas and Zalimiene2015; Reference LeoniLeoni, 2016; Reference LopesLopes, 2017; Morel et al., Reference Morel, Palier and Palme2012; Reference Nicaise and ShepersNicaise & Shepers, 2013) sets the stage for the analysis of primary data collected during this study on LTC stakeholders’ perceptions linking the two concepts – ‘long-term care’ and ‘social investment’ together.
Primary qualitative data on the perceptions of LTC stakeholders concerning the LTC system in Lithuania and social investment was collected via conducting a focus group and individual interviews. There are a variety of LTC stakeholders in Lithuania – ranging from policy makers and regulators, care providers (formal and informal, private and public), to the elderly themselves. Identification of persons with experience or expertise in at least one aspect of LTC (such as policy making, commissioning, delivering, using and/or researching long-term care services) was of primary importance when selecting the respondents for the study. Potential respondents were chosen based on purposive sample.
All selected respondents were contacted in advance and provided with information on the study and were asked to sign a consent form if they were happy to take part in the focus group or an interview.
In total 12 stakeholders engaged in the study: six in the focus group and six participating in individual interviews.Footnote 5 The respondents included policy makers’ representatives from the Ministry of Social Security and Labour and the Ministry of Health, representatives of LTC providers (public and private, institutional care, day centre, social services at home), representatives of the regulating/supervisory institution, policy experts and the elderly themselves.
The semi-structured interview guide included discussion points on: evaluation of the LTC system, identification of success stories and success factors for LTC, identification of threats and possibilities in the implementation of LTC policies, the decision making in LTC provision, perceptions of the concept of social investment and its relevance to LTC for the elderly, and perceptions of return on social investment.
The combination of the findings from the focus group and individual interviews can be justified by several arguments. First, the individual interviews had the intention to clarify information and insights received during the focus group. Individual interviews were conducted after processing the findings from the focus group. The purpose of the individual discussions was to get additional insights on several issues in relation to challenges in LTC delivery and to find out why mentioned institutional success stories were considered as such. For the clarification of the challenges in LTC delivery a respondent leading a regulatory institution on national level, two respondents representing institutional LTC delivery and an older person in institutional care were invited to share their experiences. The second task – clarification of institutional and individual success factors in LTC – was dealt with by inviting two persons (one care provider, another care recipient) from the institution that was mentioned by the focus group participants as the success story to provide their insights. The second argument justifying combination of the results is use of the same semi-structured discussion scenario in both cases.
The fieldwork was conducted in early 2017. The focus group lasted 2.5 h, much longer than the initial plan to have a discussion lasting ninety minutes. This was due to the fact that all of the participants were very enthusiastically providing their opinions and insights, the discussion was very intensive and comprehensive. The individual interviews lasted approximately one hour.
4.1. Limitations of the study
The small number of participants who engaged with this study might be considered a limitation. However, it can be argued that representatives of most of the stakeholders were represented in the study. The only stakeholder representative that was missing from the study is ‘informal carer’. This might be considered a limitation as delivery of LTC for the elderly in Lithuania is mostly provided by informal carers. However, four participants that took part in the focus group or individual interviews declared that they are informal carers for older members in their families themselves (in spite of the fact that they were invited as different LTC stakeholders). Therefore it can be argued that all the stakeholders were represented in the study.
Credibility and transferability of the findings of the study is supported by previous empirical evidence and was further enhanced by consulting experts in the area additionally for ruling out alternative explanations or interpretations.
LTC stakeholders from different cities and regions of Lithuania were invited to participate in the study. However, only those based in Vilnius finally agreed to take part. This also might be interpreted as a limitation since the respondents only cover the capital of Lithuania. This limitation was controlled for by also inviting the national level policy makers and regulators to provide their evaluation and insights on regional differences in provision of LTC for the elderly in Lithuania.
5. Findings from the qualitative study
5.1. Evaluation of the LTC system
Evaluation of the LTC by stakeholders is not straightforward in Lithuania. As one participant of the study indicated ‘not everything is good, there is variety of different institutions and different municipalities, there are a lot of practical and legal issues’. On the other hand, the stakeholders who have been working for a longer time in the system indicated ‘it depends with what you are comparing’. If comparing with the systems present in some Western European countries, there are still big differences and the system might look very underdeveloped. On the other hand, the stakeholders indicated that the situation is ‘normal’, reflecting the economic and social development of the country. The LTC system made significant progress from that inherited from Soviet times: the old system was referred to as ‘gulag’ by several participants of the study. The institutions of LTC for the elderly during the Soviet era were considered as something traumatising, as last resort for those with no other alternatives. Therefore the progress made from such a system is considered a big achievement for the country.
Initial features of the market for LTC services could already be observed in Lithuania: municipalities can choose which services and institutions to select for care provision for the residents of the municipality. However, LTC services are unequally developed in and among different municipalities. Different municipalities provide very different services, it is not always possible to choose those services that would be most appropriate in a particular case. The supervisory institutions provide general guidelines and recommendations on how to organise LTC for the elderly in the regions, but there are no legal obligations to implement them. Thus while some of the municipalities are actively including private and non-governmental institutions into the system and cooperate quite successfully, others have quite rudimentary options in choice of LTC for the elderly. As one participant noted, services often are
very fragmented: health care institution there, day care centre 100 km away. (…) If I do not like this institution and there is only one in the town: what shall I do? … Do I have to move to different town? But I lived most of my life here … so I choose to stay.
There is a lack of information on available services for the elderly provided by the municipalities. Not all the municipalities provide a complete list of services available for the elderly. It is difficult for people to understand which institutions are responsible for what, and where to apply for different support and services. The danger of an elderly person being left behind was also raised several times during the study (in the focus group and individual interviews):
if no relatives? Then a municipality is taking care usually by placing a person in a cheapest institution. Or even can leave this person behind. How this can happen? Simply … How many elderly are dying lonely at home without any care in Lithuania?
Provision of LTC for the elderly is ‘not a very attractive’ [as noted by a participant of the study] activity for the municipalities: not all the municipalities have LTC institutions for the elderly in spite of receiving financing for the social programmes from the national budget. Among such municipalities are those that are considered as ‘strong’ [as indicated by a study participant] and well taken care of. As explained by one participant a mayor would rather choose to buy institutional LTC services in neighbouring municipalities (which would be cheaper) than to have the institution themselves. Thus the differences among municipalities providing very differing level and quality of social services for the elderly were noted as a worrying sign in LTC for the elderly.
The stakeholders mentioned that the recent boom in private institutions willing to provide LTC services for the elderly and applying for licences to perform the activities is noted. However, the initial objectives to ‘use property’ or ‘make profit’ often are identified in the informal conversations when there are requests about requirements for such institutions. There are already several cases where the licences were taken away from private institutions because of poor conditions, insufficient security measures, low quality of services, no lift in a premises with several floors, etc.: ‘when initial incentives from a private provider is just profit making, that's why there are results like that’.
The LTC system intends to make it possible for the elderly to stay at home as long as possible. However, there is still long way to go to have the desired system. The present system does not apply a personalised approach. As one interviewee mentioned:
if an elderly [person] is not able live self-sufficiently, he should get care and support until he passes away. But now an elderly is being transferred from institution to institution: the weaker he gets, the “further” he is pushed away … Alzheimer's or dementia at old age is often considered as mental disease and a person with such indications ends up in huge mental care public medical institutions. Thus this person is not treated decently at older age.
Talking about the responsibilities for care at older age, most of the participants of the study confirmed findings of the survey conducted earlier on in Lithuania (Sectors for Elderly Care Transformations: Demand for Services, Labour Force and Quality of Employment, 2017):
In general LTC institutions for the elderly are still very slowly received by the society as something positive, there is still perception that four generations shall live together under one roof and that children shall take care of their elderly parents.
5.2. Success stories and success factors
When asked about success stories in LTC, the stakeholders provided examples from various perspectives: national, institutional and individual level. Starting with the individual level, a success story is a situation when a person willing and able to stay at home is able to receive help and services at home instead of being moved to an institution. The possibility of having a choice of a care institution is also very important factor at the individual level. When participants – residents of the LTC for the elderly institution – were asked what is important for them when making decision about the move to an institutional care setting, they indicated that it is very important to be around people who share similar values or interests (for example, who were exiled to Siberia during Soviet occupation, who have similar educational background, etc.). Availability of medical care 24/7Footnote 6 and the professional qualification of employees were also mentioned as a priority.
As for the institutional success stories, many stakeholders agreed that there are several institutions that could be called a ‘success story’ and provided several examples. When asked why the respondents consider specialised housing for the elderly Footnote 7 as a success, one of the explanations was about very special groups of LTC ‘clients’ and significant political support received in founding these homes. When asked additionally if such special social groups are critical for the success, one of the participants of the study explained that similar life experiences and shared values make it easier for people living together to get by and have common interests. On the other hand, several participants were very thoughtful and hesitant about social justice issues noting:
“who we are to “rate” people”
“shall we treat every individual equally?”
“shall we take into account person's input into society or not?”
Therefore it was agreed that there is no one or ‘correct’ answer in such situations.
A representative of an institution identified as a ‘success story’ mentioned that they have 24 persons over 90 years of age currently in the institution (one third of the residents). Instead of sending weak and frail elderly to a health care institution,Footnote 8 the institution reconstructed the house on the lower floor for nursing facilities with special access, bathing, specialist beds, etc. The fact that ‘we take care of the residents during all the last stages of their lives’ is received by the residents as a very important safety criteria in not being transferred from one institution to another when they get weaker. This approach of the institution towards the elderly is seen as an important success factor from both an institutional and individual perspective.
There are several institutions, public and private, which have modern infrastructure but they are not considered to be ‘success stories’ in Lithuania. Further analysing why mentioned institutions are perceived as success stories, one interviewee representing an institutional ‘success case’ emphasised the special atmosphere and ‘home environment’ there:
We know each other very well, there is no necessity to check in papers who is who, we know every single person in the House. We know the relatives very well also. (…) We all seek the same goal: that this would be a HOME for the residents and nice place to work for the employees.
Thus the ‘human factor’Footnote 9 is the crucial for the institutional success.
Talking about the success of the LTC system in a broader sense (the national level), integrity and continuity of service provision for the elderly was mentioned as very important: the elderly should get a service at home when it is sufficient, and later they should be entitled to more intensive care and assistance at home. Institutional services should be considered only if and when the situation is deteriorating. The system would work best if it ‘would be monitored’ from one ‘centre’. As several stakeholders mentioned, the possibility of providing integrated care services on the national levelFootnote 10 is already a success story.
Since separate ministriesFootnote 11 are responsible for different areas in LTC provision, cooperation among the two sectors is crucial. Differences in levels of financing of the services provided by the two sectors prevent efficient LTC development according to some of the stakeholders.
For example, if a person who is in a social care institution becomes paralysed, he is being cared for there. It would look like social care institution shall be receiving money from the health care fund for the services (if they provide exactly the same services as in a health care institution). But no – the health care fund doesn't recognise such care as a qualified medical care. (…) Why this is happening? Because the costs for nursing services within the health care sector are almost twice higher than in the social security sector. (…) This is not discussed openly in Lithuania. (…) Salaries in the two sectors often differ as much as twice.
Other stakeholders added:
they [medical employees/doctors/nurses] have strong professional unions, they lobby well in the government, have rights and the laws securing higher salaries;
If social security and health sector institutions would have equal opportunities to provide similar services [nursing, etc.] and would be reimbursed from the state budget on the same level, many issues would also disappear.
Proper development of LTC care in the country is slowed down by inadequate old age pensions. Without additional co-payments from family members or municipalities, the elderly very rarely can afford any support at older age – be it services at home or public/private institutional care:
If an elderly has too small old age pension, he depends on good will of the municipality or others. If he would have sufficient income to cover expenses for the services – immediately the system would balance.
If the price for a service would be equal to the pension, then immediately more providers would enter the market from various sources, private and NGOs.
When questions were asked about the financing situation of the LTC system in Lithuania, and if it is sufficient, some stakeholders answered that this ‘is not that problematic’. The biggest issue concerning the financial situation within the system is that:
when the money for social issues (significant amounts) from the budget are transferred to the municipalities, they are not used for the social programs. Some money are transferred to road reparations, etc..
Thus the importance of legal restrictions on using the money devoted to social programmes on other budget items would help the situation, in the stakeholders’ opinion.
Success of the LTC system as a whole most of all depends on ‘political will and integrity’:
Some of the decisions that have to be made in order to have a well-functioning LTC system might be not attractive to the electorate in the short term (invest into LTC for the elderly rather than in the infrastructure for sports, leisure, etc.), therefore politicians are not making steps for the improvement of the system.
Short-sighted political decisions prevent implementation of the LTC measures that could provide solutions to the current and coming challenges of the system.
To summarise, the respondents indicated that the most important institutional LTC success factors are related to high quality of services, human factors (such as values, attitudes, behaviour of the employees) and to the possibility of having specialised institutions where the residence is shared among persons with similar values and interests. The ‘human factor’ was most often mentioned from every aspect: be it the older people in care or employees working in the LTC sphere or politicians who shape the policies and make administrative decisions on the system.
Success factors at the national level are coordination of the LTC services provided via the health and the social sectors, adequate old age pensions, responsibility and political will of politicians and the integrity of the policy decisions.
5.3. Challenges and opportunities for LTC
Current faults in the public sector in general were mentioned among the threats and among the possibilities for improvement in the sector in Lithuania. The main challenges concerning the public sector are lack of efficiency in the governance, lack of transparency and low salaries for the sector employees.
A lot of challenges in LTC for the elderly are related to worsening of the demographic situation in Lithuania: many older people in Lithuania are left ‘behind’ by their children or relatives who could potentially care for them because of emigration. On the other hand, not just emigration, but geographical migration (significantly increased mobility of people in general) are negatively affecting the current and future situation concerning previously available informal care for the elderly. Social workers that are visiting older persons at home or who care for them in the LTC institutions mentioned that the elderly suffer from loneliness because their families live away or abroad.
One of the biggest challenges for the LTC system is the increasing number of the older people in the country and shortage of medical specialists and care providers. The educational institutions prepare relatively large numbers of carers or nurses with necessary qualifications. However many of the specialists leave the country and emigrate to Western European countries where their qualifications are recognised and where they receive salaries several times higher for the same jobs. Low salaries for employees in the social care institutions were mentioned as a serious threat for the system. The job as a social care provider or a nurse is becoming less and less attractive in the country:
You can't pay the same for cleaners and social workers even if the latter only clean … You have to communicate with an older person, answer 100 questions … You come for 5 minutes but you leave after an hour – an elderly would think of 1000 reasons to keep you around, to have your attention. But you have 27 people like that … it is very difficult job.
The inclusion of more private or non-governmental LTC institutions and better cooperation with them was mentioned as a potential direction for further development of the system. On the other hand, if potential private providers are mostly motivated by future profit, entry to LTC provision by private institutions might not provide envisaged results in improvement of the situation, as mentioned by some of the stakeholders. The form of ownership – be it public or private – does not mean a priori the efficiency or desirability of an institution.
Among possibilities for improvement of the LTC system, greater inclusion of technologies in providing care was mentioned as well as potentially wider choice of services.
To summarise, the biggest threats for the system are demographic factors (high emigration, increasing migration and low birth rates in the country), insufficient political will in making decisions in LTC provision, low old age pensions preventing older people paying the full price for LTC services and no proper coordination of the implemented policies and instruments on various political levels. Constant reforming process of the system makes it difficult to sustain and adjust to already implemented changes.
5.4. Individual choice of LTC
When the time comes to make a choice of LTC services for the elderly, most often it is a collegial decision by the older person themselves, a social worker (who is assessing needs) and family members. Problems arise when care is needed by the older person but the municipality where s/he lives does not have a LTC institution or only has institutional care without any other alternatives (such as services at home, attendance, day centre, etc.).
When respondents of the study were asked where they would like to spend their own old age, very different answers were provided: starting from a priority to stay at home, in his/her own environment to residence in an institution. Respondents representing different generations provided different perceptions about responsibilities of children towards older parents: younger respondents indicated that they do not expect to be cared for by their own children. They expressed an opinion that children should live their own lives instead of taking care of their older parents. Ideal old age for the younger respondents would be: ‘to live in specialised residence where most of the residents would be of the same age, even friends’.
Another stakeholder said that she hopes that in due time there will availability of technologies which could monitor blood pressure, sugar level in blood, etc. If there is a problem – some signals would be immediately sent to a monitoring centre from where help could be provided. It was indicated that that even though it sounds like a fantasy at the moment, this is already happening slowly in various spheres. On the other side, besides technological advancement, human contact is very important and some communication would be expected. Also, if there are no family members, then visits from social workers or somebody else would be desired.
Several LTC stakeholders mentioned that they would not be against staying in one of the institutions that they are familiar with. On the other hand, some respondents were more critical and expressed hope that when they retire there will be institutions with more comfort and it would be possible to have a separate room or an apartment in a specialised residence for older people. They also expressed hope that there will be more options to choose from, a market for various LTC services, and there will be more public or private institutions offering different levels of services.
Being treated with dignity and respect are among the criteria that the respondents were wishing for themselves while choosing their own care at older age:
those older persons that live with us are treated as human beings with their names, experiences and their history. When they are back home they are simply “grandma” or “grandpa”. Here they are interesting to us as humans. They live fulfilling lives, children are visiting them. I wouldn't mind living like this at old age.Footnote 12
LTC stakeholders participating in the study once again confirmed that specialised housing would be the most desirable form of institutional care in older age.
5.5. Social investment
When asked about the concept of ‘social investment’, most of the stakeholders were hesitant and unsure about the question. As one participant of the study stated: ‘social investment is very broad term’. Clarifying questions were asked by the respondents and only after the provision of the definition by Lopes (Reference Lopes2017, p. 1),Footnote 13 was an opinion expressed that probably such investments, when financial return is not the main objective of an investor, could be called ‘social’. Immediately some associations were mentioned with the ‘social enterprise’ phenomenon.
After this opening of the discussion on social investment, the stakeholders provided various examples of social investment: investment into employees of LTC (such as good quality training programmes), the possibility of having day care at home for older people (as it enables a person to stay fit and healthier for a longer time at the same time as allowing relatives of such a person to work). One respondent defined that from a health care perspective a situation where a person who lives a long with good quality of life might be called social investment. Other attempts to define social investment were about standards of care in LTC and improvement of quality of life in older age.
As an example of social investment in LTC for the elderly, change in institutional assessment criteria was mentioned. LTC institutions were previously assessed only by e.g. statistical data on square meters/showers/toilet seats per head, number of sheets/clothing/hygiene accessories in an institution. Current assessment criteria include questions about satisfaction of the older persons and their family with the services provided, evaluation of general atmosphere and ambience in the institutions, how cosy and comfortable rooms are, etc. This is already a big step towards improvement of quality and shows a positive direction in institutional care provision.
It can be summarised that in spite of the unfamiliarity with the concept of social investment, most of the stakeholders feel familiar with the phenomenon of it and easily relate it to various aspects of LTC for older people.
5.6. Return on social investment
When further asked about return on social investment, the discussion started about ‘return’ in a form of relations among generations. ‘Investment’ of time and resources into children does not mean that the children are ‘obliged to pay back the investment’. Social investment in LTC would allow family members of the elderly to balance better family responsibilities and professional career, as one of the stakeholders mentioned. Immediately day care centres for older people as an example of successful investment in this case were recalled again.
The agreement among most of the stakeholders was that finance should not be the most important ‘return’ on the investment. Rather, it was felt that social investment in LTC is about dignity of a person in care, thus to talk about ‘return’ on such investment is not adequate.
A concluding remark during the interviews was that investment by the state into decent old age is a meaningful social investment, it shows how ‘strong’ the state is, not just from an economic perspective, but in terms of securing physical and psychological safety in older age, enabling family members of older persons to combine various responsibilities in their lives.
6. Concluding remarks
The Lithuanian system of LTC for older people has gone through many changes during the last two decades. There are many positive changes and significant improvements in comparison to the system inherited from Soviet times, (including institutional care, quality assessment, etc). However, in spite of these improvements, the system is still considered by the stakeholders and the society in general, to be underdeveloped in terms of availability of services for older people, an insufficient market for services, administrative inefficiencies and poor remuneration of the employees in the system.
One of the main obstacles to improvement are low old age pensions which do not allow older people to buy necessary services without co-payment from family members or municipalities. Beliefs about the responsibility for caring for older persons are changing very slowly in Lithuanian society – 90.7% of those aged 50–65 believe that most reliable care in older age is provided by closest family members (Pagyvenusių žmonių globos sektoriaus transformacijos: paslaugų, darbo jėgos poreikis ir užimtumo kokybė, 2017). Nevertheless, in spite of these beliefs, the reality is that many older people are left without any family support due to high emigration rates of working age people in Lithuania. Thus, on the macro level, demographic trends are among the biggest challenges for the system. In addition to this, the shortage of social workers and other employees in the sector due to low remuneration should not be overlooked. Other challenges pertaining to LTC for older people include its system of governance, the coordination of various institutions involved in LTC provision, the availability of financial schemes that permit the older persons to buy necessary services, and development of the LTC service market.
LTC stakeholders who participated in this study associate success of the system with political responsibility of the politicians. Human factors were most often mentioned by the stakeholders as crucial for an institution's success: older people should be treated with dignity in all stages of their lives.
As for social investment within the LTC context, the majority of the LTC stakeholders who participated in the study did not immediately associate LTC for older people with social investment. However, provision of various social programmes as factors influencing improvement within the system were provided as potential examples of such investment. The majority of the stakeholders would not consider financial return on such investment as the only appropriate measure of the success. Indeed, ‘human’ criteria, such as dignity, respect, and maturity were mentioned by the participants of this study when asked about ‘return’ on social investment.
Acknowledgment
I am grateful to all the focus group and individual interview participants who provided their valuable insights, comments and opinions on long-term care for the older people in Lithuania. Special thanks to the SPRINT project colleagues who helped with their comments and insights. I am grateful to the reviewers whose insights helped to finalise the document.
Disclosure statement
No potential conflict of interest was reported by the author.
Appendix A
Focus Group Participants
Deputy Head of the Department of Social Services at Home, Vilnius City Social Support Centre, Municipality of Vilnius.
Deputy Head of the Department of Social Work, Vilnius City Social Support Centre, Municipality of Vilnius.
Head of the Department for the Institutional Supervision, The Department of Supervision of Social Services under the Ministry of Social Security and Labour.
Senior Specialist at the Social Services Department at the Ministry of Social Security and Labour.
Head of the Department of Care Coordination, Ministry of Health Care.
Head of Business Development Projects, Gemma Rehabilitation and Care Centre (Private LTC Institution).
Individual Interviewees
Head of the Department of Supervision of Social Services under the Ministry of Social Security and Labour.
Director of Fabijoniškių Social Services Home (Municipality of Vilnius).
Resident in Fabijoniškių Independent Living Home (Municipality of Vilnius).
Head of Social Care Department at Fabijoniškių Social Services Home (Municipality of Vilnius).
Resident in the Special Social Care Home ‘Tremtinių namai’ (specialised home for older people that were exiled and political prisoners during Soviet time).
Senior Social Worker of the Special Social Care Home ‘Tremtinių namai’ (specialised home for older people that were exiled and political prisoners during Soviet time).
