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The European voice for informal carers

CZECH REPUBLIC

Towards carer-friendly societies
Demographic background

Demographic forecasts clearly suggest an increase in demand and need for care in future years. Between 2008 and 2067, the number of older seniors (aged 75 and over) will approximately treble, rising from 0.69 million to 2.02 million. In 2020 the share of the population aged 65 and over was 20.3% and is projected to increase to 30.4% by 2060.

In the period 2016 to 2070, the old-age dependency ratio i.e. the share of the population aged 65 and above as a % of the population aged 20-64 is projected to rise from 30.1% (EU-28: 32.2%) to 54.8% (EU-28: 56.4%) i.e. 24.7 pps. Most of this increase is driven by the very old-age dependency ratio (people aged 80 and above relative to those aged 15-64).

In 2070, life expectancy at 65 for men and women is projected to reach 22.4/25.7 years (EU-28: 23.4/26.6) compared to 16.3/19.9 years (EU-28: 18.1/21.5) in 2016. From 2005 to 2012 healthy life expectancy for men and women rose by 1.7 and 1.9 years, respectively.

Under an assumption of no policy change (base case scenario) the EU Ageing Report 2018 suggests that the projected public expenditure for long-term care (LTC) as a share of GDP would rise from 1.3% to 3.0% in the period 2016-2070 (EU-28: 1.6%-3.0%). The impact of a progressive shift from informal to formal care in Czechia by 2070 on public expenditure on LTC as a share of GDP would be 169% (129% on average for the EU28).

Current Long-term care provision

Czechia belongs to the traditional model, where LTC is largely considered a ‘family affair’, with informal carers (mainly family members and friends) providing most care, although there is no explicit legal or even constitutional obligation to care. In 2010, internal data of the Ministry of Labour and Social Affairs (MLSA) estimated this share of informal care  between roughly 52% and 75%, depending on the degree of dependence of the service user.

With the focus of institutional care mainly targeting older people and people with dementia, Czechia’s expenditure for institutional (in-kind) services makes up 77.2% of public in-kind expenditure (EU: 66.3%), 22.8% being spent for LTC services provided at home (EU: 33.7%). At the same time there is a recent and growing trend (at least at policy level) towards greater deinstitutionalisation with regard to persons with disabilities or requiring psychiatric care.

The development of long-term care (LTC) has been carried out in a fragmented fashion in Czechia, with responsibility strictly divided between the health care sector and the social care sector. This is combined with vertical fragmentation, with competencies split between different institutional tiers: the state, regions and municipalities. This has had an impact not only on funding, but also on the provision of long-term care. There are great differences in the costs of care for clients. While the clients pay for a major part of social care, the care in health care facilities is covered by public health insurance. This discrepancy often leads to the hospitalisation of people who rather need social care. On the other hand, the clients of some homes for the elderly may suffer from a lack of adequate medical or nursing care.

A major reform step in the area of social services was accomplished in 2007. The new law on social services – Act. No. 108/2006 (Zákon o sociálních službách) –  not only recognised a much broader range of social care services and institutions than before, but also handed over a substantial share of public funds to the recipients of social services, in the form of a care allowance (Příspěvek na péči). There was an implicit expectation that recipients would decide for themselves on the most suitable way of acquiring social services, and that their decisions would positively shape the network of formal providers of social services. In reality, data shows that the care allowance has not accelerated the development of formal, in particular community-based, social services. Almost 50% of the recipients entitled to these allowances do not use them to purchase services from any registered provider. This means that the allowance serves (at least partially) to reimburse the costs of informal care provided by relatives or friends, and represents some sort of income/benefit for the carers.

Recipients of care are differentiated on a four level scale according to the recipient’s care needs, which is specified in the law. The care allowance is not means-tested except for persons under the age of 18 years. The highest level of dependency entitles the recipient to a care allowance amount which is approximately equivalent to half the average salary or a slightly above-average pension in the country. Additionally, the amount of the care allowance for the third and fourth level of dependency has been increased recently for those who are care for at home instead of in a residential care setting or institutional care. The care allowance has been increased from CZK 8,800 to CZK 12,800 in level “ dependency, and from CZK 13,200 to CZK 19,200 for level 4 dependency for those who receive care at home (not in institution). This shift from institutional long-term care to home care may not heavily decrease public costs, but may improve quality of life of recipients who receive care at home rather than in institutions.

The number of recipients of the care allowance increased from 260,000 in 2007 to almost 350,000 in 2016. In total, it accounted for CZK 23.0 billion/EUR 900 million in 2016 (compared to CZK 21.1 billion/EUR 780 million in 2015) (ČSU/CZSO, 2017). From 1 August 2016, this allowance was raised by 10%. The relevant legislation requires recipients to use the allowance exclusively for care. Labour offices are allowed to undertake checks on how the allowance is used.

Multi-source funding is a key concept of the current social services funding scheme. Clients’ fees, which is made up of the care allowance and additional private payments, represent the main resource – they account for nearly half of total costs. Other sources consist of the MLSA’s subsidies and grants flowing into regional governments’ budgets. As regards health services, health insurance funds are by far the most important resource – they cover almost all the costs.

According to the 2015 National Strategy for Social Services Development, just 15% of individuals in need of LTC are clients of institutional care in health care or social care facilities. Most long-term care is provided as informal care by persons close to those in need of care. More than 30% of those who are involved in care provision spend more than 20 hours a week providing quite intensive care. Women make up more than two thirds of informal carers. In older age groups, the proportion of men is higher.

The National Centre for Social Services Transformation Support conducted quite a complex analysis of social services for the MLSA. Using data from the Register of Social Services Providers, it suggests that residential services account for nearly 44%, and home care services for 40% of total number of social services. Less than 15% is provided in the form of day-care services. The analysis pointed out distinctive regional differences in capacities, utilisation and other features.

Social care is mostly provided by informal carers, but also by professional social services. Formal carers of social services can be registered or unregistered. If registered, they are eligible for public funding and are also bound by administrative maximum prices. If a person is unregistered, then free pricing of services applies to be fully covered by private payments. Some services, such as social prevention or rehabilitation are provided without private co-payments. For institutional care, recipient’s income (up to 85%) can be used to cover accommodation and food costs for residential care. Reimbursement of other social services is limited by the recipient’s care allowance. Any remaining costs have to be covered privately, either by the recipient or his family. However, in some cases, a top-up from the Ministry of Labour and Social Affairs and the municipalities to cover nursing care can be made available.

Notwithstanding the importance of informal carers, LTC is also a significant segment of the labour market. The trade unions estimate that there are overall roughly 100,000 employees in the social services sector. Official MLSA statistics that cover public-sector employment report nearly 45,000 employees the majority being care workers (i.e. in social services), including 24,000 social workers and 5,000 nurses.

Carer-friendly policy environment

Number of carers

There were more than 349,000 care allowance recipients requiring some level of support and care in February 2017. More than three-quarters of them receive informal care or informal care combined with social services.

Statistical data from 2010 suggest that there are about 280,000 informal carers in Czechia who provide informal care to a close relative. According to a sociological survey, there are about 120,000 ‘caring families’ providing some level of support in Czechia and about 80,000 informal carers, who provide care on a daily basis.

About 18% of men and 28% women (23% in total) provide regular support and care to a frail older family member. Women provide more intensive care in terms of time consumption than men: 42% of women and 25% of men provided care for more than 72 hours per week.

A policy document dealing with the issue of informal care is the National Strategy for the Development of Social Services 2016–2025. The strategy considers unpaid informal care to be an “exceptionally important part of the LTC system”, estimating that there are up to 300,000 informal carers, and recognises the low level of support available for them in Czechia.

Identification of carers and assessment of their needs

Informal care has recently been highlighted in several policy documents of the Ministry of Labour and Social Affairs: (i) the National Family Policy;  (ii) the National Strategy for the Development of Social Services 2016–2025 and (iii) the draft of the National Strategy of Preparation for Ageing 2018–2022.

Access to information and advice

There is growing emphasis on support of informal carers in social services and on improving the availability of respite services and counselling, and the coordination and management of care.

At the same time, a lack of information and the high costs of formal LTC services, especially for those in need of daily, more intensive care provided at home, are among the key barriers for carers to access and benefit from professional help.  The other obstacle to providing informal care is fear of a negative impact of caring on the care recipient due to lack of knowledge or skills.

Multisectoral care partnerships

To raise awareness both among the general public and among informal carers and other stakeholders such as employers, social services, local administrations and care receivers, a new multi-layered government-funded project has been brought under way to gather knowledge and data for national and local administrations, so that evidence-based policies and measures can be suggested, communicated and implemented.

Activities include analytical and research activities, as there are very little data on the topic. This includes baseline research on the numbers of informal carers and their categorization; experiences and needs of both current and former informal carers; attitudes and awareness of the general public. The project further includes awareness raising events; the preparation of information materials such as practical guides for informal carers and for local administrations; conceptual roadmaps and finally the preparation of a strategic document tackling the key issues on informal care. Finally, certified educational seminars (funded by the Continued Education Fund)were organised in regions and towns for informal carers and professionals working in social services, municipal administration and labour offices.

Access to respite care

Informal carers consider respite services the most helpful way of supporting carers and would like to have better access to respite care in communities. However, respite services are often unavailable in Czechia. Among the reasons for the low availability of respite care, according to the providers, are the irregular use of respite services and economic uncertainty in planning. For example, if respite care beds are occupied for only six months a year or irregularly, the service is not financially self-sufficient. It is also difficult for providers to plan for the provision of respite care.

Another big barrier to respite care is financial affordability for caring families. They are often (especially if they have to give up work to provide care, despite the care allowance) poor and cannot afford respite care. There is not enough awareness of the availability of respite services among caring families. The insufficient supply of this service is caused not only by lack of supply but also by low demand.

Carers’ mental and physical health

Czechia is among those countries with a less-developed supply of field social services, which does not meet the needs either of carers or of dependent people. Most public services often include just food delivery. Home care services and support is also improving and is quite available, but may however not be sufficiently developed for those with intensive care needs.  Respite support (provision of a short break from caring duties), psychological support and counselling for carers have explicitly mentioned  by representatives of dependent people’s organisations as a crucial gap that needs to be filled.

Training and recognition of carers’ skills

Among the most visible examples of civil society organisations are the Diaconia of Evangelical Church of Czech brethren (ECCb) project ‘Care at home’ (‘Pečuj doma’) providing services, training courses, and a helpline for informal carers; ‘Cesta domů’ (‘the Homecoming’), which advocates palliative care provided at home; the NGO ‘Life 90’ (‘Život 90’), which provides home and remote emergency support to seniors and their families; and the Czech Alzheimer Society, which provides counselling, education courses, peer social support groups, and dementia cafés. Certified educational seminars funded by the Continued Education Fund are organised in regions and towns for informal carers and professionals working in social services, municipal administration and labour offices.

Recognition and definition of carers

Informal care plays an important role in the sustainability of LTC and it is often the only alternative for older people living in rural areas due to the unavailability of adequate professional care. The issue of informal care has been gaining importance on the policy agenda together with raising awareness of the inadequacy of formal LTC services and the rapidly increasing demand for care. Greater understanding is also a result of awareness-raising activities led by organisations representing informal carers – such as NGOs providing services e.g. counselling to family carers, and who often organise conferences or meetings with relevant stakeholders and decision makers.

Support for informal care is considered an integral part of the LTC system and the key policy direction for ensuring the availability and sustainability of LTC. Another reason for the increased policy interest in support of informal care is a shift towards community services and an emphasis on the deinstitutionalization of LTC services.

The government has recently improved the position of informal carers providing long-term care for their relatives. The Parliament passed an amendment to Act No. 187/2006 Coll. Sickness Insurance in September 2017, and on 1 June 2018 it introduced a new sickness insurance allowance – a new direct cash benefit called “long-term carers allowance”. The group of potential informal carers is defined quite broadly: not only parents, grandparents, children, siblings and their spouses or unmarried partners, but also other relatives (for instance uncles or nieces of the person being cared for, and their spouses or even unmarried partners). To be entitled, the informal carer must have contributed to the sickness insurance system for at least three months. However, experts  criticise thevery low uptake of this benefit. One of the reasons being the prerequisite of  7 days hospitalization of the person in need of care for an employee to become eligible for this benefit.

Civil society organizations and academia play a crucial role in increasing the awareness of informal care-related issues and the needs of informal carers through advocating for better conditions for informal carers and informing the public policy agenda.

Social inclusion of carers, access to education and employment

The only direct cash benefit recently introduced for carers, is a sickness insurance allowance that was introduced on 1 June 2018 to improve the financial situation of informal carers providing long-term care for their relatives. This direct cash benefit, called “long-term carer’s allowance” (dlouhodobé ošetřovné), is expected, in particular, to improve the labour and social position of employed women.

Since 1 June 2018, the informal carer, whether employed or self-employed, is compensated for the loss of income from work due to caring responsibilities, at the same rate as in the case of short-term care, during the period when he/she provides care for a family member discharged from the hospital after at least a 7-day hospitalisation and requiring at least 30 days of further care (maximum 90 days). The entitlement is subject to the approval of the responsible physician. Data shows that by 30 June 2020, 6 050 informal carers benefited from this entitlement (nearly 80% women).

If he/she is employed, the carer cannot be dismissed and, after the termination of his/her care responsibilities, he/she is guaranteed a return to the same job under the new Labour Code regulation. In order to balance this with the interests of employers, employers are given the right to refuse to grant the care leave – because of “serious operational reasons”.

The policy resolves a difficult family social situation for just three months – quite obviously due to financial constraints – so the problem of long-term care provision and lack of good quality support services remains. However, it can be effective in facilitating the transition to home care or a sudden need for care before the family arranges for another sustainable form of care.

Another cash-benefit, which is entitled to  the person in need of care, is a care allowance. In Czechia there are about 330,000 recipients of care allowance in the country, of whom about 115,000 are at Level 3 and Level 4 dependency (in need of intensive care). The recipients can use the allowance for any kind of care: institutional, professional home care, informal care e.g. by relatives. Estimates suggest that between 50% and 70% receive only informal care. At the same time, accessibility of institutional care is not satisfactory. All of this indicates a strong pressure for the provision of informal care, with the care allowance being the main source of compensation for informal carers.

To support the financial stability and availability of social services, the government approved several amendments of the Social Services Act in March 2017, one of which moved the financing of social services into mandatory spending. The government also proposed to increase the amount of the care allowance for people with the fourth degree of ‘dependency on care’ (‘total dependency’) who receive informal care in their homes from the current 13,200 CZK to 19,200 CZK.

The aim of the measure was to support informal care and to encourage the provision of informal care in the natural environment, at home. This was the first time since the introduction of the care allowance in 2006 (the act came into force in 2007), that informal carers and care at home have been specifically encouraged and preferred in the system of social services and given priority as compared to other forms of care. Informal carers were also, for the first time, explicitly included among the recipients of social services. However, the Czech formal LTC system, especially for seniors, still does not adequately support home and community care and remains biased towards residential care

In addition, the state pays health insurance premiums, through the state budget, on behalf of persons who are dependent on assistance from others at Level 2 (medium), Level 3 (heavy) and Level 4 (full) dependency, and on behalf of those caring for these persons, including persons caring for children younger than 10 who are dependent on assistance from others at Level 1 (mild) dependency.

In addition, what is relevant for carers of dependent persons are financial benefits in the form of tax relief. These include a wastable tax credit that can be claimed by a taxpayer whose spouse’s annual income does not exceed CZK 68,000 (EUR 2,473). However, this credit is not targeted exclusively at taxpayers with dependent family members.

References
  • The 2018 Ageing Report, Economic and Budgetary Projections for the EU Member States (2016-2070), EC, 2018
  • Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability, Czech Republic, EC, 2019
  • CEQUA LTC Network – Czech Republic: Emerging policy developments in long-term care, 2017
  • ESPN Thematic Report on Challenges in long-term care – Czech Republic, EC, 2018
  • ESPN Thematic Report on work–life balance measures for persons of working age with dependent relatives, Czech Republic, 2016
  • ESPN Flash Report 2018/17, European Commission
  • UNECE Policy Brief on Ageing No. 22, September 2019
  • Petr Wija,  Institute for Social Policy and Research, Prague

Last Updated on January 19, 2021

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