STRATEGIC REVIEW OF LONG-TERM CARE SERVICES IN POLAND THE WORLD BANK JUNE 2024 © 2024 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover photo: Istockphoto Graphic design: Sylwia Niedaszkowska 2 ACKNOWLEDGMENTS The report was prepared under a Reimbursable Advisory Services (RAS) agreement, signed in March 2023 between the World Bank and the Ministry of Development Funds and Regional Policy in Poland. The work was led by Anna Kozieł (Senior Health Specialist, World Bank) who was assisted by a broad team of subject matter experts, including Anna Król-Jankowska, Agnieszka Sowa-Kofta, Jakub Stokwiszewski, Anna Dzikowska, Adrienne McManus, Andi Orlowski, Alejandro Gonzalez Aquines, Julia Nowicka, Marta Miller, Wiktoria Sobotka, and Renata Jeziółkowska. The report was prepared under the strategic guidance and direction of Rekha Menon (Practice Manager), Tania Dmytraczenko (Practice Manager), Mukesh Chawla (Chief Adviser), Marcus Heinz (Country Representative), and Barbara Skwarczyńska (Program Assistant) from the World Bank. The authors would like to take this occasion to record a deep sense of gratitude for the Ministry of Development Funds and Regional Policy, Ministry of Family, Labour and Social Protection, the Ministry of Health and the National Health Fund for their invaluable advice and support throughout the preparation of the report. This work would not have been possible without their active involvement and strategic oversight. Finally, we would like to recognize the participants of numerous meetings and workshops during which the recommendations proposed within the report were openly discussed. We have learned a lot throughout this process and have hopefully done justice to all the suggestions that we have received during the preparation of this report. 3 ACRONYMS AND ABBREVIATIONS AOTMiT  Agency for Health Technology Assessment and Tariff System/ Agencja Oceny Technologii Medycznych i Taryfikacji AWG Ageing Working Group BASiW Database of Systemic and Implementation Analyses, Ministry of Health CUS Local government unit agency competent for social services in Poland/Centrum Usług Społecznych COM Care and accommodation centers/ Centra Opiekuńczo-Mieszkalne COVID-19 2019 Novel coronavirus disease CPD Continued Professional Development CQ-index Consumer Quality Index CVD Cardiovascular disease DDOM Medical day care home/Dzienny Dom Opieki Medycznej DHI Digital Health Innovation DPS Residential home (social sector)/Dom Pomocy Społecznej ERDF European Regional Development Fund ESF European Social Fund EU European Union FTE Full-time equivalent GDP Gross domestic product GUS Statistics Poland/Główny Urząd Statystyczny IDI Individual In-depth Interview ISO International Organization for Standardization KMPT National Mechanism for Prevention of Torture/ Krajowy Mechanizm Prewencji Tortur KPO National Recovery and Resilience Plan/ Krajowy Plan Odbudowy i Zwiększania Odporności KPI Key performance indicator KRUS Social Security Agency for Farmers in Poland/ Kasa Rolniczego Ubezpieczenia Społecznego 4 LGU Local government unit LTC Long-term care LTCF Long-term care facility M&E Monitoring and evaluation MEN Ministry of National Education/Ministerstwo Edukacji i Nauki MF Ministry of Finance/Ministerstwo Finansów MFiPR Ministry of Development Funds and Regional Policy/ Ministerstwo Funduszy i Polityki Regionalnej MON Ministry of National Defense/ Ministerstwo Obrony Narodowej MRPiPS Ministry of Family, Labour and Social Policy/ Ministerstwo Rodziny, Pracy i Polityki Społecznej MSWiA Ministry of Interior and Administration/ Ministerstwo Spraw Wewnętrznych i Administracji MZ Ministry of Health/Ministerstwo Zdrowia NFZ National Health Fund in Poland/Narodowy Fundusz Zdrowia NGO Nongovernmental organization NIK Supreme Audit Institution in Poland/Najwyższa Izba Kontroli NIPiP Supreme Chamber of Nurses and Midwives/ Naczelna Izba Pielęgniarek i Położnych NIZP-PZH National Institute of Public Health – National Hygiene Institute – National Research Institute/Narodowy Instytut Zdrowia Publicznego – Państwowy Zakład Higieny – Państwowy Instytut Badawczy OECD Organisation for Economic Co-operation and Development OPS Social assistance office/Ośrodek Pomocy Społecznej PCPR County-tier family support center/ Powiatowe Centrum Pomocy Rodzinie OW Support Center (social sector)/Ośrodek Wsparcia PER Public Expenditure Review PFRON State Fund for Rehabilitation of the Disabled/Państwowy Fundusz Rehabilitacji Osób Niepełnosprawnych PHC Primary health care PLN Polish złoty 5 QALY Quality-adjusted life years RDP Family care home (a smaller-size LTCF)/ Rodzinne Domy Pomocy SHA System of Health Accounts SHARE Survey of Health, Ageing and Retirement in Europe SWOT Strengths, Weaknesses, Opportunities, and Threats TCN Third-Country National UN United Nations UO Care services/Usługi opiekuńcze WHO World Health Organization YLD Years of healthy life lost to disability YLL Years of life lost ZER MSWiA Pension and Disability Insurance Institution of the Ministry of Internal Affairs and Administration/Zakład Emerytalno- Rentowy Ministerstwa Spraw Wewnętrznych i Administracji ZOL Care and Treatment Facility (health sector)/ Zakład Opiekuńczo-Leczniczy ZPO Nursing and Care Facility (health sector)/ Zakład Pielęgnacyjno-Opiekuńczy ZUS Social Security Agency in Poland/ Zakład Ubezpieczeń Społecznych 6 CONTENTS Acknowledgments...........................................................................................................................................3 Acronyms and Abbreviations...................................................................................................................4 Executive Summary........................................................................................................................................16 Demographic, Health, and Social Context����������������������������������������������������������������������������������� 39 Demographic transition�������������������������������������������������������������������������������������������������������������������� 39 Health status of the elderly in Poland�������������������������������������������������������������������������������������� 41 Socioeconomic and cultural context���������������������������������������������������������������������������������������48 Long-term Care System in Poland�����������������������������������������������������������������������������������������������������54 Organization of the long-term care system in Poland������������������������������������������������54 Human resources for LTC������������������������������������������������������������������������������������������������������������������ 91 Financing of LTC�������������������������������������������������������������������������������������������������������������������������������������96 Key Challenges and Solutions for LTC in Poland��������������������������������������������������������������������� 118 Understanding challenges and developing solutions������������������������������������������������ 118 Prioritization of LTC solutions�������������������������������������������������������������������������������������������������������125 Governance�������������������������������������������������������������������������������������������������������������������������������������������������������132 A. Long-term care definition, legal acts, and system of services�������������������������132 B. Eligibility criteria for care access������������������������������������������������������������������������������������������ 138 C. Current and future long-term care demand and supply����������������������������������� 143 D. Data on Long-term Care������������������������������������������������������������������������������������������������������������155 E. Regional variation in strategic planning of LTC development������������������������� 161 F. Information on care services and access for the public��������������������������������������� 167 Summary of Governance Solutions������������������������������������������������������������������������������������������173 7 Financing����������������������������������������������������������������������������������������������������������������������������������������������������������� 174 A. Public expenditures on LTC���������������������������������������������������������������������������������������������������� 174 B. Increase sustainability of governmental programs����������������������������������������������� 185 Summary of Financial Solutions������������������������������������������������������������������������������������������������ 189 Human Resources��������������������������������������������������������������������������������������������������������������������������������������� 190 A. Distribution of LTC personnel������������������������������������������������������������������������������������������������ 190 B. Competences of select LTC personnel��������������������������������������������������������������������������� 205 C. Provision and quality of informal care����������������������������������������������������������������������������208 Summary of Human Resource Solutions�����������������������������������������������������������������������������217 Quality������������������������������������������������������������������������������������������������������������������������������������������������������������������ 218 A. Quality of formal LTC�������������������������������������������������������������������������������������������������������������������� 218 Summary of Quality Solutions��������������������������������������������������������������������������������������������������� 234 Infrastructure��������������������������������������������������������������������������������������������������������������������������������������������������235 A. Housing situation for seniors and persons with disabilities�����������������������������235 Summary of Infrastructure Solutions�����������������������������������������������������������������������������������244 Private Market����������������������������������������������������������������������������������������������������������������������������������������������� 245 A. Public-private partnerships in LTC������������������������������������������������������������������������������������ 245 Summary of Private Market Solutions�����������������������������������������������������������������������������������252 Alignment with LTC vision document�������������������������������������������������������������������������������������������253 Conclusion��������������������������������������������������������������������������������������������������������������������������������������������������������256 Appendix: Methodology for report analytics��������������������������������������������������������������������������� 260 8 LIST OF FIGURES Figure 1. Share of 65+ and 80+ age groups in the total population in Poland�������������������������������������������������������������������������������������������������������������������������������������40 Figure 2. CVD mortality (2021) and hospitalization (2020) rates per 100,000 of the 65+ population in Poland, by region���������������������������42 Figure 3. Cancer mortality (2021) and hospitalization (2020) rates per 100,000 of the 65+ population in Poland, by region��������������������������� 43 Figure 4. Diabetes mortality (2021) and hospitalization (2020) rates per 100,000 of the 65+ population in Poland, by region���������������������������44 Figure 5. Do you have a long-term condition or health problem (that is, presenting for at least six months)?����������������������������������������������������������������������� 47 Figure 6. Thinking about getting old, which aspects of declining health do you fear the most?�������������������������������������������������������������������������������������������������������48 Figure 7. Change in demographic indicators in Poland in 2017–2050 (old-age dependency ratio, parent support ratio and caregiver support ratio)�������������������������������������������������������������������������������������������������������������������������� 52 Figure 8. Simplified landscape of LTC services available in Poland����������������������� 57 Figure 9. Total number of users and DPS facilities in the social sector, 2017–2021������������������������������������������������������������������������������������������������������������������������������������ 59 Figure 10. Number of DPS facilities available for each target client category, 2021���������������������������������������������������������������������������������������������������������60 Figure 11. Users of DPS facilities per 100,000 population, in the social sector, by region, for 2017, 2019, and 2021���������������������������������������������������������������������������� 62 Figure 12. Population of DPS residents by facility type and DPS bed occupancy rate (share of beds that are occupied by residents— bottom axis and line), 2021�������������������������������������������������������������������������������������������64 Figure 13. Number of clients using selected OW services, by type�������������������������66 Figure 14. Total number of users and facilities for day care services (OW and shelters with UO), in the social sector, 2017–2021������������������ 67 Figure 15. Users of day care services (OW and shelters with UO) per 100,000 population, in the social sector, by region, 2017, 2019, and 2021�����������������������������������������������������������������������������������������������������������68 9 Figure 16. Total number of clients and average cost per client associated with basic services (UO) in the social sector��������������������������������������������������������������� 72 Figure 17. Users of basic care services (OU) per 100,000 population, in the social sector, by region, 2017, 2019, and 2021������������������������������������� 73 Figure 18. Total number of clients and total costs associated with specialized services (UO) in the social sector, 2017–2021������������ 74 Figure 19. Users of specialized care services (UO) per 100,000 population, in the social sector, by region, for 2017, 2019, and 2021����������������������������� 75 Figure 20. Total number of patients and ZOL/ZPO facilities in the health sector, 2017–2021����������������������������������������������������������������������������������������������������������������80 Figure 21. ZOL and ZPO facilities by region, end of 2021, according to GUS���������������������������������������������������������������������������������������������������������������� 81 Figure 22. Patients of ZPO/ZOL facilities per 100,000 population, in the health sector, by region, 2017, 2019, and 2021����������������������������������������������������������������� 82 Figure 23. Total number of patients of home-based nursing and total number of home-based nursing providers in the health sector, 2017–2021��������������������������������������������������������������������������������������������������������������������������������� 85 Figure 24. Patients receiving home-based nursing care per 100,000 population, in the health sector, by region, 2017, 2019, and 2021����������������������������������������������������������������������������������������������������������������������������������� 85 Figure 25. LTC system of personnel, including number of countable LTC personnel�������������������������������������������������������������������������������������������������������������������������������� 92 Figure 26. Rate of LTC workers per 100 people age 65+, 2019 and 2011 (or nearest year)������������������������������������������������������������������������������������������������������������������ 93 Figure 27. LTC workers (health and social sectors) as share (%) of total workforce, 2019��������������������������������������������������������������������������������������������������������������������94 Figure 28. Inpatient LTC workforce—social sector (DPS workforce), excluding administration staff��������������������������������������������������������������������������������� 95 Figure 29. Inpatient LTC workforce—health sector (ZOL and ZPO workforce)��������������������������������������������������������������������������������������������96 Figure 30.  LTC funding and financial flows in Poland������������������������������������������������������ 97 Figure 31. Level and distribution of LTC financing in 2021 in Poland (the total expenditure given for the social and healthcare sector does not include cash benefit and government programs)���������������98 Figure 32.  LTC expenditure as share of GDP across EU countries in 2021��������100 10 Figure 33. Total costs in the social sector (excluding cash benefits, out-of-pocket spending, and RDP) in 2019, 2020, and 2021����������������101 Figure 34. Total costs in the health sector (ZOL/ZPO and home care, excluding out-of-pocket payments) in 2019, 2020, and 2021������������102 Figure 35. LTC inpatient care users (DPS, ZOL/ZPO) and home care users as a percentage of total user population and total spending in both sectors������������������������������������������������������������������������������������������� 103 Figure 36. OW service count and spending in 2021 (excluding out-of-pocket payments)������������������������������������������������������������������������������������������105 Figure 37. Total number of and total cost of basic services (UO) in the social sector����������������������������������������������������������������������������������������������������������106 Figure 38. Total number of and total cost of specialized services (UO) in the social sector, 2017–2021���������������������������������������������������������������������������������108 Figure 39. ZOL/ZPO services and spending, 2021 (excluding out-of-pocket payments)����������������������������������������������������������������������������������������������������������������������������� 112 Figure 40. Breakdown of EU-funded projects (count and share of total), by ERDF and ESF funding source, 2014-2020���������������������������������������������� 117 Figure 41.  Total value of projects and the amount of EU subsidies����������������������� 117 Figure 42. Additional acts of law concerning LTC in Poland (that is, excluding the Act on Social Welfare Services and the Act on Publicly Funded Health Care Services)����������������������������������������������������134 Figure 43. Should there be a change in the way dependency/disability of persons requiring LTC is certified?���������������������������������������������������������������� 141 Figure 44. Persons receiving selected LTC services in 2021 (as a number and percentage of the adult population)���������������������145 Figure 45 Share of the elderly in the population versus average life expectancy���������������������������������������������������������������������������������������������������������������������������146 Figure 46. Comparative analysis of the number of people using public sector LTC (excluding cash benefits) in 2021�������������������������������149 Figure 47. Old-age dependency ratio versus number of LTC clients – social sector���������������������������������������������������������������������������������������������������������������������150 Figure 48. Old-age dependency ratio versus number of LTC clients – health sector������������������������������������������������������������������������������������������������������������������150 11 Figure 49. In your opinion, are the long-term care services available in Poland sufficient (that is, meet the needs of people in poor health, persons with disabilities and the elderly)?�����������������152 Figure 50. Share of care use in each setting in the social sector, by region������������������������������������������������������������������������������������������������������������������������������� 162 Figure 51. Share of care use in each setting in the health sector, by region�������������������������������������������������������������������������������������������������������������������������������� 162 Figure 52. Mapping of regional aging agenda by the number of aging-related measures planned in each region in Poland������������������������������������������������������������������������������������������������������������������������������� 164 Figure 53. What kind of support is most needed to be able to provide care for an elderly person or a person with a disability?��������������������������������� 168 Figure 54. Expected increase in LTC expenditure during 2019–2070 as share of GDP based on AWG scenario������������������������������������������������������� 176 Figure 55. “Thinking of LTC services in Poland, what is your opinion about...”����������������������������������������������������������������������������������������������������������������������������������� 179 Figure 56. Willingness of respondents to copay for LTC and percentage of the costs of care respondents willing to pay out of pocket��������� 183 Figure 57. Nurses in LTC health sector in Poland��������������������������������������������������������������� 191 Figure 58. Age and gender of LTC personnel in the health sector, 2017–2021��������������������������������������������������������������������������������������������������������������������������������192 Figure 59. Forecasted average monthly care demand of older adults (in hours) in Poland.�������������������������������������������������������������������������������������������������������������� 197 Figure 60. Human resources required for care provision in the formal and informal sectors����������������������������������������������������������������������������������������������������� 197 Figure 61. In your opinion, who should be responsible for care and assistance to you in your daily activities in case of a sudden deterioration in your health (mild, moderate, severe)?�������������������������������������������������������������� 209 Figure 62. If your health were to deteriorate significantly in the next two years and long-term care was necessary, how would you want that care to be arranged?������������������������������������������������������������������ 210 Figure 63. Have you ever talked to your family or friends about the issues related to aging and your future care needs?����������������������������������������������211 12 Figure 64. How should LTC quality be understood?�������������������������������������������������������229 Figure 65. What kinds of tools can be used to improve the perceived quality of long-term care in Poland?������������������������������ 230 Figure 66. Percentage of people aged 65 plus living alone�������������������������������������� 243 13 LIST OF TABLES Table 1. Main solution areas identified for assessment by the client and resulting determination of appropriateness and feasibility from the analysis��������������������������������������������������������������������������������������������������������������������� 37 Table 2. DPS facilities by region, 2017–2021 (including one regional DPS facility)��������������������������������������������������������������������������������������������������������������������������������������������� 61 Table 3.  Cash benefits for dependent persons and their caregivers���������������������88 Table 4. LTC expenditure as percentage of GDP in Poland in 2019–2021 by LTC health and social sectors����������������������������������������������������������������������������������99 Table 5. Public spending on LTC services in the social sector (excluding out-of-pocket payments)����������������������������������������������������������������������� 101 Table 6. Public spending on LTC services in the health sector (excluding out-of-pocket payments)���������������������������������������������������������������������� 102 Table 7. DPS service count and spending in 2021 (excluding out-of-pocket payments)����������������������������������������������������������������������������������������������������������������������������������104 Table 8. Services and spending in the category of basic care services (excluding specialized services) in 2021, (excluding out-of-pocket payments)��������������������������������������������������������������������������������������������������������������������������������� 107 Table 9. Services and spending in the category of specialized care, 2021 (excluding out-of-pocket payments)�����������������������������������������������������������108 Table 10. Services and spending in the category of specialized services for people with mental health conditions, 2021 (excluding out-of-pocket payments)����������������������������������������������������������������������������������������������� 110 Table 11. Home-based nursing care: services and spending, 2021 (excluding out-of-pocket payments)�����������������������������������������������������������������������113 Table 12. Home-based mechanical ventilation: services and spending, 2021 (excluding out-of-pocket payments)���������������������������������������������������������� 114 Table 13.  Cash benefits: recipients and spending by category, 2021����������������������115 Table 14. National framework for achieving an integrated long-term care continuum in Poland, based on WHO guidelines, 2021�������������������������� 120 14 Table 15. Key issues for LTC and solution areas������������������������������������������������������������������� 124 Table 16.  First phase solution areas and justification������������������������������������������������������126 Table 17.  Implementation phase for each solution area������������������������������������������������127 Table 18.  SWOT analysis for enactment of Act on LTC in Poland��������������������������� 138 Table 19. Demand for care, in average monthly hours of care per person, by Poland’s NUTS1 regions in 2019 (definition of regions – GUS 2013)�� 147 Table 20. Projected demand for monthly hours of care by Poland’s NUTS1 regions in 2022–2060 (definition of regions - GUS 2013)������������������������148 Table 21. Proportion of those with limited health literacy by socio- demographic group, in Poland and select EU countries��������������������������171 Table 22. Number of LTC patients per nurse in inpatient and home care (health sector only) in select EU countries – Poland data not available in the OECD dataset������������������������������������������������������������������������� 194 Table 23.  Projections of the availability of informal carers�������������������������������������������212 Table 24. Indicators of potential support, parental support, and caregiving capacity in 2017–2050 (calculations based on GUS, BASiW)������������������������������������������������������������������������������������������������������������������ 214 Table 25. Key framework and corresponding key indicators for assessing the quality of LTC to be considered in Poland��������������� 219 Table 26. Number and results of voivodes’ inspections over the period 2017–2021��������������������������������������������������������������������������������������������������������223 Table 27. Number of residents in 24-hour care facilities run by registered private providers in 2021������������������������������������������������������������������������������������������������247 15 EXECUTIVE SUMMARY Poland has experienced a powerful demographic shift, driven predominantly by increased life expectancy, a sizable baby boomer generation nearing retirement, and persistently low birth rates. The 65+ cohort accounts for 19.5 percent of the country’s population, with the 80+ cohort at 4.2 percent of the total. In 2023, male life expectancy was 73.4 and female life expectancy was 81.1 years. The COVID-19 pandemic has disproportionately affected the elderly population, causing a temporary decline in life expectancy. The national statistics agency, Główny Urząd Statystyczny (GUS, Statistics Poland), projects a continuous rise in the rate of the elderly population, with the 65+ and 80+ groups projected to account for 24.6 percent and 8.7 percent of Poland’s population, respectively, by 2040. While it is challenging to determine congruent estimates of the disability-affected population due to diverse definitions of disability in Poland, the National Population Census of 2021 estimates that about 14 percent of the population is certified as disabled in some capacity. Poland is characterized by demographic and spatial disparities, where life expectancy differs significantly by gender and region, and age-informed income disparities are observed as older people face above-average poverty risks. A substantial and widening gap exists between life expectancy and healthy life expectancy, that is, the number of years a person can expect to live in good health. This trend is moderated by gender, where women face greater comorbidity risks despite living longer. Regional variations in life expectancy and healthy life expectancy contribute to these inequalities: the highest healthy life expectancy is reported in Wielkopolskie and the lowest in Lubelskie in 2021. However, the highest life expectancy was reported in Małopolskie and the lowest in Łódzkie. The old-age dependency ratio in 16 Poland is projected to double from 30 per 100 working-age people in 2022 to 60 in 2060, highlighting the increasing burden of aging on the working-age population. This is made more concerning due to the high rates of cardiovascular diseases (CVDs), cancer, and diabetes in the population, along with falls among the elderly—which constitute the major causes of morbidity and mortality among seniors. Poland’s population are also fearful of these future health outcomes. Self- reported health surveys conducted by the World Bank show a decline in health perception with age, along with citizens reporting concerns about possible future physical deficits, cognitive decline, and specific chronic diseases. This higher burden of disease among senior citizens is coupled with income challenges, as elderly people report above- average relative poverty rates, with many living in substandard housing conditions. In Poland, long-term care (LTC) is mostly provided informally – about 80 percent of the total, with formal care accounting for the remaining 20 percent – and the burden on informal and formal care services is set to increase. Informal care is delivered by family, friends, and community members, while formal care is organized and financed from different public resources. However, the caregiver role, expectations, and readiness to provide care have been evolving due to demographic shifts fueled by the aging population, declining fertility rates, and socioeconomic changes. In particular, the members of the ‘sandwich generation’ (those of ages 45–64) must deal with serious challenges as they attempt to fulfill their caregiving duties regarding children and parents at the same time. An overall trend from multigenerational households to nuclear families (with no more than two generations living under one roof) further affects the caregiving dynamics, potentially leading to increased reliance on public or private LTC services. Where adequate support is not available from informal networks, spillover in demand for state- or privately provided formal care services is expected, with the absolute number of the elderly set to increase. Therefore, while the burden of care is likely to increase for 17 informal caregivers, it will also place more demand on formal care services. Both the health and social sectors provide formal LTC services in Poland. Benefits can be provided in kind (as services) or in cash. Service delivery is organized on an inpatient basis (24/7 care facilities), in a day care setting, or in a community or home setting. In the social sector, inpatient facilities primarily include two care settings: residential home, Dom Pomocy Społecznej (DPS), which cater to a significant proportion of seniors with care needs and persons with disabilities, offering them a broad range of board and lodging services, care services, support, and educational services; and a family care home (smaller-size long-term care facility [LTCF]), Rodzinne Domy Pomocy (RDP), which offer round- the-clock care to individuals who need 24/7 assistance due to age or disability. In the health sector, Care and Treatment Facility, Zakład Opiekuńczo-Leczniczy (ZOL), and Nursing and Care Facility, Zakład Pielęgnacyjno-Opiekuńczy (ZPO), provide board and lodging plus medical services, as needed. Day care services are available from facilities and shelters operating in the social sector. Community- or home-based services in the social sector are available within the package of care services; in the health sector they are included within the category of home-based nursing care or home-based mechanical ventilation care. The range of community-based services in the social sector is enhanced through programs such as Opieka 75 Plus (Care for 75+) and Opieka wytchnieniowa (Respite Care). Cash benefits play a vital role, offering financial assistance to seniors and persons with disabilities as well as to their caregivers. Notwithstanding all the available facilities and programs, Poland is currently facing formidable challenges relating to the provision of high quality and affordable long-term care. LTC capacity in Poland is affected by low availability of labor—formal and informal carers, along with other resource constraints including governance capacity, fiscal and financial resources, and a lack of quality oversight and standard 18 setting. It is in this context that the Ministry of Development Funds and Regional Policy, Ministerstwo Funduszy i Polityki Regionalej (MFiPR), has commissioned the World Bank, in collaboration with and support from the Ministry of Health, Ministerstwo Zdrowia (MZ), and the Ministry of Family, Labour and Social Policy, Ministerstwo Rodziny, Pracy i Polityki Społecznej (MPRiPS), to prepare this Strategic Overview (referred to as the ‘report’ henceforth) to provide an overview of the LTC system in Poland, identify key challenges to the system, and propose corresponding recommendations. This report constitutes one of the products prepared by the World Bank at the request of the MFiPR; it is situated in a broader program of policy reform and informed by an LTC vision document that outlines sweeping aspirations for Poland to achieve in relation to its obligations to its aging population. This strategic review constitutes the next step in developing a catalogue of solutions for addressing key challenges and supporting a better way forward toward achieving the LTC vision. The next phase of this work is to define action plans for solutions, and the associated human resource and investment needs associated with their achievement. Therefore, this report does not seek to conduct feasibility analyses for each solution area. The objective of the report is to identify recommendations that are necessary for Poland to address the identified key challenges facing LTC through the strategic review. These challenges therefore form the structure of this report, and are Governance, Financing, Human Resources, Quality, Private Sector, and Infrastructure. Three main reforms need to take place in the coming year or two to accelerate LTC system development. One, a legal definition of LTC for Poland will be needed to improve LTC system governance, financing, and quality in both health and social systems. Second, increases in LTC financing will improve access and quality of services as well as governance and efficiency of the LTC system. The third element of the reform is the preparation of the LTC quality framework—a document 19 proposing a new system of quality, monitoring, and data gathering and use, to improve service quality. One unifying definition, additional financing, and a quality framework comprise the first phase of LTC development. These are imperative for setting the foundations for further reforms. Financing and legislation are two enabling factors that allow the pursuit of other solution areas in this report, including human resource reforms, increasing access to services, and promoting coordination across the system. These areas enhance the effectiveness of the existing system while paving the way for further reforms in the future. Quality is an area that must be pursued in parallel to ensure that no matter the service, care is being provided in a safe, effective manner that meets its goals. The second and third phase solution areas are outlined in the section ‘Prioritization of LTC solutions’. Detailed LTC challenges and recommendations are summarized below. GOVERNANCE The LTC governance system in Poland is underdeveloped and fragmented across health and social sectors. The LTC governance system currently lacks cross-sectoral coordination between the two sectors; this means that care delivery is disconnected, potentially resulting in inefficiencies across care dimensions. Poor coordination and governance also mean that progress on expansive policy proposals, such as deinstitutionalization of care, can be slowed down. The weakest points of LTC governance in Poland include the absence of a unified governance approach and diffuse funding sources. The complexity of the governance system has trickle-down impacts over the LTC delivery system, notably through regulatory dynamics and regional misalignment in service funding and delivery. A critical input for governance oversight and decision-making is data, but this is similarly fragmented. 20 In Poland there is no single definition of LTC need applicable to both health and social sectors. While there is an LTC definition developed by the MZ, there is no one definition common to both social and health sectors. Various definitions have been in use, with the Council Recommendation (2022) and Social Protection Committee (2021) broadening LTC to include services and support for those in need of long-term assistance with daily living activities or permanent nursing care due to frailty, disease, or disability. The terms, senior citizen, disability, and dependency are not legally defined and can therefore be used in different contexts and understood differently by decision- makers, service providers and beneficiaries themselves. Additionally, it is estimated that there are some 70 pieces of legislation governing LTC in Poland. In the absence of a uniform and comprehensive information system on LTC services in Poland, there has been information and competence deficiencies, and an often-prolonged pathway toward accessing publicly financed interventions. There are demand- and supply-side issues that contribute to delayed care attainment. For one, people seeking care find it challenging to navigate the system given scarce and sometimes unclear communication about service scope, that is, what is offered, and where and how it can be accessed in the public system. This can also create confusion on the supply side as system providers may not have a systemic or integrated picture of what is available, for example who is eligible for what service in another sector. Further, LTC consumers interested in using a private provider or at times, forced to use private services due to the lack of appropriate public alternatives and/or information about them, consider various options without knowledge as to what care should include or information about the reliability of service providers, particularly those not registered with voivodes’ registries, and other elements necessary to make a decision. This can result in incomplete knowledge and suboptimal consumer decisions. 21 PROPOSED SOLUTIONS  reate a unified body of LTC regulations, including an LTC definition 1. C or amend the relevant acts of law.  efine transparent eligibility criteria for access to LTC services and 2. D programs for all users, with due consideration for various levels of care (that is, inpatient/residential, home and community care). 3.  Map LTC facilities at the local level, with a view to allowing information sharing on LTC facilities operating in health and social sectors. 4.  Designate LTC coordinators e.g. at the social assistance office, Ośrodek Pomocy Społecznej or at the local government unit agency competent for social services in Poland, Centrum Usług Społecznych (OPS/CUS) and expand the role of select primary health care (PHC) coordinators as contact persons for LTC matters. 5.  Develop template data sharing agreements for ministries, local government units (LGUs) and service providers. 6.  Revise existing acts to ensure appropriate and coordinated LTC data collection policies and guidelines in place. 7.  Ensure that the monitoring and evaluation of programs supporting LTC, including those supported by European Union (EU) funds, informs LTC interventions by identifying what has been successful and aligned with national and regional needs. 8.  Develop an interactive dashboard with demographic, care demand, and service provision analytics for each region (voivodeship). 22 9.  Accelerate the development and implementation of plans (for example, local deinstitutionalization plans) that support the enhanced delivery of local services. 10.  Ensure that strengthening communication and access to information on LTC is part of the LTC coordinator’s role. 11.  Ensure effective public outreach using an awareness-building campaign, a national government website, and local government websites. 12.  Continue to enhance the health literacy of the public regarding the needs of the aging population and persons with disabilities and availability of care and LTC service offerings to raise awareness using available communication tools. FINANCING In 2021, estimated public spending on LTC services fell below the EU average. According to Eurostat data in 2021 Poland’s LTC spending amounted to 0.5 percent of gross domestic product (GDP) compared to average of 1.7 percent in the EU.1 Low expenditures on LTC in Poland is a cross-cutting issue that requires comprehensive and strategic solutions. Public dissatisfaction with funding levels has been evident in public opinion surveys and social consultations organized by the World Bank. An important source of LTC financing in Poland is from European funds that support the development of services provided in the local community. Making the most of available funding, including EU financing, remains a challenge. Currently, the way funding is leveraged 1 The System of Health Accounts (SHA) is the only comprehensive annual data source on LTC expenditure at the European level. However, while all member states report data for the health component, only half of them do so for the social component. The expenditure quoted above is therefore incomplete as it assumes that expenditure on the social component equals zero for those member states where it is not reported. Source: European Commission 2021. 2021 Long-Term Care Report Trends, Challenges, and Opportunities in an Ageing Society, Volume I. 23 has contributed to fragmented financing across Poland’s regions – revealing a need to better coordinate and direct these funds. Instability that comes with short-run and targeted government programs could be addressed with a carefully designed planning, management, and monitoring system. Once evidence-based solutions are put in place, efficiency improvements in LTC funding will become more attainable.  Spending on LTC reflects differences between health and social systems service provision. In 2021 in Poland, public spending on LTC services of various types consumed PLN 8.5 billion, cash benefits excluded. Most of the services were provided by the social sector (PLN 6.6 billion), with just PLN 1.9 billion allocated to LTC through the health- care system. This reflects the number of beneficiaries accommodated by each of the sectors, with the lion’s share of LTC users reported in the social sector. In both sectors there are notable cost disparities between different settings of care, for instance, the annual spending on 24/7 inpatient care by far exceeds the budget allocated to home care. PROPOSED SOLUTIONS 1. Increase LTC allocation in the state budget. 2.  Conduct a Public Expenditure Review (PER) to evaluate the effectiveness of public finances for LTC and propose budgetary solutions to ensure the fiscal sustainability of the system. 3.  Ensure sufficient LTC funding at different service delivery levels (central, regional, local) and at different service delivery settings (home, day care and inpatient) including the possibility to introduce publicly funded vouchers, managed at local government levels as demand-side subsidies to targeted groups, giving the opportunity to purchase LTC services on a well-regulated, private market. 24 4.  Introduce support mechanisms for LGUs which commit to develop LTC interventions and follow strategic directions. 5.  Evaluate the existing copayment arrangement and prepare to implement a revised copayment mechanism for LTC services to generate additional revenue without putting financial strain on vulnerable populations. 6.  Provide incentives and encourage the use of tools for individuals who are willing to plan for future LTC needs through health-related investments and voluntary financial investments, such as savings, insurance, and similar schemes. 7.  Coordinate the financing and legislation for LTC programs pursued by the government.  rovide multiyear funding for LTC initiatives to ensure stability 8. P for planning and resource allocation. 9.  Create feedback loops connecting LTC funding and performance assessments, reward quality, excellence, and responsiveness in the context of evolving need. HUMAN RESOURCES In Poland, there are deficits in the volume, distribution, and capacity of the LTC workforce. A key challenge for the development of LTC services is labor shortages. Given the dual nature of service delivery, split between the social sector and health sector, there is a lack of standardized professional regulations or employment requirements that cover both sectors. While DPS facilities must abide by certain staffing requirements, other social sector providers offering LTC services do not need to follow such standards. In contrast, employment in 25 the health sector is more strictly regulated in terms of the professional qualifications of the staff. There are also minimum mandatory pay rates for nurses and physicians working in certain health-care facilities. In practice, the health sector has been more attractive for potential jobseekers than the social sector. While workforce projections indicate an upward trend in the size of human resource pools in both sectors, challenges such as an aging workforce and low job prestige persist. There are several nonfinancial disincentives to participating in an LTC occupation, such as challenging and intensive working conditions, low growth opportunities, and often inadequate support in delivering LTC services. These issues are amplified in the informal delivery of LTC services—which Poland’s elderly population are heavily reliant on—raising concerns about the potentially suboptimal expertise, knowledge, and capacity of family caregivers, as well as those hired through private means. The proposed solutions should support effective use of human resources and, at the same time, improve the quality of the LTC job market. PROPOSED SOLUTIONS 1.  Ensure, where appropriate, that remuneration of LTC workers is raised to support the supply of workers for care continuity across service settings. 2.  Incentivize LTC facilities to rely on complementary sources of labor— migrants, family caregivers, nongovernmental organizations (NGOs). 3.  Step up efforts intended to standardize and formalize the profession of medical caregiver. 4.  Boost the prestige and attractiveness of care work—for example, through outreach campaigns, education, and additional packages of nonfinancial incentives such as mental health support, 26 physiotherapy options, occupational courses/training, and professional development. 5.  Implement protection measures for care providers from violence and abuse in all its forms. 6.  Facilitate access to upskilling and training for the LTC workforce, formulate a skills framework and career paths, and offer career advancement and promotion mechanisms based on a common skills framework and rotation between LTC roles and settings. 7. Develop a definition for informal caregiving. 8.  Facilitate informal caregiving and mitigate negative labor market consequences for carers, including family members, through pension credits, tax credits, work flexibility, and job guarantees. 9.  Provide financial and nonfinancial support for informal caregivers, including family members, such as, care vouchers, education and training, physiotherapy, mental health support, and respite care. 10.  Introduce temporary and transition care to give families who have elected to become caregivers time to adjust their work patterns, become trained in care, and adapt the home to the beneficiary’s needs. QUALITY Quality assurance in LTC service delivery in Poland has been inadequate due to the low availability of quality measures and limited oversight. The ‘standards’ that regulate how LTC facilities may offer their services on the market are provided for in applicable secondary legislation, but there is no harmonized definition of quality expected 27 from health and social sector facilities; likewise, there are no universal key performance indicators (KPIs) to guide the evaluation of care quality. In addition to the low availability of quality standards, LTC facilities may be inspected by a number of agencies and authorities (including voivodes, local government units, or the National Health Fund, Narodowy Fundusz Zdrowia [NFZ]), but such inspections have not been conducted on a regular basis. The most common irregularities detected during inspection involve noncompliance with medical care standards and staff shortages. When assessing public opinion on LTC quality, nearly half of Poland’s adult population report a negative opinion, and those who use LTC services are even more critical. Respondents participating in social consultations with the World Bank believe that the issue of LTC quality assurance should be addressed at the system level and called for strong leadership from national agencies and a buy-in from regional authorities. PROPOSED SOLUTIONS 1.  Appoint an expert team to develop an integrated LTC quality framework and KPIs. 2.  Include the LTC quality definition, framework, and KPIs in the relevant LTC acts of law. 3.  Launch a national monitoring and evaluation (M&E) mechanism applicable to LTC providers, facilities, and organizations. 4.  Introduce user-engagement surveys to assess the experiences of patients and their families within the LTC system. 5.  Create a publicly accessible database reporting the KPIs of public and private LTC providers. 28 6.  Employ technological solutions to enhance data management, potentially with the real-time use of data, and to improve LTC beneficiary’s care and LTC outcomes. 7.  Promote scientific research on LTC to improve services and the system. INFRASTRUCTURE The growing elderly population in Poland increases the urgency of addressing housing-related issues. Housing conditions affect safety, security, and quality of life of seniors and persons with disabilities, especially because these populations often have mobility impairments. Most seniors in Poland live in their own housing units, and one-third of women aged 65+ live alone, making them vulnerable to the potential inadequacies of their housing. Current policies should be enhanced to address specific needs that come with population aging to ensure that there is an adequate supply of housing stock suitable for seniors and people with disabilities. While it is true that the proposed solutions go beyond the mandate of health and social sectors, age-appropriate housing is an upstream factor influencing older people’s likelihood of engaging with the health or social care sectors, such as due to falls or premature institutionalization in a residential care facility because of unsafe living conditions. Developing adequate and aging-appropriate housing is critical for the deinstitutionalization of the LTC system, notably by preventing entry to residential care and strengthening home care delivery—which is an often-preferred care setting for aging people. As these solutions fall outside of the purview of the health and social sector, they should be considered by the appropriate ministries and/or ministerial agency that would be involved in their implementation. 29 PROPOSED SOLUTIONS 1.  Continue the development of the housing stock for people with disabilities and seniors. 2.  Continue regulating design standards for buildings and dwelling units intended for people with disabilities and those intended for seniors and ensure that digital technologies and solutions are included. 3.  Extend greater financial support for home adaptations and access to assistive services and digital technologies to give seniors and people with disabilities, who prefer to live in their home, an option to stay at home for as long as possible. 4.  Collaborate with LTC coordinators (e.g., OPS/CUS) to conduct a needs analysis and help people to access funding for home adaptations. 5.  Conduct regular diagnostics of housing needs in local contexts and manage the housing stock with due consideration of community needs. 6.  Align the planning processes to local conditions, ensuring access to necessary transport and amenities, including social life, shopping, and health care. PRIVATE MARKET Public-private or social economy partnerships exist in LTC delivery, but the full cooperative potential between the sectors has not been realized. Private LTC services have the potential to complement the public system. And while there are some available data on private LTC facilities, little is known about services contracted with private providers 30 by public LTC facilities. The information gaps undermine the capacity of enforcing a potential quality assurance system, and regulatory and monitoring mechanisms are essential to safeguard service quality in private institutions. Measures should be taken to foster coordination between the sectors so that prospective beneficiaries can navigate them without worrying that continuity or quality of care might be compromised. The plurality of private and nongovernmental actors in LTC delivery, including for-profit enterprises, NGOs, and social enterprises, adds complexity to coordination challenges within the LTC sector, but there are opportunities to leverage the mix of supply options to deal with regional deficits or disparities. The following proposed solutions should foster strong public-private partnerships and improve coordination of LTC services. As with the solution areas under infrastructure, these solutions fall outside of the purview of the health and social sector and therefore should be considered by the appropriate ministries and/or ministerial agency that would be involved in their implementation. PROPOSED SOLUTIONS 1.  Routinely update a database of all (public and private where possible) care services, including available capacity to facilitate searches of places and to make good use of supply. 2.  Give LTC coordinators access to the LTC facility database to enable them to advise their clients about new openings and service availability. 3.  Improve and operationalize oversight and control mechanisms applicable to private institutions in line with the requirements set out in quality standards for private and public providers. 4.  Continue to promote public-private- and nongovernmental partnerships and information sharing. 31 This report presents an overview of the LTC system in Poland focusing on care integration, deinstitutionalization, and the labor market. The challenges facing long-term care in Poland have been identified from several key sources: the experience and perceptions of LTC stakeholders (patients, clients, families, communities, NGOs and other groups); a system-level analysis of several aspects of long-term care; the views of national policymakers; and identified by the European Commission—in the National Recovery and Resilience Plan which includes reform A4.6 ‘Increasing the economic activity rate of specific groups through the development of long-term care’. The aim of this reform is, among others, a strategic review of LTC in Poland to define priorities for necessary reforms, including deinstitutionalization, labor market strengthening and improved coordination. The three focus areas of reforms and the respective solutions are outlined below: Coordination/Integration: This reform area aims to achieve a strategic and integrated approach to care provision and governance. Person- centered care, that is conducive to independent living, is hampered by fragmentation between different sectors, across care settings, and in legislation and policy. Integrated and coordinated care should ensure that people move seamlessly through the continuum of care, and that care is adequately provided across a continuum of care needs, which includes integrating informal, home, and community-based care, and, as needed, residential care. A coordinated system of care is also required to support the transition from institutionalized forms of care to community-based systems.2 The proposed solutions that address improved coordination, among others, include creating a unified body of LTC regulations; defining transparent eligibility for access to all types of care; mapping LTC resources and needs; designating LTC 2 European Commission. 2022. “Communication from the Commission to the European Parliament, the Council, The European Economic and Social Committee and the Committee of the Regions on the European Care Strategy.” Brussels, 7.9.2022. https://eur-lex.europa.eu/legal-content/EN/TXT/ PDF/?uri=CELEX:52022DC0440 32 coordinators; developing data sharing agreement and LTC data collection legislation; conducting M&E of interventions that informs coherent strategic planning; developing analytics of service provision and demand; employing public awareness campaigns; coordinating the financing and legislation for LTC programs pursued by the government; and while the private sector is already involved, ensuring those activities are coordinated, managed, and assessed more effectively. Labor market: LTC is a human resource-intensive service, therefore the system hinges on adequately provided, well-trained, and supported caregivers. In many advanced economies,3 population aging has been outpacing the growth of the LTC supply. In these settings, the level of the workforce in LTC has stagnated or declined, even in countries where the LTC supply is typically higher.4 Poland’s population is one of the most rapidly aging in the EU,5 and with an already low supply of LTC workers, demand is projected to continue to far outstrip supply. Responding to this trend will require solutions that help attract, retain, and strengthen the LTC labor market, while measures are also needed to support informal caregivers and minimize disruption to their labor market status. LTC also necessitates more than just personal care, often requiring engagement in complex care tasks. Proper training, certification and support is therefore imperative to ensuring high quality care. The proposed solutions that seek to address labor market development in Poland include increasing the remuneration of workers; boosting prestige of caregiving professions through educational campaigns and financial and nonfinancial benefits; protecting workers against abuse; facilitating LTC workers access to upskilling and training; and strengthening the provision and quality of informal caregiving through several holistic measures described later in the report. 3 More than half of the countries in the Organisation for Economic Co-operation and Development (OECD). 4 OECD. 2021. “Long-Term Care Workers.” Health at a Glance: OECD Indicators. https://www.oecd-ilibrary.org/ sites/c8078fff-en/index.html?itemId=/content/component/c8078fff-en 5 Eurostat. “Population Structure and Ageing.” https://ec.europa.eu/eurostat/statistics-explained/index. php?title=Population_structure_and_ageing#:~:text=Regarding%20the%20share%20of%20 people,%25)%20had%20the%20lowest%20shares. 33 Deinstitutionalization: Across the EU, hundreds of thousands of people living with disabilities, mental health problems, or in old age live in large segregated residential institutions.6 Evidence now shows that this type of care setting fails to deliver on providing person-centered care that fulfils people’s right to inclusion, particularly by limiting people’s access to their communities.7 Strengthened community and home-based care options can therefore ensure individual well-being by offering care where its preferred. The proposed solutions that address deinstitutionalization include mapping existing LTC resources; conducting M&E of interventions, particularly those advancing deinstitutionalization; enhancing planning efforts toward deinstitutionalization, such as accelerating the development and implementation of local deinstitutionalization plans that support the enhanced delivery of local services; strengthening health literacy; implementing performance-based financing that can support the development of high-quality care with a focus on noninstitutional care; and developing housing solutions that support aging at home and in communities. Several of the solutions outlined in this report address all three reform areas and seek to improve the existing system of care provision. An LTC legal act or amending the relevant acts of law forwards all three reform goals by defining the entitlements of individuals to various forms of care across different settings, defining informal caregivers, and ensuring coordination between actors across the continuum of care by clarifying roles and responsibilities. LTC coordinators too address all reform areas by supporting families access needed care services of all kinds, including day and home care, and by better coordinating a complex care system. Financing solutions –increasing financing from the state budget, conducting a PER, 6 European Expert Group on the Transition from Institutional to Community-Based Care. 2012. “Common European Guidelines on the Transition from Institutional to Community-based Care.” https:// deinstitutionalisation.com/wp-content/uploads/2017/07/guidelines-final-english.pdf 7 Ibid. 34 examining funding optimization and the use of financial mechanisms by the public, ensuring financing is allocated sufficiently and sustainably to different care settings, and regions are supported in pursuing recommended LTC interventions – are necessary for all reform goals. For example, deinstitutionalization will require investment into the system by augmenting different types of care provision, described later in the report. Labor market development will be enhanced through increased staffing, training and benefits, and other retention activities. Investment will also be required to engage in the various coordination activities, including mapping care services and demand. Finally, quality solutions aim to secure the well-being, safety, and outcomes of care recipients. This has cross-cutting implications for deinstitutionalization, labor markets, and coordinating care activities in line with quality outcomes. Assessing patients and their families’ opinions on LTC helps drive the quality vision forward, while conducting M&E of care provision using an integrated quality framework holds providers and decision-makers to account. The solutions outlined in the report also remain consistent with the recommendations of the United Nations Committee from 2018, which indicate, among others: the need to develop and adopt specific actions in the field of deinstitutionalization and transition (in specific time frames) to independent living of people with disabilities in local communities, as well as to provide adequate financial resources for this process.8 This report is a key deliverable of the Reimbursable Advisory Services (RAS) agreement between the World Bank and the MFiPR in Poland. This report is the second deliverable of the RAS agreement, following an identification of LTC needs and values that form the LTC vision 8 UN Committee. (2018) Recommendations for Poland. UN Committee on the Rights of Persons with Disabilities. Online access: https://bip.brpo.gov.pl/pl/content/rekomendacje-dla-polski-komitetu-onz- komitetu-ds-praw-osob-z-niepe%C5%82nosprawnosciami 35 document. The aim of this Strategic Review is to produce a detailed analysis of the LTC system in Poland and to propose relevant solutions that are guided by three broad goals of LTC reform: better coordination of the LTC system, deinstitutionalization of care, and strengthening of the labor market for care provision. To develop solutions, this report examines the social and health systems and their respective LTC service provision, governance, and financing arrangements with a view to developing a more integrated and coordinated system of LTC functions. To address system-wide challenges, it should be noted that for purposes of clarity, this report applies a consistent nomenclature for the main settings of care delivery across both sectors (that is, home care, day care, inpatient care). The term ‘home care’ is not used in the social sector and it was adopted only for the purpose of this report. ‘Inpatient care’ is an approximation used to facilitate comparisons between the two sectors, as social sector actors would typically refer to this care setting as ‘residential care’. The first part of the report presents the landscape of LTC services in both health and social sectors, focusing on key information to navigate the reader through the complexities and factors specific to each sector. The second part of the report analyzes the main issues and proposes solutions—system-wide interventions as well as project-scale approaches—that can be considered and implemented in the short to medium term. As part of the solution identification for this report, a set of priority areas proposed by the client were considered. Each proposed solution by the client has been assessed in terms of its appropriateness for the context and challenges in Poland and for its feasibility. The determination for the appropriateness and feasibility for each is listed below (Table 1) and developed in greater detail in the body of the report. 36  ain solution areas identified for assessment Table 1. M by the client and resulting determination of appropriateness and feasibility from the analysis ASSESSED SOLUTION AREA APPROPRIATENESS/ FEASIBILITY REASON FOR DETERMINATION Integration of LTC functions9 Not appropriate or feasible at The current LTC system is too diffuse to this point of LTC development pursue integration solutions; the report proposes coordination of select solutions to support improved LTC functioning. Deinstitutionalization Appropriate and feasible Possible through rapid development of of LTC services day and home care, including community care; further discussed in the report. Single authority for LTC Not appropriate or feasible at Current legislation precludes this approach; the this point of LTC development report proposes actions aimed at legislative changes toward better coordination and governance. Reduce fragmentation Appropriate and feasible Through revision of LTC governance and financing, further discussed in the report. Create a stable system Appropriate and feasible A stable system of financing supports core of financing LTC functions, but this should be extended to ‘additionally’ provided services, that is, those that fall outside of the mandated provision, these would require sustained financing; further discussed in the report. Quality framework Appropriate and feasible Quality control is to be developed; discussed in the report. Care benefits Appropriate and feasible Benefits are to be revised; discussed in the report. This report is organized in two parts: the first part presents an overview of the LTC system including the available services, how they are organized, beneficiary groups, and provision and utilization levels, followed by a brief overview of human resources and financing for LTC. The second part of the report presents the main challenges facing the LTC system that have been identified through a system analysis, surveys, extensive consultations with LTC stakeholders and national policymakers. These challenges are organized by six main themes: Governance, Financing, Human Resources, Quality, Private Sector, and Infrastructure. Each theme comprises a set of proposed solutions 9 Integration understood as the combination of LTC services in the health care system and the social assistance system into one, separate LTC system. 37 to meet the LTC challenges. The report has also organized the solution areas in three implementation phases. The final section concludes this report. A detailed methodology of the conducted analyses can be found in the appendix. The next step should be to develop specific action plans that outline the costs, human resources, implementing agency, and time frame for the solution implementation. 38 DEMOGRAPHIC, HEALTH, AND SOCIAL CONTEXT DEMOGRAPHIC TRANSITION Poland’s population has been aging rapidly, and several key factors drive this demographic trend. First, life expectancy has been generally increasing, albeit with a temporary disruption with the spike in COVID- 19-related mortality during the pandemic. Second, the proportion of Poland’s older population is expanding as the baby boomer generation born in the 1950s and the subsequent boom of births in the late 1970s reach retirement age. Third, Poland faces low birth rates that fall below the population replacement level, which puts more pressure on family members providing long-term care (LTC) for the elderly as the ratio of younger people to older people continues to shrink. With those demographic shifts, the size of the 65+ population has been steadily increasing; the older population reached 7,353,000 individuals in 2022, of which women represent 59.9 percent. The proportion of people aged 65+ within the country’s population stands at 19.5 percent, and the proportion of people aged 80+ stands at 4.2 percent. The last cohort relies on LTC services more than any other age group. More women make up the 80+ population at 69.1 percent, significantly outnumbering men. According to demographic forecasts by Statistics Poland, Główny Urząd Statystyczny (GUS), the 65+ population is expected to grow from a projected rate of 24.6 percent in 2040 to 32.6 percent in 2060. Correspondingly, the 80+ population share is predicted to rise to 8.7 percent by 2040, and to 11.6 percent by 2060 (Figure 1). 39 Share of 65+ and 80+ age groups in the total population Figure 1.  in Poland 35 30 25 20 15 10 5 0 2022* 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 65+ share 80+ share Source: Word Bank 2023, own compilation based on GUS 2023 data. While major progress has been observed in overall life expectancy, gender disparities have emerged in longevity and healthy life expectancy in Poland. Except for a drop during the COVID-19 pandemic, Poland has seen continuous progress in life expectancy over the past seven decades. Male life expectancy has improved by nine years and women have seen a gain of eleven years.10 In 2023, this translates into 73.42 years of life expectancy at birth for men and 81.06 years for women. While men and women experience different lifespans, this gender gap in longevity has two distinct dimensions. The first is that men do not live as long due to lifestyle choices, occupational hazards, and accident rates, which altogether influence the number of men surviving to older age compared to women. But for men and women who do reach an older age (65), the gender gap shrinks, with men expecting an average of 14 additional years and women expecting 18.4 years.11 The other dimension is that while women do live longer, 10 GUS. 2023. Sytuacja demograficzna Polski do 2022 r. Warszawa. 11 GUS. 2023. Sytuacja demograficzna Polski do 2022 r. Warszawa. 40 they spend a smaller proportion of their life without a major health condition—measured in terms of healthy life expectancy – compared to men. Across all European Union (EU) member states, Poland reports the largest disparity in healthy life expectancy between men and women, equivalent to three years. In 2021, women's healthy life expectancy represented 79.2 percent of their life expectancy.12 This gender-based variation suggests that while women have a longer life expectancy, they face an elevated risk of comorbidities and lifestyle limitations that could compromise their independent living. Like life expectancy trajectories, healthy life expectancy disparities narrow as cohorts get older. Regions across Poland also report differential levels of life expectancy and healthy life expectancy. Notably, Małopolskie reports the highest life expectancy for men (73.5) and women (81.0); while Lubuskie reports the lowest life expectancy for men (70.5), and Śląskie for women (78.9). In terms of healthy life expectancy, Wielkopolskie stands at the top (much above the country average), whereas Podlaskie reports the lowest value, despite having relatively high life expectancy for women. HEALTH STATUS OF THE ELDERLY IN POLAND From the standpoint of mortality and burden of disease, the leading health concerns include cardiovascular diseases (CVDs) and cancer. The presence of a chronic condition or comorbidities is linked to disability and loss of independent living, which are further exacerbated by sensory impairments and joint disorders. Falls and impaired mobility pose significant risks to seniors and require preventive measures and comprehensive care. These health risks are made worse by poverty, where individuals with low incomes struggle to afford health-care 12 NIZP-PZH (National Institute of Public Health - National Research Institute / Narodowy Instytut Zdrowia Publicznego – Państwowy Instytut Badawczy). 2020. Sytuacja zdrowotna ludności polski i jej uwarunkowania 2020. 41 costs for services not reimbursed from public funds; this is especially true for disability pensioners. Substandard housing conditions, particularly in rural areas, also contribute to poor health outcomes. The multidimensional nature of seniors’ health and well-being necessitates holistic strategies and improved living conditions for the elderly. Cardiovascular diseases, including stroke, are the leading cause of death in Poland and can affect people’s ability to carry out daily activities. CVD mortality rates also vary significantly by region. In 2021, Podlaskie and Lubelskie regions in eastern Poland recorded the highest CVD-related mortality and hospitalization rates among the elderly population (Figure 2). CVD patients, especially stroke survivors, often require rehabilitation, physiotherapy, and even round-the-clock care in an inpatient facility. CVD mortality (2021) and hospitalization (2020) rates per Figure 2.  100,000 of the 65+ population in Poland, by region CVD mortality rate in 65+ population CVD hospitalization rate in 65+ per 100k in Poland in 2021 population per 100k in Poland in (Poland = 2215.0) 2020 (Poland = 7938.9) 2093.5 5637.8 1755.9 8495.3 2196.5 6802.7 2497.8 8761.8 8817.2 2338.5 1993.1 8794.5 8115.1 2745.8 1711.1 8761.8 1962.0 8300.5 2580.6 2881.3 7031.4 10059.5 2232.4 2281.3 2431.9 8531.8 7646.0 7555.1 2153.0 9236.5 2308.0 7335.3 max min Source: NIZP-PZH-PIB data, 2020–2021. 42 Cancer is the second leading cause of death in the elderly population, and cancer treatment and management tend to be care intensive. In 2021, Małopolskie, Pomorskie, and Kujawsko-Pomorskie reported top mortality rates due to cancer, while the highest cancer-related hospitalization rates were recorded in Podlaskie and Świętokrzyskie (Figure 3). Cancer patients need continuous medical attention during the acute phase and the remission phase of their chronic condition. Due to the nature of care required during the acute phase, hospice and palliative care may be indispensable. Notwithstanding the health toll, cancer substantially contributes to disability risk. Cancer mortality (2021) and hospitalization (2020) rates Figure 3.  per 100,000 of the 65+ population in Poland, by region Cancer mortality rate in 65+ Cancer hospitalization rate in 65+ population per 100k in Poland population per 100k in Poland in in 2021 (Poland = 963.2) 2020 (Poland = 4382.0) 1014.7 4978.3 987.6 4195.1 1001.8 4938.8 918.6 6520.8 1014.7 3422.0 928.0 4000.8 881.8 1001.7 6063.0 4907.2 929.4 6373.1 4824.3 865.5 974.4 4961.2 942.6 3168.6 951.1 1020.2 3018.4 3703.2 852.0 3558.7 1005.8 2287.5 max min Source: NIZP-PZH-PIB data, 2020–2021. 43 While not a top cause of senior mortality in Poland, diabetes contributes to severe health complications. Diabetes accounts for just 2.2 percent of all senior deaths, however the complications arising from this disease affect CVDs such as atherosclerosis, stroke, and myocardial disease; ocular and renal disorders; and neurological impairments. As the population ages, the number of people presenting with Type 2 diabetes, which is typically diagnosed around the age of 60, is anticipated to rise dramatically (Figure 4). Diabetes mortality (2021) and hospitalization (2020) Figure 4.  rates per 100,000 of the 65+ population in Poland, by region Diabetes mortality rate in 65+ Diabetes hospitalization rate in 65+ population per 100k in Poland in 2021 population per 100k in Poland in 2020 (Poland = 126.9) (Poland = 345.1) 163.6 209.4 191.8 371.5 99.8 278.0 118.5 329.6 137.5 354.2 110.7 269.3 162.6 446.7 279.9 109.0 109.1 365.4 120.7 125.9 358.9 537.8 75.3 453.8 135.8 158.0 325.0 325.0 81.4 449.8 104.8 346.9 max Source: NIZP-PZH-PIB, 2020–2021. min 44 Mobility issues and the risk of falls are caused by a mix of physical and environmental factors and falls increase the likelihood of severe outcomes for the elderly when they occur. Impaired mobility and falls are associated with neurodegenerative disorders, bone and joint maladies, and visual impairments, all of which are more often a feature of advanced age. Beyond physical characteristics, fall risk also depends on housing conditions and the extent of daily support available to the senior. About 16 percent of seniors (aged 65+) reportedly fall at least once in a year; of these, nearly 14 percent result in a bone fracture.13 Falls among seniors are three times more likely to result in the person’s death compared to a fall within the general population. Lubelskie and Śląskie have the highest fall-attributable mortality rates, according to NIZP-PZH-PIB data. As people age, the risk of disability, loss of independent living and mental health conditions rises significantly. While it is challenging to determine congruent estimates of the disability-affected population due to diverse definitions of disability in Poland, public statistics report that about 14 percent of the population is certified as disabled in some capacity (5.4 million people).14 For older people, the risk is comparatively higher for enduring health issues and chronic conditions: those that last longer than six months. In 2019, 32 percent of those aged 80+ were officially certified as disabled, while nearly all (96 percent) of the 80+ population reported having long-term health issues. It is important to emphasize the likely underestimation of the incidence of disability in the elderly population and, therefore, the potentially higher demand for care than that estimated from official registers. Disability is attributable in part to high incidences of cancer and CVD, but health degradation 13 Halik, R. 2023. Presentation entitled “Accidents Among 65+ Population. An Underestimated Challenge for Long-Term Care.” Department of Population Health Monitoring and Analysis, NIZP-PZH. 14 GUS distinguishes between a legal definition of disability (people who hold a disability certificate or equivalent), and a biological definition of disability (a condition self-reported in response to questions about potential difficulties with daily living due to poor health) (GUS 2022, Stan zdrowia ludności Polski w 2019 r., Warszawa). According to the National Census in 2021, there were 5,447,548 people with disabilities in Poland (both legally and biologically disabled). 45 also comes from sensory functions such as impaired eyesight and hearing, and physical challenges aggravated by rheumatoid ailments, which are more common in women. In addition to physical ailments, depression and mental health conditions are prevalent in the elderly population: more than half of women, along with 40 percent of 80+ men, experience symptoms indicative of depression.15 Those with a neurodegenerative disease have an elevated risk of depression. The culmination of chronic conditions, disabilities, and mental health conditions can result in a progressive loss of independent living. This means that many people aged 65+ find it difficult to engage in routine activities such as heavy housework (59 percent of older people), shopping (35 percent), and meal preparation (19 percent). For the 80+ population, the rates of difficulty in daily activities are even higher, with over 40 percent of this cohort reporting difficulties in basic self-care activities such as getting up, bathing, or showering. These rates are even more pronounced among elderly women. 16 Women report higher rates of chronic conditions in Poland. In 2019, 39 percent of the adult population in Poland (18+) reported at least one chronic condition, slightly above the EU average of 36 percent.17 In the 65+ cohort, the presence of two or more chronic conditions was reported by more than 65 percent of the population.18 A 2023 survey commissioned by the World Bank had similar findings: just below one in four respondents (23 percent) reported some form of long-term condition or health problem, with women (at 26 percent) more afflicted than men (at 20 percent). There is also a strong relationship between self-reported chronic conditions and age. In 2023, only one percent of respondents below the age of 30 reported having a chronic condition, compared to more than 60 percent in the 65+ age group. The most 15 GUS. Stan zdrowia ludności Polski w 2019 r. 16 GUS. Stan zdrowia ludności Polski w 2019 r. 17 OECD/European Observatory on Health Systems and Policies. 2021. Polska: Profil systemu ochrony zdrowia 2021. State of Health in the EU. Paris: OECD Publishing / Brussels: European Observatory on Health Systems and Policies. 18 State of Health in the EU. 46 common health problems were hypertension (59 percent), diabetes (26 percent), and osteoarthritis (22 percent) (Figure 5). Do you have a long-term condition or health problem Figure 5.  (that is, presenting for at least six months)? Gender Age Total 1% 1% 1% 1% 1% 1% 1% Yes 100 No 37% I don't know, 80 it's hard to say 60 73% 79% 98% 94% 79% 76% 40 20 1% 5% 26% 20% 20% 62% 23% 0 Female Male 18-29 30-44 45-64 65+ n=624 n=576 n=156 n=291 n=521 n=232 n=1200 Source: World Bank. 2023. Survey of a representative sample of Poland’s population (18+). Most older people do not feel they are in good health, and much of the general population fears the physical and cognitive toll of health deterioration with age. Self-reported health declines significantly with age. Almost all respondents (97 percent) under the age of 29 rated their health as good, followed by 92 percent in the 30–44 age group and 77 percent in the 45–64 age group, but at 65+, less than half of the sample self-reported good health (just 43 percent). When asked about their top concerns, most respondents (67 percent) pointed to physical deficits, such as mobility issues – walking and getting up – as their primary concern, while more than half of the sample (54 percent) mentioned potential cognitive deficits regarding perception, memory, and attention span. Fifty-two percent were worried about the risk of specific diseases such as cancer, heart disease, or dementia. Fear of pain and physical impairment intensifies with age, while discomfort associated with the change in physical appearance becomes less 47 intense. Only 4 percent of people had no concerns about age-related health declines (Figure 6). Thinking about getting old, which aspects of declining Figure 6.  health do you fear the most? Physical deficits (mobility, frailty, etc.) 67% Cognitive deficits (perception, attention, memory, etc.) 54% Specific health conditions (e.g., cancer, heart disease, 52% stroke, dementia, etc. ) Pain 43% Changed appearance (body weight, wrinkles, grey hair, etc.) 22% No fears 4% Other/I don’t know 0% Source: World Bank. 2023. Survey of a representative sample of Poland’s population. SOCIOECONOMIC AND CULTURAL CONTEXT Poverty among the elderly in Poland has been higher compared to the rest of the population, with income levels often falling below the average as well as below the minimum wage threshold. In 2022, the relative poverty rate of the 65+ population in Poland was slightly above the national average: 15.2 percent compared to the national figure of 13.7 percent.19 However, compared to regional benchmarks, Poland’s old-age poverty rate is 2.1 percentage points below the EU average. Income inequality among pensioners is also lower than in the general population, as measured by the Gini coefficients of 0.240 and 0.314, respectively. However, this relatively lower level of inequality 19 EU-SILC (EU Survey of Income and Living Conditions) 2022 data. 48 comes with lower general pension levels compared to average income, as the average retirement pension represents about a quarter of the average wage in Poland, and 70 percent of pensioners collect pension benefits lower than the minimum wage, amounting to PLN 3,010 gross in 2022.20 On the other hand, it should be noted that retirement benefits, while low, do seem to safeguard seniors from extreme poverty; less than 4 percent of the households with an older member (65+) are at risk of extreme poverty. While inequality is lower among pensioners, disparities in retirement income remain and are largely driven by spatial and socioeconomic determinants, such as holding a degree, the type of occupation held during employment, or living in an urban area. Seniors might accumulate more assets if they retired later in life, but this is a decidedly gendered decision, as women are more likely to drop out of the labor market for family reasons—to take care of their children, grandchildren, elderly parents, or a spouse. As such, women tend to have fewer assets accumulated for retirement due to comparatively lower earnings and contributions. Households with older residents face high costs of living and expenditures related to satisfying their health needs. According to GUS,21 the average monthly disposable household income per household member in 2022 was PLN 2,250, and in pensioner households it was PLN 2,281, an increase of PLN 31 per person in pensioner households. However, pensioners' expenses amounted to PLN 1,637 per person, compared to the average household expenses of PLN 1,475 (that is, PLN 162 higher), pointing to potentially lower overall disposable income. The household consumption gap may well be attributed to spending on health services, medications, and other pharmaceutical products. The status is even worse in the households 20 In accordance with the regulation of the Council of Ministers of September 14, 2021 on the amount of the minimum remuneration for work and the amount of the minimum hourly rate in 2022 (Journal of Laws of 2021, item 1690), 21 GUS. 2023. Badania budżetów gospodarstw domowych (Household Budget Survey).Warszawa. https:// stat.gov.pl/obszary-tematyczne/warunki-zycia/dochody-wydatki-i-warunki-zycia-ludnosci/sytuacja- gospodarstw-domowych-w-2022-r-w-swietle-badania-budzetow-gospodarstw-domowych,3,22.html 49 that rely on disability pension as their principal source of income: their average disposable income lags the average in the population by PLN 441, and their expenditures are PLN 46 higher. Consequently, expenditures consume a staggering 84 percent of disposable income in disability pension households. Where a household member – a child or an adult – has a disability, the household has a greater risk of poverty. Elevated spending on medical treatment and rehabilitation not only puts financial pressure on households, but there could also be secondary pressures whereby one member of the household cannot work due to disability and the other therefore cannot work due to caregiving demands. A sizable share of senior citizens in Poland live in dwellings that face accessibility issues. The housing situation of older people is improving, and according to subjective evaluations most of the older respondents say that their homes are in proper technical and sanitary condition.22 However, in 2020, 32.4 percent of urban inhabitants reportedly still live in housing that is affected by architectural barriers making access more difficult; this rate is just below 20 percent in rural areas. When considering the infrastructure of the locality in which residential buildings are based, the situation inverts—where rural households are much more likely to be in areas with poor infrastructure (11.5 percent) compared to 1.4 percent in cities.23 This suggests that the housing situation of seniors is highly context specific. What these data do not capture is the experience of seniors that were directed to residential and inpatient care facilities and required care that could not be provided at home. Hence while many seniors do report appropriate and improving living conditions, efforts to effectively deinstitutionalize care likely requires significant home adaptation. 22 GUS. 2020. The Situation of Older People in Poland in 2018. GUS: Warsaw, Poland. https://stat.gov.pl/ obszary-tematyczne/osoby-starsze/osoby-starsze/sytuacja-osob-starszych-w-polsce-w-2020-roku,2,3.html 23 GUS. 2020. The Situation of Older People in Poland in 2018. GUS: Warsaw, Poland. https://stat.gov.pl/en/ topics/older-people/older-people/the-situation-of-older-people-in-poland-in-2020,1,3.html 50 In Poland, long-term care is dominated by informal help typically provided by family members, friends, and neighbors, and while the demand for LTC services has been on the rise, the relative availability of informal care support has dwindled. Informal care makes up 80 percent of LTC services, with the remaining 20 percent being formal care.24 The link between population aging and availability of informal care is best presented through support ratios. The crudest measure is the old-age dependency ratio, which helps to compare the numbers of working-age citizens (15-64) to older people (65+). In Poland, this is forecast to double from 30 older persons per 100 working-age people in 2022 to 60 per 100 by 2060 (Figure 7). Similarly, the parent support ratio—the numbers of those who are likely to take care of their parents (Figure 7) is expected to halve by 2060. In addition, most caregivers in Poland are women and they are the ones who do most of the care work, especially when it comes to high-intensity and high- frequency caregiving duties.25 Therefore a measure of this dynamic is the caregiver ratio, the number of women aged 50–64 per 100 persons aged 80+ (Figure 7) which is also expected to halve by 2060. In practice, as it stands, the burden of care on the working population is set to double. 24 WHO. 2022. “Long term care.” https://www.who.int/europe/news-room/questions-and-answers/item/long- term-care. 25 WHO. 2022. “Long term care.” 51 Change in demographic indicators in Poland in 2017– Figure 7.  2050 (old-age dependency ratio, parent support ratio and caregiver support ratio) 468.9 453.8 439.0 432.7 434.0 436.0 363.5 243.0 234.8 226.8 223.3 223.9 224.2 226.7 186.0 115.9 51.8 25.0 26.1 27.2 28.1 28.9 30.9 34.4 2017 2018 2019 2020 2021 2023 2030 2050 Old age dependecy ratio (number of 65+ people per 100 people aged 15-64) Parent support ratio (number of people aged 80+ per 100 people aged 50-64) Caregiver rario (number of women aged 50-64 per 100 people aged 80+) Source: World Bank 2023, based on 2021 GUS data. The burden of care for those in need, such as children and old-age dependents, puts pressure on the working-age population, and declining fertility rates are likely to contribute to lower availability of informal care in the future. In 2022 in Poland, for every 100 people of working age, there were 31 people of pre-working age (0–14) and 39 people of post-working age (65+),26 which means that the working-age population carries a particularly heavy burden of family responsibilities for their children and aging parents. The 45–64 cohort is termed a ‘sandwich generation’, as they bear a double responsibility for older and younger family members and, at the same time, continue their professional careers. The difficulty in reconciling paid work and 26 GUS. 2023. Sytuacja demograficzna Polski do 2022 r. Warszawa. 52 caregiving responsibilities27 is a reason for low labor market participation of caregivers aged 50–65; other reasons include the legal retirement age,28 limited access to formal LTC services, and traditional reliance on family care. As people tend to have fewer children or not have children at all, this puts downward pressure on the supply of informal caregivers. The mismatch between the growing demand for care and the relative decline in the size of the working-age population is becoming more and more prominent. In 2022, Poland reported a historically low fertility rate of 1.261, linked to delayed motherhood and a decrease in the number of children per family.29 With such demographic shifts, the caregiver pool is set to continue to shrink. Household composition and structure have evolved as well, with new norms and younger people moving to the cities. Poland is witnessing a change in family structures from multigenerational households to nuclear families with one or two children, putting more seniors at risk of social isolation. Only 28 percent of the population have a household member aged 65+, and 9.8 percent of seniors (65+) feel socially isolated.30 Younger family members choose larger cities over their home villages and towns. The absence of a family member in an elderly person’s community means that care deficits are likely to emerge even when a senior requires a small amount of assistance. Whether due to distance, capacity, or willingness, the care gap will push individuals to seek assistance from public institutions operating in the social and health sectors or from those operating in the private sector, which creates even more pressure on LTC supply. These complex demographic and socioeconomic factors should be addressed with comprehensive strategies and policies to support caregivers, enhance work-care balance, and ensure availability of much-needed LTC services.31 27 Jurek, Ł. 2015. Polityka łączenia pracy zawodowej z opieką nad osobą starszą. Acta Universitatis Lodziensis. Folia Oeconomica 2 (312): 95–110. 28 In Poland, women can retire at the age of 60, men at the age of 65. 29 GUS. 2023. Small Statistical Yearbook 2023. Warszawa. 30 GUS. 2019. Jakość życia osób starszych w Polsce. Warszawa. 31 Jakość życia osób starszych w Polsce 53 LONG-TERM CARE SYSTEM IN POLAND ORGANIZATION OF THE LONG-TERM CARE SYSTEM IN POLAND Long-term care in Poland is based on services available from the social sector and the health sector and organized at the central and subnational levels. At the central level, both the Ministry of Family, Labour and Social Policy, Ministerstwo Rodziny, Pracy i Polityki Społecznej (MRPiPS), and the Ministry of Health, Ministerstwo Zdrowia (MZ), bear responsibility for LTC policymaking and monitoring. Subnational authorities of various levels also play a significant role. In Poland, the relevant subnational levels involved in the delivery of LTC services, and which will be used throughout this report, are regions (voivodeships), counties (powiats), and municipalities (gminas). Regions are the highest subnational administrative unit – there are 16 in total; counties are the intermediate level of authority, and each have a local government unit – there are 380 counties; municipalities are the smallest administrative level, there are 2,477.32 Apart from LTC services delivered in-kind, cash benefits are an essential component of the LTC system in Poland; they are payable to LTC recipients by the Social Insurance Institution (Zakład Ubezpieczeń Społecznych [ZUS]), Agricultural Social Insurance Fund (KRUS) or Pension and Disability Insurance Institution of the Ministry of Internal Affairs and Administration (ZER MSWiA) or by the local government units (LGUs). 32 GUS, data as of January 1, 2023. 54 In the social sector, LTC services are the responsibility of local government units, who – on top of their own mandate – deliver the tasks delegated to them by the central government administration. When it comes to LTC services deliverable in the social sector, the following actors play a role: 1.  Social assistance office/LGU agency competent for social services (Ośrodek Pomocy Społecznej, OPS or Centrum Usług Społecznych, CUS); 2.  Support centers (Ośrodek Wsparcia, OW), including day care homes, special shelters for people experiencing homelessness which also provide care services, other clubs, and support centers; this category also includes facilities for people with mental health conditions (self- help clubs and community self-help homes); 3.  Residential homes (larger-size long-term care facility [LTCF]) (Dom Pomocy Społecznej, DPS) 4.  Family care homes (smaller-size LTCF) (Rodzinne Domy Pomocy, RDP) Each of these actors can cooperate with social economy organizations, including nongovernmental organizations (NGOs), social enterprises, social cooperatives, religious associations, and the Catholic Church. In the health sector, LTC services are delivered by various providers contracted by the public payer, the National Health Fund, Narodowy Fundusz Zdrowia (NFZ). LTC services are priced in accordance with the tariff developed by Poland’s Agency for Health Technology Assessment and Tariff System, Agencja Oceny Technologii Medycznych i Taryfikacji (AOTMiT). LTC services are delivered by the following categories of health-care providers: 55 1.  Facilities that employ nurses who provide LTC nursing care, self- employed nurses, or nurses hired based on civil law contracts— sometimes referred to as contract nurses; 2.  Home-based care teams for ventilated adults, adolescents, and children; 3.  Care and treatment facilities (Zakład Opiekuńczo-Leczniczy, ZOL); 4.  Nursing and care facilities (Zakład Pielęgnacyjno-Opiekuńczy, ZPO). A health-care facility may be set up on a commercial basis; as an independent public health care unit; as a state budget unit—for example, run by the Ministry of National Defense (Ministerstwo Obrony Narodowej, MON) or the Ministry of Internal Affairs and Administration; operated by a research institute, a foundation, or an association established specifically for health-care purposes; by a religious association, the Catholic Church, or a military agency. Select LTC initiatives are also implemented supported with EU funds; their objective is to increase LTC supply and deinstitutionalize service delivery. These facilities have been funded by the European Social Fund (ESF) and the European Regional Development Fund (ERDF). Within the financial perspective 2014-2020 and 2021-2027 support is provided for the implementation of solutions in deinstitutionalization; establishment of sheltered and supported housing; and support for community self-help homes and day care homes. EU funds have also supported training programs for LTC staff, including those providing care services. Mapping the landscape of the system of LTC services in Poland requires taking stock of both social and health sectors. A simplified diagram of LTC services in Poland has been developed for the purposes of this strategic overview. Figure 8 presents the mapping of LTC services available in Poland funded from public or private sources. 56 For clarity, this report applies a consistent nomenclature for the main settings of care delivery across both sectors (that is, home care, day care, inpatient care). It should be noted that the term ‘home care’ is not used in the social sector and it was adopted only for the purpose of this report. ‘Inpatient care’ is an approximation used to facilitate comparisons between the two sectors, as social sector actors would typically refer to this as ‘residential care’. Figure 8. Simplified landscape of LTC services available in Poland PUBLIC SYSTEM NON-CASH BENEFITS SOCIAL SECTOR HEALTH SECTOR CASH BENEFITS INPATIENT INPATIENT DAY CARE HOME CARE DAY CARE HOME CARE CARE CARE Care and Residential Support Care services Nursing home Nursing supplement treatment home (DPS) center (OW) (UO) care facility (ZOL) Including: Home-based Nursing and Family care Shelters with specialized mechanical Nursing allowance care facility home (RDP) care services care services vantilation for (ZPO) (SUO) adults Specialized care services Home-based Medical day Supplementary Care and residential center for persons mechanical care home benefit program (COM) with mental ventilation for (DDOM) health children conditions Telecare (within the Senior + 75 Plus Health Centers + (incl Permanent benefit Senior Support Program geriatric teams) Corps Program) Nursing benefit Cash benefits for seniors/people with disabilities Programs: "Respite care" and Special caregiver "Respite care for caregivers of Cash benefits for caregivers allowance persons with disabilities" Selected programs (projects) run by central government (i.e., programs that concern the Programs: "Personal assistant financing and implementation of new types Caregiver allowance for the disabled" and "Personal of benefits that are not covered by guaranteed asistant for a person with services; implemented for a specified period) disability" Guaranteed services Source: World Bank 2023, own compilation. 57 LTC IN THE SOCIAL SECTOR: ORGANIZATION AND BENEFITS A. INPATIENT CARE Inpatient LTC services delivered in the social sector are offered by two categories of long-term care facilities (LTCFs): DPS and RDP. DPS facilities perform similar functions to nursing homes and are usually large facilities with an average of 98 beds per facility in 2021.33 A DPS provides inpatient care services for people who require 24/7 care due to age, disease, or disability and cannot live independently, and in whose case the existing family or community LTC services are inadequate. Most DPS residents have chronic conditions (mental or physical) or physical disabilities. Large DPSs often have branches and deliver services in several buildings. A person who needs care should be referred to the nearest DPS facility, that is, the least distance from their place of residence, and if the waiting period in that facility exceeds three months, they can be referred to a more remote facility. Once a DPS admission request has been filed by the beneficiary, a social worker makes a recommendation considering the information collected during family interview. Decisions with respect to a referral to the DPS and the fee for staying in the DPS are issued by the municipal authority competent for the person on the day he or she is referred to the DPS. In turn, the decision to place a person in a DPS is issued by the authority of the municipality running the DPS or the authority of the county running the DPS. In the case of regional DPS, the decision is issued by the voivodeship authority. A much smaller alternative for those seeking an inpatient LTCF are RDPs—smaller-size LTCFs. An RDP can be established by an individual or an authorized organization based on a contract signed with a municipality, but there are still few of these facilities: in 2021, there were just 44 RDPs in Poland, with a total of 327 places for 24-hour stay, and 322 residents. A place in the RDP may be 33 MRPiPS-05 data for 2021. 58 obtained by a person who requires 24-hour care due to age or disability. Like DPS, RDPs provide living (accommodation and meals) and care services. RDPs, as small facilities, accept between three and eight people. Fees for staying at the RDP are determined based on an agreement with the facility. A DPS can be operated by an LGU, the Catholic Church or other churches and religious associations, an NGO, a foundation or association, other legal entities, or individuals. There is a law applicable to DPS facilities irrespective of the provider. A decision to have a new DPS established must be pre-approved by the region’s governor. There are many different types of DPS facilities: for seniors, for persons with chronic physical conditions, for persons with chronic mental conditions, for adults with intellectual disabilities, for children and adolescents with intellectual disabilities, for persons with physical disabilities, or for persons with alcohol addiction. As shown in Figure 9, there were 826 DPSs in Poland in 2021, a slight increase since 2017. Total number of users and DPS facilities in the social Figure 9.  sector, 2017–2021 100 000 900 90 000 800 80 000 700 70 000 600 60 000 500 Facilities 50 000 Users 400 40 000 300 30 000 20 000 200 10 000 100 – – 2017 2018 2019 2020 2021 Total users Total DPS Facilities Source: World Bank 2023, based on 2021 MRPiPS-05 data. 59 A DPS facility can accept several different client groups. Figure 10 shows the breakdown of facilities which include 170 facilities for patients with chronic mental conditions, 137 facilities for persons with chronic physical conditions, 119 for seniors and persons with chronic physical conditions, 115 for adults with intellectual disabilities, and 93 DPS facilities for seniors. The breakdown presented in Figure 10 counts facilities more than once where they cater for multiple beneficiary groups. Number of DPS facilities available for each target client Figure 10.  category, 2021 For persons with chronic mental conditions 170 For persons with chronic physical conditions 137 For seniors and persons with chronic physical conditions 119 For adults with intellectual disabilities 115 For seniors 93 For adults with intellectual disabilities and children 64 and adolescents with intellectual disabilities Other, as per Article 56a(2)(3) of the Act 47 on Social Welfare Services For children and adolescents with intellectual disabilities 39 For seniors and persons with physical disabilities 21 For persons with chronic physical conditions and persons with physical disabilities 14 For persons with physical disabilities 7 For persons with alcohol addiction 1 Source: World Bank 2023, based on 2021 MRPiPS-05 data. 60 Between 2017 and 2021, five new DPS facilities in Poland were added to the total number. This figure is on a net basis as some facilities closed during this period. Of those that opened, five were in Podkarpackie region. Dolnośląskie, Lubelskie, Podlaskie, and Świętokrzyskie gained two facilities each, and during that period, Pomorskie and Warmińsko- Mazurskie ‘lost’ two DPS facilities each – see Table 2. In Podlaskie there is one regional DPS facility offering space for 200 beneficiaries.34 Figure 11 demonstrates that the rates of users have been somewhat stable in the regions between 2017 and 2021, however variation can be observed between regions in terms of the user population. DPS facilities by region, 2017–2021 Table 2.  (including one regional DPS facility) REGION 2017 2018 2019 2020 2021 2017–2021 DYNAMICS Dolnośląskie 58 57 57 59 60 2 Kujawsko-pomorskie 46 46 46 46 46 0 Lubelskie 44 44 44 46 46 2 Lubuskie 23 23 23 23 23 0 Łódzkie 56 56 55 55 55 −1 Małopolskie 92 92 92 91 91 −1 Mazowieckie 94 94 94 93 93 −1 Opolskie 29 29 29 29 29 0 Podkarpackie 47 50 50 50 52 5 Podlaskie 21 22 22 23 23 2 Pomorskie 43 43 42 42 41 −2 Śląskie 98 98 98 98 98 0 Świętokrzyskie 32 33 34 34 34 2 Warmińsko-mazurskie 43 43 42 42 41 −2 Wielkopolskie 64 63 63 63 63 −1 Zachodniopomorskie 32 32 32 32 32 0 Poland 822 825 823 826 827 5 Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. 34 The MRPiPS-05 report presents DPS parameters in the breakdown into municipal, county, and regional levels (in 2021, there was one regional DPS in Podlaskie). The report provides information on the number of residents and the number of DPS facilities as of December 31 of the reporting year. Therefore, based on MRPiPS-05 report, one cannot determine how many residents stayed in DPSs throughout the year. All we know is that on December 31, 2021, there were 199 residents in the facility. However, the total number of DPS residents in Podlaskie throughout 2021, presented in the MRPiPS-06 report, is 2,410, with 2,178 beds. 61 Users of DPS facilities per 100,000 population, Figure 11.  in the social sector, by region, for 2017, 2019, and 2021 400 2017 Users per 100k population 350 2019 300 2021 250 200 150 100 0 Opolskie Łódzkie Warmińsko-mazurskie Świętokrzyskie Małopolskie Zachodniopomorskie Lubuskie Podkarpackie Lubelskie Śląskie Dolnośląskie Kujawsko-pomorskie Wielkopolskie Podlaskie Pomorskie Mazowieckie Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. According to the MRPiPS data, half of DPS service users are seniors, and although DPS services are quite diverse, medical care is not included. DPS facilities offer board and accommodation as well as care, support, and educational services, including social work in the form of occupational therapy, social skills training, education for children, and addiction treatment for those in need. Senior citizens (65+) account for about half of DPS residents across all DPS facilities (50.5 percent), so it is to be expected that the DPS service mix is adapted to their functional capacity and needs. Approximately 13 percent of DPS residents are bed- confined due to extremely poor health and severe functional limitations. Bed occupancy rates vary from 84 to 98 percent across different types of DPS facilities. At the same time, there are waiting lists for vacancy admission.35 For each DPS resident, a personalized plan of 35 MRPiPS-05 report for 2021. 62 care should be prepared within six months or, in the case of alcohol rehabilitation facilities, within two months from admission. Since DPS services do not include medical care, anyone in need of significant medical attention should be referred to a health-care facility, a ZOL or ZPO. DPS facilities charge up to 70 percent of a resident’s personal income, and if the resident cannot afford to cover the cost of the stay on their own, DPS charges must be covered by the family (spouse, ascendants, or descendants) or by the LGU which referred the person to the facility. The number of residents in DPS facilities in 2021 was lower than in 2017, and the drop is largely attributed to the COVID-19 pandemic. There were approximately 86,480 DPS residents in 2021, which was 2,800 less than in 2017 (see previous Figure 9). In recent years, Kujawsko-Pomorskie and Świętokrzyskie were the only regions in Poland to report growing numbers of DPS residents, whereas all other regions saw a decline in DPS occupancy rates. Figure 12 provides an overview of occupancy rates by facility type (absolute numbers and percentage shares). 63 Population of DPS residents by facility type and DPS Figure 12.  bed occupancy rate (share of beds that are occupied by residents—bottom axis and line), 2021 Residents 20 000 10 000 14 000 18 000 16 000 12 000 4000 8000 6000 2000 0 For persons with chronic mental conditions 18741 97.5 For persons with chronic 12236 physical conditions 94 For adults with 9945 intellectual disabilities 97.5 For seniors and persons with 9251 chronic physical conditions 90.2 Other, as per Article 56a(2)(3) of the Act 9050 on Social Welfare Services 95.4 For seniors 5529 For adults with intellectual disabilities and children 90 and adolescents with intellectual disabilities 5404 98.1 For children and adolescents with intellectual disabilities 2677 97.2 For persons with chronic physical conditions and 1575 persons with physical disabilities 94 For seniors and persons with 1566 physical disabilities 84.3 For persons with physical disabilities 614 96.9 For persons with alcohol 48 addiction 87.3 75 80 85 90 95 100 residents Occupancy rate (%) occupancy rate Source: World Bank 2023, compilation based on 2021 MRPiPS-05 data. B. DAY CARE There are several types of support centers (OW) that operate in the social sector in Poland and specialize in day care services: Support centers (OW) for people with mental health conditions, z  including community self-help homes and self-help clubs; 64 Shelters for homeless people that offer care services (Schronisko z  z UO); z Day care homes (including Senior+ facilities); z  Self-help clubs. Running OW is the responsibility of both powiats and gminas, but it is obligatory for powiats. A separate category of OW are support centers for people with mental health conditions, run by the government administration, and commissioned to LGUs at the gmina and powiat levels. Some OW in the social system operate as shelters for people experiencing homelessness or as facilities for single mothers with children and pregnant women. These facilities have been included in this analysis to a limited extent, as they do not provide LTC services for those who have become dependent due to age- or health-related reasons. OW facilities are also permitted to provide 24/7 care. In 2021, there were a total of 276 OWs operating 24-hour temporary stay places in Poland.36 Support centers (OWs) cater to those who need assistance with their daily living activities due to age, a long-term health condition, or disability. The Act on Social Services defines who qualifies as an OW beneficiary. To access OW services, the applicant must obtain preapproval from the local OPS management. The services provided by OWs include therapeutic activities, a meal, and LTC services or specialized LTC services.37 OW beneficiaries usually have a disability 36 MRPiPS-06 data for 2021. 37 The category of OW facilities operating in the social system in Poland includes shelters for people experiencing homelessness and for single mothers, but those facilities are not at the core of this analysis since they do not provide LTC services to those who need support with the activities of daily living due to advanced age or poor health. 65 which can include mental health conditions. One in three beneficiaries of day care services (33 percent) use the services of community self-help homes, which provide occupational therapy and offer psychological support for people with a disability or mental health condition. The second biggest group of OW service recipients are senior citizens (22 percent), who use the services of day care homes. The number of clients using selected OW services is presented in Figure 13. In 2021 most beneficiaries used the OW services offered within community services (35,113 people in total). Figure 13. Number of clients using selected OW services, by type Community centers 35 113 Day care centers 22 787 Other self-help facilities 18 635 Shelters for the homeless that offer LTC services 1 698 Self-help centers for persons with mental disorders 1 168 Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. Most OW facilities are focused on people with mental health conditions or operate as day care homes, and the pool of users has shrunk since 2017. Except OW for persons with mental health conditions, operated by municipalities on a delegated task basis, the decision to operate an OW facility is typically made by municipal authorities on a discretionary basis, that is, not mandated. County authorities are also required to operate their OW facilities for people with mental health conditions on a delegated task basis. The maximum length of stay in a community home is three months, with an option for extension, if justified. 66 In 2021, there were 2,471 OW facilities in Poland, including 883 facilities for persons with mental health conditions, 503 day care homes, 628 self- help clubs (not for persons with mental health conditions), and 31 shelters that accept the homeless and offer them LTC services, and other facilities. The pool of OW service users has shrunk compared to 2017. In 2021, there were 104,928 OW beneficiaries (106,626 including shelters with Usługi opiekuńcze, UO), 24.6 percent lower compared to 2017—the drop was most probably caused by the COVID-19 pandemic (see Figure 14) Total number of users and facilities for day care Figure 14.  services (OW and shelters with UO), in the social sector, 2017–2021 180 000 3000 160 000 2500 140 000 120 000 2000 Facilities 100 000 Users 1500 80 000 60 000 1000 40 000 500 20 000 – 0 2017 2018 2019 2020 2021 Total users Total Facilities Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. 67 When considering the number of day care service users per 100,000 population, there has been a decline observed between 2017 and 2021 in almost every region (see Figure 15). In some regions this decline was observed even prior to the pandemic. User rates only capture part of the picture, in the figure below Mazowieckie is among the regions with the lowest user rate per population, while it has the highest number of OWs (see Figure 36 in the Financing section). Users of day care services (OW and shelters with UO) Figure 15.  per 100,000 population, in the social sector, by region, 2017, 2019, and 2021 800 700 Users per 100k population 600 500 400 300 200 100 0 Warmińsko-mazurskie Świętokrzyskie Lubuskie Opolskie Kujawsko-pomorskie Podlaskie Łódzkie Małopolskie Zachodniopomorskie Wielkopolskie Poland Pomorskie Śląskie Lubelskie Podkarpackie Dolnośląskie Mazowieckie 2017 2019 2021 Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. 68 In recent years, day care homes were the fastest growing category of facilities due to the implementation of the Senior Plus (+) program, introduced by the central government. The program was first announced in 2015 to increase consumption of day care services delivered in various facilities dedicated for senior citizens. The program targets local governments, which can apply for funds on an annual basis to establish and operate a day care home or a similar facility for senior citizens. By the end of 2020, 971 day care homes had been established in Poland with an estimated total of 55,700 beneficiaries. But, according to the Supreme Audit Office, Najwyższa Izba Kontroli (NIK), this figure may be inaccurate as it does not account for beneficiary turnover.38 Day care services have also been supported by the Solidarity Fund. Since 2019, LGUs have filed more than 100 applications to establish care and residential centers (Centra Opiekuńczo-Mieszkalne, COM). Their mission is to provide day care services as well as inpatient services, although there is a limit of one year for the duration of an inpatient stay. A COM facility can be set up by municipal or county authorities, if they have applied for funding and offer day care or 24/7 care for people with a severe or moderate degree of disability (or equivalent), as acknowledged with a relevant certificate. The COM admission decision is made by a social worker employed in an OPS or county-tier family support center (Powiatowe Centrum Pomocy Rodzinie, [PCPR]). To date, the program has had two iterations: the first in 2019–2021, the second in 2021–2024. A third is in place for 2023–2026. Since 2019, 122 applications from local governments have been approved, comprising 37 new COM facilities in the first iteration, 62 in the second, and 23 in the third, with a total project allocation of PLN 330 million. 38  upreme Audit Office. 2022. Program "Senior+” – dobry pomysł, zasady finansowania do poprawki. S ["Senior+" program - good idea, financing rules need to be improved]. https://www.nik.gov.pl/aktualnosci/ program-senior-plus.html. 69 C. HOME CARE39 In Poland, the responsibility for care provided in the client’s place of residence (home care services) rests primarily with the social assistance office, Ośrodek Pomocy Społecznej or the LGU agency competent for social services in Poland, Centrum Usług Społecznych (OPS/CUS) centers operating at municipal (gmina) levels: this has resulted in considerable variation in service delivery across localities. Every municipality in Poland and every borough in Warsaw has an OPS center in its jurisdiction. Since 2019, based on the Act on Social Services Implemented by Social Service Centers, OPS centers can be transformed into CUS centers,40 but only 56 LGUs have decided to carry out the transition to date out of approximately 2,000 OPSs in existence. The package of benefits and services delivered by municipal OPS or CUS centers can be divided into tasks delegated to the municipality and those that are ‘owned’ by the municipality. Supply of LTC services and specialized LTC services is a task owned by the local government, while the supply of specialized LTC services for persons with mental health conditions is a task delegated to the local government. Although LTC service delivery is a task owned by LGUs on a mandatory basis, not all municipalities in Poland comply with that requirement. The reasons for noncompliance might be staffing, budget constraints and, sometimes, the attitude of local authorities who might believe that social services such as LTC have low priority or that they should not be a municipal responsibility in the first place. LTC services can be delivered directly by OPS/CUS staff, or they can be outsourced to a service provider (private or non-profit). According to 2021 data, about 10 percent of OPS centers did not provide home care at all. 39  ote: Home care is not a term used with reference to social sector services in Poland; it is applied here for N transparency and clarity. 40 Forty-one of those were created from European funds as part of a pilot project implemented under the  Knowledge Education Development Program 2014–2020 (POWER). 70 Social sector LTC services delivered in home-based settings most often provide basic assistance with the activities of daily living, and access to these services is approved by an OPS/CUS manager in accordance with eligibility criteria and delivered by a social care worker. Social sector services provided at the place of residence can be divided into basic and specialized services. Basic services apply to those who require assistance with the activities of daily living due to advanced age, disease, or disability and who cannot rely on the assistance of their family members. Basic care services include assistance with activities of daily living, maintaining hygiene, doctor-recommended nursing care, or support with housework, and to the extent possible, social interaction. Specialized services in contrast are tailored to specific disease or disability needs and are delivered by highly trained personnel. Access is approved by OPS or CUS staff based on an interview and at the request of, or with the consent of, the person in need of care. In exceptional circumstances such as a health emergency, the services may be authorized by OPS or CUS staff on an emergency basis. Municipalities are responsible for determining access to basic and specialized services and the level of out-of-pocket payments. Except for people below the income criterion, the services are not free, and the level of out-of-pocket payments required, as well as the detailed terms and conditions of service delivery, are approved by a resolution of the municipal council. The quantum of out-of-pocket payments is specified by the municipal council with reference to an income criterion, and full payment applies only when the beneficiary’s or family’s income is at least six times greater than the threshold. Service delivery is managed by OPS or CUS, who also specify service scope, frequency, duration, and care setting. The council may also set out terms for which the payment can be waived. Clients are not income tested for access, but the financial status of the client and their family may be a factor in determining the level of out-of-pocket payments or the waiver decision. One exception for determining the level of out-of-pocket payments is specialized services for people with mental health conditions; for these 71 services, copayment rules are regulated by MRPiPS. In 2021, the total users of basic services (UO) decreased slightly compared to 2019 but the number had been increasing prior to the pandemic (Figure 16). Similar trends can be observed for specialized care, while overall users are lower (Figure 18). Across both care types, the average cost of care per client in 2021 increased compared to both 2017 and 2019 figures. Total number of clients and average cost per client Figure 16.  associated with basic services (UO) in the social sector 140 000 7 000 Average Cost per Client, PLN 120 000 6 000 100 000 5 000 80 000 4 000 Clients 60 000 3 000 40 000 2 000 20 000 1 000 – – 2017 2018 2019 2020 2021 Total Clients Average Cost per Client Source: World Bank 2023, compilation based on 2021 MRPiPS-03 data. In 2021, there were more than 110,000 beneficiaries of basic and specialized care services in Poland, and the number of service recipients nationwide increased by 5 percent since 2017. Although the recipient population has been on the rise, service coverage remains low: the average national ratio is just 291 users per 100,000 population (see regional variation in Figure 17). This is below expected levels given the needs of older people and the size of the population with disabilities. The upward trend in user numbers, observed until 2019, was halted during the COVID-19 pandemic. Substantial regional disparities in the numbers of service users also exist. In absolute numbers, the most populated regions, Mazowieckie, Wielkopolskie, 72 and Śląskie, report the highest user numbers— approximately 14,500, 12,400, and 11,600 in 2021, respectively. Over the last five years, the strongest growth dynamics in the number of basic services was recorded in the Wielkopolskie (18.0 percent), Podlaskie (17.5 percent), and Pomorskie (13.1 percent). Figure 17. Users of basic care services (OU) per 100,000 population, in the social sector, by region, 2017, 2019, and 2021 450 Users per 100k population 400 350 300 250 200 150 100 50 – Warmińsko-mazurskie Dolnośląskie Zachodniopomorskie Kujawsko-pomorskie Wielkopolskie Lubuskie Pomorskie Świętokrzyskie Łódzkie Opolskie Mazowieckie Lubelskie Śląskie Małopolskie Podkarpackie Podlaskie 2017 2019 2021 Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. 73 Specialized services are delivered far less frequently than basic services and are also subject to high levels of regional disparities. In 2021, despite a 10.4 percent increase in their volume compared to 2017, access was approved for approximately 5,500 people (see Figure 18). Such low availability (below 15 users per 100,000 inhabitants) could be attributed to a shortage of properly trained personnel and barriers associated with out-of-pocket payment requirements. Total number of clients and total costs associated with Figure 18.  specialized services (UO) in the social sector, 2017–2021 8000 6000 Average Cost per Client, PLN 7000 5000 6000 4000 5000 Clients 4000 3000 3000 2000 2000 1 000 1000 0 0 2017 2018 2019 2020 2021 Total Clients Average Cost per Client Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. There are also significant differences in access to specialized services from one region to another (see regional variation in Figure 19). For specialized care services, the highest rates of access per 100,000 population was in Śląskie (29.3) followed by Kujawsko-Pomorskie (29.1), and the lowest rate was recorded in Podlaskie (1.1). Between Śląskie and Podlaskie, there is a nearly 30 factor difference in the number of users per 100,000 population. There have also been fluctuations in the volume of services delivered in recent years, for example, service volume increased by more than 80 percent in Mazowieckie, but decreased by 74 over 60 percent in Świętokrzyskie. Differences in the size of beneficiary pools may also result from access barriers that exist outside the social assistance system, such as due to individual health profiles or awareness of available services. Users of specialized care services (UO) per 100,000 Figure 19.  population, in the social sector, by region, for 2017, 2019, and 2021 40 35 Users per 100k population 30 25 20 15 10 5 0 Świętokrzyskie Śląskie Kujawsko-pomorskie Opolskie Lubelskie Mazowieckie Zachodniopomorskie Małopolskie Pomorskie Dolnośląskie Łódzkie Podkarpackie Wielkopolskie Warmińsko-mazurskie Lubuskie Podlaskie 2017 2019 2021 Source: World Bank 2023, compilation based on 2021 MRPiPS-06 data. Home-based specialized services for people with mental health conditions, measured by service volume, have been limited. This service category is owned and funded by the central government and delegated to municipalities. The purpose is to improve the quality of life of people with mental health conditions through the development of life skills, physical rehabilitation to the extent not covered by the health sector, and housing assistance. The decision on service scope, type, and duration is made by OPS/CUS. 75 Supply of home care services has been supported by several public programs: Care 75 Plus, Neighborhood Services, and Senior Support Corps. In 2018, the Care 75 Plus program was established to enable municipalities with less than 60,000 inhabitants to apply for funds from the central budget to subsidize LTC services for their 75+ residents. A municipality that organizes LTC services with its own funds or in partnership with a social cooperative is eligible for a maximum subsidy equivalent up to 60 percent of their own expected project cost.41 In 2023, Neighborhood Services were introduced as a new, additional channel of LTC services. Select local governments had already tested Neighborhood Services, using volunteers, as part of a social innovation scheme before a full legal basis for the program was established. Currently, following the amendments to the Act on Social Services, a neighbor can offer paid services to other members of the community, subject to supervision from a local OPS or CUS. Another program that supports home-based LTC services is the Senior Support Corps, initiated during the COVID-19 pandemic.42 The goal of this program is to facilitate access to community-based services for the 65+ population, including through volunteer work and telecare. Every year, a municipality can apply for funding for up to 80 percent of a project’s cost. From 2024, the Senior Support Corps program aims to provide financial support to municipalities in organizing care services provided in the form of neighborhood services (Module I) and in the implementation of care services through access to the so-called ‘remote care’ aimed at improving the safety and ability to function independently in the place of residence of older people (Module II). Since the three programs – Care 75 Plus, Neighborhood Services, Senior Support Corps—are not permanently available social 41 Ministry of Family and Social Policy. Program "Opieka 75+.” [Program Care 75+] https://www.gov.pl/web/ rodzina/program-opieka-75. 42 Mazowsze Regional Authority (MUW Warsaw). Program ”Korpus Wsparcia Seniorów” na rok 2023. ["Seniors Support Corps" program] https://www.gov.pl/web/uw-mazowiecki/korpus-wsparcia-seniorow-na- rok-2023. 76 services and draw on additional funding and supplement the pool of benefits embedded in the system, they are not included in the mapping of the LTC landscape (Figure 8). There has been significant geographical variation in access to home care services across the country; the highest rates are reported in Warmińsko-Mazurskie, Kujawsko-Pomorskie, Zachodniopomorskie, and Wielkopolskie. The biggest improvement in service availability over the period of analysis was reported by Podlaskie (up 18.1 percent) and Wielkopolskie (up 17.1 percent). Even with the observed improvements in home care availability, Podlaskie still reports the lowest rate of service availability overall, while at the same time records the highest average life expectancy for women, the lowest population density, and is characterized by a high share of rural areas. As of 2021, services of this kind were unavailable in 10 percent of municipalities, however, this is a significant improvement on the figure of 20 percent in 2018 according to an analysis by NIK.43 Available data point to significant geographical variation in service availability across the 16 regions in Poland. Limited availability may result from lack of knowledge about the scale of unmet care needs of the local community due to inadequate monitoring and mapping of such needs, including those of the elderly and people with disabilities. It may also be associated with staff shortages or the absence of private sector entities or social economy actors that could fill the gaps in service supply. There are also specific programs with access to personal support for people with disabilities, sponsored by the Solidarity Fund: the ‘Personal assistant for the disabled’ and ‘Personal assistant to a person with disability’.44 Although similarly named, each of 43 NIK. 2018. "O usługach opiekuńczych świadczonych osobom starszym w miejscu zamieszkania – Seniorzy bez opieki [„About care services provided to older people in their place of residence - Unaccompanied seniors”]” July 18, 2018. https://www.nik.gov.pl/aktualnosci/seniorzy-bez-opieki.html. 44 Biuro Pełnomocnika Rządu do Spraw Osób Niepełnosprawnych. Nabór wniosków w ramach programu resortowego Ministra Rodziny i Polityki Społecznej "Asystent osobisty osoby z niepełnosprawnością” [Personal assistant for a person with a disability] dla Jednostek Samorządu Terytorialnego - edycja 2024. https://niepelnosprawni.gov.pl/a,1478,nabor-wnioskow-w-ramach-programu-resortowego- ministra-rodziny-i-polityki-spolecznej-asystent-osobisty-osoby-z-niepelnosprawnoscia-dla-jednostek- samorzadu-terytorialnego-edycja-2024. 77 the programs is intended for implementation by a specific actor: either for an LGU or for an NGO. The applicants – LGUs or NGOs – can use these program funds to pay for personal assistant services to people with disabilities. A Respite Care program was initiated in 2019 to temporarily relieve family caregivers of their duties, by making community-based services or short-term inpatient services and other support mechanisms available. In 2019–2021, more than 16,500 people benefited from Respite Care services organized by LGUs. In 2021, NGOs joined the program, and nearly 4,000 people benefited from NGO support. The programs that foster development of home care have been instrumental in propagating innovative solutions that support dependent people and their caregivers, and their popularity has been on the rise. However, their scope and coverage have been limited due to personnel and financial constraints. LTC IN THE HEALTH SECTOR: ORGANIZATION AND BENEFITS Long-term care in the health care sector covers all medical and social activities involved in the provision of long-term nursing care, rehabilitation, therapeutic services and nursing and care services as well as continuation of pharmacological and dietary treatment to chronically ill and dependent people who do not require hospitalization. To be eligible for LTC services, a patient must be covered by public health insurance or have another entitlement.45 Available services include 24/7 inpatient care, home care, and day care. The latter is at a very early stage of development. 45 There are rare cases whereby the decision can be taken by the municipal or city mayor. 78 A. INPATIENT CARE The two inpatient settings of LTC service delivery in the health sector are the care and treatment facilities (ZOL) and the nursing care facilities (ZPO). Both categories of facilities provide medical, nursing and living services for those who do not require hospitalization but require 24/7 nursing and care services, as well as rehabilitation and follow-up treatment. The conditions for the provision of guaranteed benefits in ZOL/ZPO are specified in the Regulation of the Ministry of Health of November 22, 2013 on guaranteed benefits in the field of nursing and care services within long-term care (Journal of Laws of 2024, item 253). For this type of care, health insurance will typically cover medical bills, but the patient must pay for board and accommodation. In addition to accessing relevant medical, nursing, and rehabilitation services and living services, the facilities are also supposed to educate patients and their families to ensure that they are ready to become caregivers. Admission is based on referral issued by a physician, assessment of the person’s independence according to the Barthel Index scale, the patient's application, and the disclosure of income data. Facilities have different profiles adapted to various patient groups; these include general facilities, facilities for those with specific needs – for example, people with mental health issues or neurological diseases – and age-specific (children only, adults only) facilities. A facility can operate on a stand-alone basis or within a larger medical structure; in practice, most ZOL facilities form part of a hospital organization while most ZPO facilities operate autonomously. Residents pay for board and accommodation; the monthly fee for these cost items is equivalent to 250 percent of the lowest retirement pension, however the amount users pay cannot exceed 70 percent of the resident’s monthly income. Healthcare services and devices, even highly sophisticated ones, are covered by health insurance. ZOL/ZPO medical and nursing services include consultations with specialist physicians, nursing care, rehabilitation care, nutritional care, occupational therapy, and pharmacotherapy. 79 There are 527 ZOL and ZPO facilities across Poland, but the distribution of these facilities across regions is varied. According to NFZ data, in 2021 there was a total of 461 such LTCFs, including 349 ZOL and 123 ZPO facilities46 (Figure 20). GUS estimates are higher, likely due to the inclusion of facilities that provide LTC services without an NFZ contract. According to GUS data, in 2021 there were 370 ZOL and 157 ZPO facilities in Poland (Figure 21), of which 47 facilities provided 24/7 care for ventilated patients, 14 catered to children and adolescents, and 7 facilities supported ventilated children and adolescents. The average length of stay was 163 days for ZOL and 177 days for ZPO. Figure 21 presents the number of ZOL and ZPO facilities by region (at the end of 2021, based on GUS estimates). In 2021, Mazowieckie and Dolnośląskie had more ZOL facilities than any other region in Poland (45 each), while Zachodniopomorskie reported just 9 ZOL facilities. As for the ZPO pool, the highest number was recorded in Mazowieckie and Śląskie, and the lowest in Opolskie and Lubuskie (at one ZPO facility). As 46 percent of LTCF residents are 80+, it would be expected that more facilities would be present in places with greater numbers of elderly populations. However, a region’s demographic composition does not seem to correlate with LTCF numbers or distribution. Total number of patients and ZOL/ZPO facilities Figure 20.  in the health sector, 2017–2021 50 000 500 45 000 450 40 000 400 35 000 350 30 000 300 Facilities Patients 25 000 250 20 000 200 15 000 150 10 000 100 5 000 50 – – 2017 2018 2019 2020 2021 Total Patients Total ZPO/ZOL Facilities Source: World Bank 2023, compilation based on 2017-2021 NFZ data. 46 The ZOL/ZPO facility count is greater than the number of LTCFs as more than one LTC facility can operate both a ZPO/ZOL 80 ZOL and ZPO facilities by region, end of 2021, according to GUS Figure 21.  Care and Treatment Facility (ZOL) 4000 3865 100 Poland Average bed count per ZOL 90 3500 ZOL count Bed and ZOL count 370 2971 80 3000 70 2500 60 2000 50 Bed count 21,758 1500 40 956 949 30 1000 924 763 523 540 20 451 500 356 10 45 2.4 27 1.2 15 23 1.5 36 45 26 1.5 312 41 2.5 16 Average 10 14 10 22 13 18 9 0 0 bed count Dolnośląskie Kujawsko-pomorskie Lubelskie Lubus kie Łódzkie Małopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Śląskie Świętokrzyskie Warmińsko-mazurskie Wielkopolskie Zachodniopomorskie per ZOL 59 ZOL count Bed count Average bed count per ZOL Nursing Care Facility (ZPO) Poland 900 Average bed count per ZPO 860 60 800 ZPO count Bed and ZPO count 157 692 700 50 600 40 500 477 472 485 427 415 400 30 319 Bed count 7,524 300 252 252 20 200 158 100 115 10 56 19 11 7 13 3 22 1.1 1 6 14 9 6 22 1.3 3 5 10 11 1 0 0 Average Dolnośląskie Kujawsko-pomorskie Lubelskie Lubus kie Łódzkie Małopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Śląskie Świętokrzyskie Warmińsko-mazurskie Wielkopolskie Zachodniopomorskie bed count per ZPO 48 ZPO count Bed count Average bed count per ZPO Source: GUS (2022), Zdrowie i ochrona zdrowia w 2021 r., based on Ministry of Health / Ministerstwo Zdrowia (MZ) and Ministry of Interior and Administration / Ministerstwo Spraw Wewnętrznych i Administracji (MSWiA) data. 81 Patient volume increased by 5.5 percent between 2017 and 2021. In 2021, there were 45,180 residents across all ZOL/ZPO facilities in Poland, which is approximately 119 people per 100,000 population. ZOL/ZPO patient volume has increased by 5.5 percent between 2017 and 2021, but each region has its own dynamics (see Figure 22). For example, the patient count in Lubuskie increased by over 40 percent, whereas Łódzkie and Warmińsko-Mazurskie experienced an 18 percent reduction. The trend is not analogous to the one observed in DPS facilities in the social sector, where the patient population went down in almost every region in Poland during the same period. In fact, there are long waiting lists for ZOL/ZPO admission. As of the end of 2020, 11,593 people were awaiting admission, including 1,420 urgent cases and 10,173 stable cases. The waiting time in urgent cases ranged from 0 to 43 days, with Świętokrzyskie reporting a record 47 days. In stable cases, the median waiting time was 15 days, with Lubuskie reporting an extreme of 354 days. While the patient volume is low, costs have increased significantly over the analyzed period of 2017 to 2021 by nearly 60 percent, see the section ‘Financing in the health sector’. Patients of ZPO/ZOL facilities per 100,000 population, Figure 22.  in the health sector, by region, 2017, 2019, and 2021 180 160 Patients per 100k population 140 120 100 80 60 40 20 – Podkarpackie Opolskie Świętokrzyskie Małopolskie Dolnośląskie Śląskie Łódzkie Poland Mazowieckie Lubelskie Warmińsko-mazurskie Podlaskie Kujawsko-pomorskie Pomorskie Zachodniopomorskie Lubuskie Wielkopolskie 2017 2019 2021 Source: World Bank 2023, compilation based on 2017-2021 NFZ data. 82 B. HOME CARE Home-based LTC services in the health sector are mostly provided in the form of home-based nursing care. Home-based nursing care can be accessed based on a referral from a physician (general practitioner, specialist, or hospital physician). Eligibility is defined as poor health resulting in severe dysfunctions as measured by the Barthel Index scale.47 Eligibility is granted with a score of 40 points or lower on the Barthel scale.48 Nursing services include wound care and dressings, administering medications, delivering injections, supporting family caregivers in performing nursing activities, engaging the patient in respiratory and general exercises, advising on access to medical support, and providing proper rehabilitation equipment. The nurse is also authorized to prescribe selected pharmaceutical products and issue referrals for certain tests and medical items such as diapers. Visits are made regularly, at least four times a week, and recorded on the patient's chart. To be eligible, a patient must meet the above- mentioned criteria and must not be in the acute phase of a mental health condition or simultaneously benefit from home care for ventilated patients, home hospice services, or inpatient facility services. The other category of home-based care services is ventilation services for people with respiratory failure. Home-based care for ventilated patients can also be provided by an LTC team, including LTC nurses, doctors and physiotherapists. Respiratory failure can be caused by a number of conditions, including chronic obstructive pulmonary disease, neuromuscular diseases, conditions that result in severe chest deformity, diseases of the central nervous system or metabolic diseases.49 Home-based ventilation can be initiated provided that treatment for the acute failure has been administered – usually in 47 Barthel Index for Activities of Daily Living includes assessment of bathing, dressing, toileting, transferring, continence, and feeding. 48 This criterion does not apply to children under three or people suffering from AIDS. 49 Borys, M., and M. Kubicz. 2021. Raport – Wentylacja mechaniczna w Polsce [Report – Mechanical ventilation in Poland]. https://ptmr.info.pl/wp-content/uploads/2021/12/Raport-WentylacjaMechaniczna.pdf. 83 a hospital setting – and home-based ventilation has been recommended by a pulmonologist or anesthesiologist based on the relevant diagnostic tests. To be eligible for home-based ventilation services, a person cannot be using hospice services or home-based nursing care. The number of recipients of home-based nursing care decreased between 2017 and 2021, while users of home-based ventilation services increased over the same period. A total of 60,639 people used home-based nursing services in 2021, which is less than 160 per 100,000 population. This represents a slight decrease of 4.8 percent nationally in the number of patients of home-based nursing services between 2017 and 2021 (see Figure 23). The number of patients using these services in relation to the number of inhabitants was the highest in Śląskie (308 per 100,000) and Opolskie (294 per 100,000), and the lowest in Pomorskie (51 per 100,000): a sixfold difference in beneficiary to inhabitant ratio between the highest and lowest reporting regions (see Figure 24 below and Table 11 in the Financing section). In 2021, there were 1,544 health-care providers offering home-based LTC services, with the highest numbers in Mazowieckie (212), Śląskie (161), and Podkarpackie (160), and the lowest numbers reported in Pomorskie (30) and Podlaskie (34).50 In contrast, the users of home-based mechanical ventilation services increased by 52.3 percent in the five years under review. In 2021, there were 8,120 adults (18+), which is 21 per 100,000 population, and 782 beneficiaries under the age of 18 of this type of home-based care. 50 Ministry of Health. “Long-Term Care in Poland.” https://basiw.mz.gov.pl/en/maps-of-health-needs/map-of- health-needs-for-the-period-2022-2026/analyses/long-term-care/ 84  otal number of patients of home-based nursing Figure 23. T and total number of home-based nursing providers in the health sector, 2017–2021 70 000 1800 1600 60 000 1400 50 000 1200 Providers 40 000 Patients 1000 30 000 800 600 20 000 400 10 000 200 – – 2017 2018 2019 2020 2021 Total Patients Total Providers (facilities, teams, nurses) Source: World Bank 2023, compilation based on 2017-2021 NFZ data. Patients receiving home-based nursing care per Figure 24.  100,000 population, in the health sector, by region, 2017, 2019, and 2021 400 350 Patients per 100k population 300 250 200 150 100 50 – Opolskie Śląskie Podkarpackie Świętokrzyskie Poland Małopolskie Lubelskie Dolnośląskie Zachodniopomorskie Wielkopolskie Mazowieckie Łódzkie Lubuskie Podlaskie Warmińsko-mazurskie Kujawsko-pomorskie Pomorskie 2017 2019 2021 Source: World Bank 2023, compilation based on 2017-2021 NFZ data. 85 C. DAY CARE LTC day care services were introduced in the form of pilot programs through ESF projects, but most initiatives were discontinued after the project period ended due to the inability of LGUs to cover the continued cost of service delivery. A form of day care was introduced on a pilot basis within the Operational Program Knowledge Education Development (POWER) 2014–2020, and some projects within regional operational programs for providing medical day care homes (Dzienny Dom Opieki Medycznej, DDOM) received additional financing from ESF in 2014–2020. These facilities delivered rehabilitation services, psychomotor stimulation, diagnostic tests, specialized consultations, and education for dependents. They operated on weekdays for up to eight hours per day. Target beneficiaries included seniors (65+) not covered by home-based nursing care or inpatient facility care (ZOL or ZPO), recently discharged from hospital, and with a Barthel Index score between 40 and 60 points. According to the database of DDOM participants, a total of 5,698 people, including patients and their caregivers, received support. Of those people, 93.5 percent completed the pre-planned pathway, while 3.7 percent did not. For the remaining 2.8 percent, it was not determined whether the project had been completed as planned. According to SL2014 system data,51 3,101 patients were enrolled in a DDOM pilot facility and completed their therapy.52 DDOM facilities were supported financially during the project lifetime, however local governments were expected to take over after project closure. Consequently, most initiatives have been discontinued because LGUs were unable to finance their operation without external funding. However, according to an MZ program, ‘Healthy Future: Strategic framework for health care system development in 2021–2027, with an outlook to 2030’, includes the operation or establishment of new DDOM facilities in the country. 51 SL2014 is a database system that contains information on DDOMs in Poland. 52 Research cofinanced by ESF. Ewaluacja Ex Post Projektów Po Wer Dotyczących Tworzenia i Prowadzenia Dziennych Domów Opieki Medycznej. https://www.ewaluacja.gov.pl/media/84484/ewaluacja_ex_post_ DDOM_dostepny.pdf. 86 Another initiative to be implemented in the health sector is ‘75 Plus Health Centers’, also mentioned earlier in the report, which will provide day care services, among other responsibilities. Services will be deployed in primary health-care facilities, on geriatric floors, and in the new 75+ Health Centers, which are to be launched with the intention of being near to a patient’s home. Still novel in the health sector in Poland, delivery of day care services has been explored as a potential service by experts and policymakers for several years. According to the Act on Special Geriatric Care of August 17, 2023, ‘75 Plus Health Centers’ will be established in the health sector.53 They will be developed according to regional plans for the introduction of geriatric care. Their catchment area will be demarcated as part of a county, an entire county, or a combination of several counties with a 75+ population of between 6,000 and 12,000, and their distribution will be defined in regional plans for the introduction of geriatric care. They may operate as independent entities or as subunits of other health-care facilities, and their service catalog may include geriatric services delivered by a physician and a nurse; physiotherapy; psychiatric and psychological care; nutritionist consultations; occupational therapy; and health education. Each center is expected to operate an outpatient clinic, day care services, a geriatric home care team, and a team of health educators. CASH BENEFITS The purpose of cash benefits is to provide financial support to those who cannot do without daily assistance and to compensate their caregivers. The people in need of support may include senior citizens with age-related LTC needs, people with disabilities, and their caregivers (Table 3). Thus, cash benefits help beneficiaries to deal with the consequences of dependency. Cash benefits discussed here do not include the social pension benefit: this is a benefit granted to adults 53 Ministry of Family and Social Policy. Centra Zdrowia 75+ to opieka geriatryczna blisko domu. https://www.gov.pl/web/zdrowie/centra-zdrowia-75-to-opieka-geriatryczna-blisko-domu. 87 who are temporarily or indefinitely unable to work.54 In the event of serious deterioration of health status, a person may apply for social security benefits—delivered within the framework of social security and social assistance—which are intended to partially compensate for the cost incurred by the loss of independence. When intensive LTC services are required, there is financial support for the caregiver, provided that the dependent is a person with disability.  ash benefits for dependent persons and their Table 3. C caregivers A SENIOR CITIZEN AND/OR A PERSON WITH DISABILITY A CAREGIVER TO A PERSON WITH DISABILITY Nursing supplement Nursing benefit It is payable to a person entitled to a pension or Under the terms applicable until December 31, 2023: disability pension if the person has been recognized Nursing benefit is payable to a parent, a de facto guardian as completely incapable of work and of the child, a relative who acts as foster family for the independent living or is over 75 years of age. child, a foster parent or legal guardian who takes care of A person entitled to a pension or disability pension a person who is certified as a person with disability issued staying in a ZOL or ZPO is not entitled to a nursing with the following annotation: requires permanent or long- supplement unless he or she stays outside this term care or assistance of another person due to loss of facility for a period longer than 2 weeks a month. independent living. In case a person cares for more than one dependent, the benefit is paid per dependent. It cannot be combined with a nursing allowance (paid by the local government). The benefit is payable if the disability originated before the applicant turned 18 or during high school/university In 2023, it was PLN 294.34 and since education, but no later than the age of 25. It cannot be March 1, 2024, PLN 330.07. combined with benefits such as special caregiver allowance, Paid monthly caregiver allowance, retirement, or disability pension. Payer: ZUS/KRUS/ZER MSWiA The nursing benefit granted from January 1, 2024, is available to parents and other persons caring for disabled children up to 18 years of age without any restrictions on taking up employment or other paid work and may be combined with receiving pensions/pensions. The amount is announced each year, in 2023 it was PLN 2,458, in 2024 it is PLN 2,988. Paid monthly Payer: LGU 54 A social pension is payable to adults who have total incapacity for work acquired due to impairment of the body's mobility during childhood, until they complete their education, that is, up to the age of 25. 88 A SENIOR CITIZEN AND/OR A PERSON WITH DISABILITY A CAREGIVER TO A PERSON WITH DISABILITY Nursing allowance Special care allowance Nursing allowance was designed to partially Payable to those who gained a right to the benefit before cover the expenses arising from the need the end of 2023 and is not granted to new applicants since to provide care and assistance to a person January 2024. Until the end of 2023, the benefit was paid affected by the loss of independent living. to those who do not take up gainful employment or give it up to be able to take care of a person who is certified as Therefore, the following categories of beneficiaries a person with severe disability or holds a disability certificate are eligible for nursing allowance: with the following annotations: ‘requires permanent or  A child with disability; long-term care or assistance of another person due to loss of independent living’ or ‘requires day-to-day assistance  A person with disability who is over 16, as long with treatment, rehabilitation and education’. Income as s(he) holds a certificate of severe disability; criterion: per capita household income cannot exceed  A person with disability who is over 16, as long as PLN 764 net in the year directly preceding the year in s(he) holds a certificate of moderate disability, provided which the application is filed. This allowance is payable to that such disability originated before s(he) turned 22; the caregiver regardless of the age of the dependent.  A person over 75. From January 1, 2024, special care allowance is available only based on protection of acquired rights. Nursing allowance is not payable when: Amount in 2023: PLN 620  The applicant is eligible for nursing supplement; Paid monthly  The applicant lives in an inpatient facility with free board and lodging; Payer: LGU  A family member is eligible for a benefit—payable by another country—designed to cover the expenses related to LTC over the applicant, unless otherwise provided for in the regulations on coordination of social security systems or in bilateral social security agreements. Amount: PLN 215.84 Paid monthly Payer: LGU Supplementary benefit for people unable to live Caregiver allowance55 independently (so-called 500+ supplement) Only for those who had lost their title to the caregiver Available to persons ages 18+ with loss of independent benefit as of July 1, 2013, in connection with the living (as acknowledged in a certificate written to their expiration (by law) of the decisions on their eligibility name and stating any of the following: ‘complete loss for the caregiver benefit. From the beginning of 2024, of independent living’, or ‘totally unable to work and the benefit can be combined with employment. live independently’, or ‘totally unable to work on a farm Amount: PLN 620 and live independently’, or ‘totally unable to serve and live independently’; cannot collect retirement pension Paid monthly or disability pension or claim any other publicly funded Payer: LGU benefit i.e. such as a permanent or temporary benefit (the condition does not apply to one-off benefits), or if they do collect such benefits, the gross value of those benefits must be below PLN 2157.80. This cap does not apply to the survivor's pension of a child who lost independent living or ability to work before the Source: World Bank 2023, based on age of 16 or 25, in the case of continuing education. 2021 MRPiPS and ZUS data.56 Paid monthly Note: ZUS: Social Security Agency in Poland / Zakład Ubezpie- czeń Społecznych. KRUS: Social Security Agency for Farmers Payer: ZUS/KRUS/ZER MSWiA in Poland / Kasa Rolniczego Ubezpieczenia Społecznego. 55 Pursuant to the provisions of December 7, 2012, only the caregivers of children or adults whose disability originated before they turned 18 (or 25, if still in schooling) were entitled to the nursing benefit, while the caregivers of adults (including seniors) whose disability presented later in life had lost the title to the benefit. This was deemed unconstitutional and, in 2013, a caregiver allowance was introduced for the caregivers who had lost the title to the benefit. 56 To some extent, the gap between benefit amount payable to a caregiver who takes care of a child dependent (caregiver benefit), which is close to the minimum wage in net terms, and benefit amount payable to a caregiver who takes care of an adult dependent (special caregiver allowance) may be accounted for by the fact that an adult with disability receives disability pension from the social security system, and therefore has regular income of their own. In addition, the caregivers who collect the benefits mentioned have their old age and disability pension contributions covered. Of all the cash benefits disbursed to beneficiaries, the largest share is the nursing supplement allocated to senior citizens, the next largest amount is the nursing allowance allocated to seniors and people with disabilities. According to World Bank calculations, in 2021, cash benefits were disbursed to 4.1 million people. Of this, 3.1 million people were either senior citizens receiving the nursing supplement or senior citizens and persons with disabilities receiving the nursing allowance. Permanent allowance from the social system was disbursed to 173,000 recipients. A permanent benefit is granted to an adult who is unable to work due to old age or disability, if his or her income is lower than the income criterion (for a single person/person in the family). In addition, nearly 222,000 recipients were caregivers of dependents with disability certificates who complied with access criteria listed in Table 3. Introduced in the beginning of 2024, changes to cash benefit policies now allow caregivers of disabled children and receiving the nursing benefit to continue to participate in paid work. Before that, the indicated cash benefits addressed to caregivers could not be combined with taking up paid work. Enabling the combination of professional activity with care is beneficial in terms of reducing dependence on social benefits, but also from the perspective of integrating caregivers with the community and facilitating their return to the labor market after the end of care. Nevertheless, the decision to take up work is voluntary, so it is also possible to receive benefits and remain inactive in the labor force. Beginning in 2024, adults (18+) with disabilities are eligible to apply for the support benefit. The support benefit is approved based on an application filed to ZUS, and a dedicated team appointed at the regional level will assess the needs and decide how much support is required in each case. The support benefit is a new measure; it has its own assessment mechanism and is not tied to other income support measures. The support benefit depends on the level of needs determined on a case-by-case basis, and awarded at 40, 60, 80, 120, 180, 90 or 220 percent of the social pension. A disability certificate is required to demonstrate eligibility. In 2024, the support benefit is paid to those with the greatest needs – about 50,000 beneficiaries, according to estimates. In 2025, those with moderate needs (about 150,000 beneficiaries) will become eligible, and from 2026, the support benefit will also be payable to those with the lowest needs – some 300,000 beneficiaries. The support benefit cannot be collected in combination with caregiver benefit. In the next steps, further efforts should be made to simplify the benefit system and gradually eliminate the special carer's allowance and carer's allowance in cases where a dependent person becomes entitled to a support benefit. Caregivers who want to return to the labor market, lose their entitlement to benefits (for example, care benefit), or a person with a disability receives a support benefit, should be provided with access to professional activation instruments in the form of vocational and reintegration training conducted by county (powiat) labor offices or employment entities. social (clubs and social integration centers) and through facilitating employment in the social economy sector, including social services (for example, care).57 HUMAN RESOURCES FOR LTC There is a significant undersupply of LTC human resources, and this is likely to worsen. Projections of future care demands suggests that care requirements will continue to put pressure on public systems, and while technological innovation can lead to better efficiencies in delivering care, it is still a human resource intensive activity. This is more concerning given that Poland reports an undersupply of LTC workers compared to EU averages, where LTC supply issues are also noted in the region. This section presents select data on human resources for LTC in 57 Ibid 91 Poland. Further analysis and data are presented in the Human Resource section within Key Challenges and Solutions. One cross-cutting issue in this report is that not all LTC workers are counted in Poland, and of the data that are collected, it is insufficient for informing policy making. The available data for Poland only allowed for the analysis of personnel in select inpatient LTC settings, including DPS, ZOL, and ZPO and LTC home care in the health sector (Figure 25). Data collected by the World Bank through a novel survey allowed for additional analysis of informal care. Hence, the report solution pertaining to better monitoring and standardizing of roles should also improve national-level strategic planning around this critical resource of the LTC system.  TC system of personnel, including number of Figure 25. L countable LTC personnel LONG-TERM CARE HR 2021 PUBLIC SOCIAL SECTOR HEALTH SECTOR HOME CARE HOME CARE INPATIENT CARE DAY CARE INPATIENT CARE DAY CARE 6,918 22,221 Residential home Care and Support center Nursing home (DPS) Care services (UO) treatment facility (OW) care 36,647 (ZOL) Home-based Including: Family care home Shelters with care Nursing and care mechanical specialized care (RDP) services facility (ZPO) vantilation for services (SUO) adults Specialized care Home-based services for Care and residential center program Medical day care mechanical persons with (COM) home (DDOM) ventilation for mental health children conditions Telecare (within the Senior 75 Plus Health Centers + (incl geriatric Senior + Program Support Corps teams) Program) Cash benefits for seniors/people with disabilities Programs: "Respite care" and "Respite Cash benefits for caregivers care for caregivers of persons with disabilities" Selected programs (projects) run by central government (i.e., programs that concern the financing and implementation of new types Programs: "Personal assistant for the of benefits that are not covered by guaranteed disabled" and "Personal asistant for services; implemented for a specified period) a person with disability" Guaranteed services 92 According to data reported to regional and international databases (including the Organisation for Economic Co-operation and Development [OECD]), Poland has one of the lowest numbers of LTC workers per 100 people aged 65 or older. The rates have remained unchanged over the last decade. The rate in 2011 and 2019 remained at 1 LTC worker per 100 elderly persons (Figure 26). Rate of LTC workers per 100 people age 65+, Figure 26.  2019 and 2011 (or nearest year) 14 12 10 8 6 4 0.89 0.57 2 0 Norway Sweden2 Iceland Switzerland Netherlands1 Finland Denmark Luxembourg Belgium1 Estonia Germany Spain Austria Ireland Czechia Italy France1 Slovenia Hungary Slovak Republic Latvia Lithuania Potugal Poland Greece 2011 Source: OECD 2021.58 2019 Note: 1. Break in time series. 2. Data for Sweden cover only the public providers. In 2016, 20 percent of beds in LTC for the elderly were provided by private companies (but publicly financed). A large majority EU countries, including Poland, have reported significant numbers of unfilled vacancies, or have estimated increases in the need for personnel and expected staff shortages in the LTC sector. Nursing professionals were ranked first among the occupations experiencing the highest labor shortages in 2020. Several factors may contribute to increasing staff shortages in the future, notably the 58 OECD 2021. Long-term care workforce: caring for the ageing population with dignity. https://www.oecd. org/els/health-systems/long-term-care-workforce.htm 93 expected increase in demand for formal long-term care due to a larger population of old people, as well as ongoing trends such as the increasing labor market participation by women and the greater mobility of people, which may influence the availability of informal carers.59 In 2019, LTC non-residential workers in Poland represent less that 0.3 percent of the total workforce in that country, while LTC residential workers 0.8 percent (Figure 27). LTC workers (health and social sectors) as share (%) of Figure 27.  total workforce, 2019 8 7 6 5 4 3 2 2.2 1 0.8 0.9 0.3 0 Greece Cyprus Romania Poland Bulgaria Estonia Lithuania Croatia Italy Hungary Czechia Ausrtia Spain Slovakia EU27 Portugal Luxemburg Malta Germany France Finland Belgium Netherlands Sweden Residential Non-residential Source: Eurostat 2019.60 Overall LTC workforce figures suggest small increases in staff in the social sector, small declines in health, and an incomplete picture of the home care settings. In the social sector, between 2019 and 2021, the number of DPS employees in educational, personal care, and therapeutic positions increased by 1,250 people, reaching a total of 59 European Commission 2021. 2021 Long-Term Care Report Trends, Challenges, and Opportunities in an Ageing Society, Volume I. 60 Eurostat 2019. Long-term care workforce: Employment and working conditions. https://www.eurofound. europa.eu/en/publications/2020/long-term-care-workforce-employment-and-working-conditions 94 36,647 staff (Figure 28). From 2019 to 2021, the health sector saw a small decline in the pool of medical staff in ZOL/ZPO facilities (a reduction of 360 people) down to a total 16,860 employees in 2021 (Figure 29). The workforce includes physicians, nurses, physiotherapists, physical therapists, psychologists, and addiction therapy specialists. Inpatient LTC workforce – social sector Figure 28.  (DPS workforce), excluding administration staff DPS FTE Staff 2019-2021 for Poland DPS Client-Staff Ratio 2019-2021 for Poland 2.55 2.34 2.36 35 397 37 944 36 647 2019 2020 2021 2019 2020 2021 Region FTE staff 2021 vs. Region Client/ 2021 vs. 2021 2019 staff 2019 ratio Dolnośląskie 2698 -52 Dolnośląskie 2.30 -0.02 Kujawsko-pomorskie 1851 24 Kujawsko-pomorskie 2.43 -0.02 Łódzkie 2643 -87 Łódzkie 2.51 -0.11 Lubelskie 1976 104 Lubelskie 2.35 -0.37 Lubuskie 1157 29 Lubuskie 2.05 -0.22 Małopolskie 4181 -39 Małopolskie 2.10 -0.05 Mazowieckie 4474 179 Mazowieckie 2.15 -0.22 Opolskie 1380 144 Opolskie 2.43 -0.30 Podkarpackie 1913 172 Podkarpackie 2.56 -0.55 Podlaskie 1106 -123 Podlaskie 2.18 0.22 Pomorskie 1891 28 Pomorskie 2.33 -0.14 Śląskie 3702 346 Śląskie 2.60 -0.34 Świętokrzyskie 1281 246 Świętokrzyskie 2.82 -0.68 Warmińsko- 1555 133 Warmińsko- 2.58 -0.31 mazurskie mazurskie Wielkopolskie 3072 -24 Wielkopolskie 2.27 -0.06 Zachodniopomorskie 1767 170 Zachodniopomorskie 2.51 -0.39 Source: World Bank 2023, based on 2019 and 2021 MRPiPS-05 data.  95 Inpatient LTC workforce – health sector Figure 29.  (ZOL and ZPO workforce) ZOL + ZPO FTE Staff 2019-2021 for Poland ZOL + ZPO Client-Staff Ratio 2019-2021 for Poland 2.7 2.41 2.68 17 220 17 117 16 860 2019 2020 2021 2019 2020 2021 Region FTE staff 2021 vs. Region Patient/ 2021 vs. 2021 2019 staff 2019 ratio Mazowieckie 2172 -11 2021 Śląskie 2064 -323 Zachodniopomorskie 3.00 -0.17 Małopolskie 1785 -73 Kujawsko-pomorskie 2.93 0.46 Dolnośląskie 1566 -67 Małopolskie 2.91 0.34 Podkarpackie 1413 -162 Wielkopolskie 2.90 -0.02 Łódzkie 1198 45 Mazowieckie 2.85 0.21 Lubelskie 854 -24 Lubelskie 2.80 0.26 Świętokrzyskie 2.79 -0.18 Wielkopolskie 843 1 Łódzkie 2.79 0.25 Pomorskie 835 13 Lubuskie 2.78 -0.07 Kujawsko-pomorskie 793 0 Śląskie 2.63 0.42 Świętokrzyskie 667 84 Dolnośląskie 2.50 0.25 Opolskie 644 54 Warmińsko- 2.48 -0.20 Podlaskie 611 29 mazurskie Warmińsko- 508 20 Pomorskie 2.46 -0.22 mazurskie Podkarpackie 2.45 0.41 Zachodniopomorskie 466 -5 Opolskie 2.27 -0.09 Lubuskie 441 59 Podlaskie 2.06 0.03 Source: World Bank 2023, based on 2021 NFZ data. FINANCING OF LTC Long-term care services in Poland are financed from public and private funds. The main sources of public funding include health and social insurance, the central budget, local government budgets, and EU funds. Services delivered by private facilities and informal care are financed solely on an out-of-pocket basis – all the costs are covered by LTC patients and clients. However, comprehensively reviewing LTC 96 spending in Poland is a formidable challenge due to the diverse nature of funding mechanisms and the multitude of financial benefits involved. To understand the financing situation more broadly, Figure 30 presents a simplified overview of the financing flows for different care modalities. Figure 30. LTC funding and financial flows in Poland Health Health care insurance sector (inpatient contributions care and home- based care) Private Private market investors (inpatient care and home-based care) Social security contributions Family-based care (delivered by the next of kin) Out-of-pocket Social welfare General sector (inpatient purpose fiscal care, home-based revenues and day care) Source: World Bank 2023, own compilation. In 2021, the total spending on LTC services (without cash benefits and out-of-pocket payments) was PLN 8.5 billion. Additionally, PLN 16 billion was allocated for cash benefits, and patients paid PLN 1.4 billion out of their own pocket for inpatient services (Figure 31). 97 Figure 31. Level and distribution of LTC financing in 2021 in Poland (the total expenditure given for the social and healthcare sector does not include cash benefit and government programs) LONG-TERM CARE COSTS 2021 NON-CASH BENEFITS CASH BENEFITS PUBLIC PRIVATE 16,880.2 FOR/NON FOR SOCIAL SECTOR HEALTH SECTOR MILLION PROFIT 6,589.3 MILLION 1,928.2 MILLION Services to INPATIENT DAY CARE HOME CARE INPATIENT HOME CARE Nursing caregivers 3,840.28 1,898.55 DAY CARE 850.5 million 1,235.7 million 692.5 million supplement 36.8 million million 6,941.6 million million Support Nursing Annual DPS 3834.27 Care services patient Nursing Centers ZOL services Respite million 702.1 million copayment to allowance 1867.45 million 404.8 million 2,351.1 care for DPS: million family 1,083 million Shelters Pediatric ven- members RDP 6.01 Of which: spe- PLN providing care tilation or million cialized UO 29.3 ZPO 1173 PLN (per services 36.78 caregivers (2022) million patient/ Supplementary 31.1 million million 36.8 million month) benefit 1,952.4 million Specialized COM 30.8 million care servic- Adult es for persons DDOM (2020) ventilation 7.6 million 250.94 Annual with mental patient disorders million Permanent Senior+ 59.1 million copayment to benefit 148.4 million ZOL/ZPO: 948 million 311 million PLN (per patient/ 75 Plus Health Centers + (incl Nursing benefit month) Senior + geriatric teams) 4,460.2 million Telecare Program Special caregiver allowance Care services for the disabled 161.42 million 25 million (2020) Cash benefits for seniors/people with disabilities Caregiver Cash benefits for caregivers allowance 65.5 million Personal assistant Selected programs (projects) run by central 230.4 million government (i.e., programs that concern the financing and implementation of new types of benefits that are not covered by guaranteed services; implemented for a specified period) Guaranteed services Patient/clients co-payments Source: World Bank 2023, based on MRPiPS, ZUS, KRUS, NFZ data for 2017–2021. Considering total spending on LTC, including cash benefits, non-cash benefits, and copayments, Poland’s spending accounted for 1.02 percent of gross domestic product (GDP) in 2021 (PLN 26.8 billion). When only considering non-cash benefits, this amount is 0.32 percent 98 (PLN 8.5 billion), and when considering non-cash benefits and out-of- pocket payments, the amount is 0.38 percent (PLN 9.9 billion PLN) (see Table 4). This value differs from that reported by Eurostat and calculated within the framework of the System of Health Accounts (SHA).61 According to 2021 Eurostat data and comparing like-with-like figures, Poland spent 0.5 percent of GDP on LTC in 2021. The EU average was 1.7 percent (see Figure 32). LTC expenditure as percentage of GDP in Poland Table 4.  in 2019–2021 by LTC health and social sectors YEAR AMOUNT LTC HEALTH AS LTC SOCIAL AS TOTAL LTC AS (PLN, BILLIONS) % OF GDP % OF GDP % OF GDP Non-cash benefits only 2019 7.68 0.07 0.27 0.34 2020 8.36 0.08 0.28 0.36 2021 8.52 0.07 0.25 0.32 Non-cash benefits + out-of-pocket payments 2019 — — — 2020 — — — 2021 9.91 — — 0.38 Cash benefits + non-cash benefits 2019 20.23 — — 0.88 2020 24.01 — — 1.03 2021 25.36 — — 0.97 Cash benefits + non-cash benefits + out-of-pocket payments 2019 — — — — 2020 — — — — 2021 26.79 — — 1.02 Source: World Bank 2023, based on MRPiPS, ZUS, KRUS, NFZ data for 2017–2021. 61 Total spending reported by SHA includes government and compulsory contributory health-care-financing schemes; voluntary health care payment schemes; household out-of-pocket payments; and rest of the world financing schemes (non-resident). Comparability issues still exist regarding the expenditure data on LTC within the framework of SHA. All conclusions should therefore be treated with caution. More information can be found in OECD (2020) - A System of Health Accounts 2011. https://www.oecd.org/ health/a-system-of-health-accounts-2011-9789264270985-en.htm 99 LTC expenditure as share of GDP across EU countries Figure 32.  in 202162 % 5 4 3 2 1.7% 1 0.5% 0 EU27 Belgium Bulgaria Czechia Denmark Germany Estonia Ireland Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxemburg Hungary Malta Netherlands Ausrtia Poland Portugal Romania Slovenia Slovakia Finland Sweden Source: World Bank 2023, based on Eurostat data 2021 / SHA 2011.63 The quantum of LTC funding in the health sector is quite different from the social sector financial envelope. In 2021, the annual average cost of LTC services per patient in the health sector was PLN 17,000, while in the social sector it was PLN 20,700. The gap is also evident across LTC settings (inpatient care, day care, home care), with higher costs incurred in the social sector (see Table 5 and Table 6). It should be noted, however, that these two sectors operate under different principles and are governed by separate acts of law which means comparable LTC services may not be accounted for in the same way. Figure 33 and Figure 34 show the total costs in the social sector and health sector, respectively, during 2019–2021 for three settings of care provision. 62 Ibid. 63 Eurostat 2021. Long-term care (health) expenditure. https://ec.europa.eu/eurostat/databrowser/view/ TPS00214/bookmark/table?lang=en&bookmarkId=b7e42601-5edd-4620-b05b-082f366d9b46 / OECD. System of Health Accounts 2011. https://www.oecd.org/health/a-system-of-health-accounts-2011 -9789264270985-en.htm 100 Total costs in the social sector (excluding cash Figure 33.  benefits, out-of-pocket spending, and RDP) in 2019, 2020, and 2021 4500 4000 3500 3000 PLN millions 2500 2000 1500 1000 500 – DPS Day Care Home Care 2019 2020 2021 Source: World Bank 2023, based on 2019–2021 MRPiPS-03 data. Public spending on LTC services in the social sector Table 5.  (excluding out-of-pocket payments) PUBLIC SPENDING PER CLIENT 2017 2018 2019 2020 2021 PER YEAR, IN PLN  Inpatient care  – – 38,578 43,771 44,240 Day care  – – 12,326 16,434 17,806 Home care  5,590 5,741 6,065 6,641 6,782 Social sector, total -– – 16,469 20,074 20,667 PUBLIC SPENDING PER CLIENT 2017 2018 2019 2020 2021 PER MONTH, IN PLN Inpatient care  – – 3,215 3,648 3,687 Day care  – – 1,027 1,370 1,484 Home care  466 478 505 553 565 Social sector, total – – 1,372 1,673 1,722 Source: Word Bank 2023, based on MRPiPS data for 2017–2021. Note: ‘—' indicates a lack of data from MF for years 2017–2018. 101 Total costs in the health sector (ZOL/ZPO and home Figure 34.  care, excluding out-of-pocket payments) in 2019, 2020, and 2021 1400 1200 1000 PLN millions 800 600 400 200 – ZOL+ZPO Home Care 2019 2020 2021 Source: World Bank 2023, based on 2019–2021 MZ and NFZ data. Public spending on LTC services in the health sector Table 6.  (excluding out-of-pocket payments) PUBLIC SPENDING PER PATIENT PER YEAR, IN PLN  2017 2018 2019 2020 2021 Inpatient care  18,107 19,867 22,530 27,301 27,352 Home care  8,482 9,315 9,402 10,533 9,969 Health care sector, total  12,326 13,575 14,619 17,070 17,032 PUBLIC SPENDING PER PATIENT PER MONTH, IN PLN  2017 2018 2019 2020 2021 Inpatient care  2,930 3,164 3,755 4,550 4,559 Home care  707 776 784 878 831 Health care sector, total  1,027 1,131 1,218 1,423 1,419 Source: Word Bank 2023, based on MZ and NFZ data for 2017–2021. 102 Inpatient care in the social sector accounts for 45 percent of total annual social sector LTC spending, whereas health sector inpatient care is only 14.5 percent of the total health sector LTC spending. When out-of-pocket payments are included, the share of inpatient care in the social sector increases to 49.7 percent and 15.6 percent in the health sector. Home care spending represents 10 percent of total annual LTC spending in the social sector, compared to 8.1 percent in health (Figure 35).  LTC inpatient care users (DPS, ZOL/ZPO) and home Figure 35.  care users as a percentage of total user population and total spending in both sectors Inpatient care Home care 29.0% 15.8% 20.0% 10.5% 13.2 Beneficiaries/ 9.5 patients as % of all LTC users Social sector Health sector Social sector Health sector 45.0% Financing (without 30.5 10.0% 8.1% 14.5% 1.9 copayments) as % of total annual LTC costs Social sector Health sector Social sector Health sector 49.7% Financing with 15.6% 34.1 copayments as % of total annual LTC costs Social sector Health sector Source: World Bank 2023, based on MRPiPS, MZ and NFZ data for 2021. 103 FINANCING IN THE SOCIAL SECTOR A. INPATIENT CARE In 2021, the total spending on DPS services was PLN 3,834.3 million, and the RDP budget envelope was PLN 6.0 million. DPS facilities account for most of the inpatient care provision in Poland with more than 86,000 residents in 2021, while as of 2021, there were just 44 RDPs in Poland, with 327 inpatient beds and 322 residents. Table 7 reports the breakdown of spending on DPS services and user counts by region. Out-of-pocket payments are not included. DPS service count and spending in 2021 Table 7.  (excluding out-of-pocket payments) DPS FACILITIES Poland REGION FACILITIES BEDS RESIDENTS PER 100,000 827 POPULATION facilities Dolnośląskie 60 5,815 6,213 215.4 Kujawsko-Pomorskie 46 3,982 4,503 219.2 Lubelskie 46 4,526 4,651 222.9 beds 80,783 Lubuskie 23 2,245 2,367 236.0 Łódzkie Małopolskie 55 91 6,193 8,122 6,634 8,761 273.4 257.0 residents 86,483 Mazowieckie 93 9,461 9,607 177.3 residents Opolskie 29 3,082 3,354 344.6 per 100,000 population 226.6 Podkarpackie 52 4,899 4,892 231.2 Podlaskie*64 23 2,378 2,410 (2,625*) 206.1 (224.5*) total annual Pomorskie Śląskie 41 98 4,093 8,705 4,414 9,642 188.1 215.6 spending, PLN, billion 3.83 Świętokrzyskie 34 3,270 3,609 296.3 annual Warmińsko-Mazurskie 41 3,708 4,011 284.3 spending Wielkopolskie 63 6,419 6,985 200.1 per resident, 44,200 Zachodniopomorskie 32 3,886 4,430 263.4 PLN Poland 827 80,784 86,483 226.6 Source: World Bank 2023, compilation based on MRPiPS-05 data for 2021. Note: * Bracketed figures are those including the regional DPS facility in Podlaskie, however these figures are not those used in national calculations. 64 Calculations in brackets include Podlaskie DPS. Resident count was estimated as the sum of resident count reported on December 31 (199) and the number of people who died in this DPS in the reporting year (16). However, nationwide calculations for Poland did not include the regional DPS from Podlaskie because the exact number of residents from this DPS is unknown and not relevant for nationwide calculations. 104 B. DAY CARE In 2021, total spending on OW services was PLN 1,867.45 million, and total spending on shelters for people experiencing homelessness that also provide care services was PLN 31.1 million, out-of-pocket payments are not included. The majority of OW support people with mental health conditions or operate as day care homes. The use of these services has seen a decline since 2017. Like other care settings, there is substantial regional variation in the use of these services. Mazowieckie leads in the number of OWs currently in operation, whereas Podlaskie, Opolskie, and Lubuskie not only have the lowest count of OW facilities, but they also reported a sizable decrease in the number of OW beneficiaries over the five years between 2017 and 2021 (Podlaskie by 43.8 percent, Lubuskie by 43.3 percent, Opolskie by 27.2 percent), evidencing the high regional variation in OW dynamics (Figure 36). OW service count and spending in 2021 Figure 36.  (excluding out-of-pocket payments) 14 000 600 12 000 500 users per 100,000 population beds, facilities, users 10 000 400 8 000 300 6 000 200 4 000 2 000 100 0 0 Dolnośląskie Kujawsko-pomorskie Lubelskie Lubuskie Łódzkie Małopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Śląskie Świętokrzyskie Warmińsko-mazurskie Wielkopolskie Zachodniopomorskie facilities users beds per 100,000 population POLAND 2,471 users per total annual annual spending facilities users 100,000 spending, PLN, per resident, PLN population billion 85,955 beds 104,928 275 1.87 17,800 Source: World Bank 2023, based on MRPiPS-03, MRPiPS-06 for 2021. 105 C. HOME CARE Although there has been a decrease in the number of services, LGU spending on basic care services went up by 24 percent between 2017 and 2021. In 2021, total LGU spending on basic services, excluding specialized care services, was 672.8 million: a 24 percent increase since 2017 (see Figure 37). The increase was mainly driven by salary and minimum wage increases, while the growth in service use volume played a much smaller role. On average, PLN 6,375.9 was spent per service user in 2021, with significant regional variation: from PLN 4,252.7 in Śląskie to PLN 9,746.4 in Świętokrzyskie (Table 8). Out-of-pocket payments are not included in these figures. Total number of and total cost of basic services (UO) in Figure 37.  the social sector 50 000 000 800 000 000 45 000 000 700 000 000 40 000 000 600 000 000 35 000 000 500 000 000 Services 30 000 000 25 000 000 400 000 000 PLN 20 000 000 300 000 000 15 000 000 200 000 000 10 000 000 100 000 000 5 000 000 – – 2017 2018 2019 2020 2021 Total Services Total Cost of Services Source: World Bank 2023, based on 2021 MRPiPS-03 data. 106 Services and spending in the category of basic care Table 8.  services (excluding specialized services) in 2021, (excluding out-of-pocket payments) 2021 BASIC SERVICES ONLY REGION OPS/CUS OPS/CUS UNITS USERS USERS PER TOTAL ANNUAL UNITS WHICH WHICH DO NOT 100,000 ANNUAL SPENDING PROVIDE PROVIDE SUCH POPULATION SPENDING, PER USER SUCH SERVICES PLN, PLN SERVICES MILLION Dolnośląskie 158 11 8,849 306.8 48.29 5,456.8 Kujawsko-Pomorskie 134 10 6,987 340.1 40.80 5,839.1 Lubelskie 181 32 5,150 246.8 35.65 6,922.3 Lubuskie 80 2 3,210 320.0 15.73 4,901.8 Łódzkie 142 35 6,432 265.0 33.62 5,227.2 Małopolskie 175 7 7,133 209.3 46.18 6,473.7 Mazowieckie 285 47 13,168 243.0 73.00 5,543.8 Opolskie 61 10 2,814 289.1 16.40 5,826.3 Podkarpackie 140 20 4,864 229.9 34.87 7,168.3 Podlaskie 83 35 2,168 185.4 14.22 6,556.9 Pomorskie 116 7 7,413 316.0 48.57 6,552.0 Śląskie 146 21 10,275 229.7 43.70 4,252.7 Świętokrzyskie 86 16 3,674 301.6 35.81 9,746.4 Warmińsko-Mazurskie 115 1 5,593 396.5 43.05 7,696.7 Wielkopolskie 211 15 12,084 346.1 102.56 8,487.0 Zachodniopomorskie 107 6 5,716 339.8 40.42 7,071.1 Poland OPS/CUS units OPS/CUS users per total annual annual which provide units which users 100,000 spending, PLN, spending per basic services do not provide population million user PLN basic services 2,220 275 105,530 276.5 672.84 6,375.9 Source: World Bank 2023, based on MRPiPS-03 for 2021. In 2021, total spending on specialized services in Poland was PLN 29.3 million, 32.8 percent more than in 2017. Figure 38 presents the costs of specialized services over 2017–2021. Similar to service volume, spending figures have been quite varied from one region to another, ranging from PLN 0.2 million in Podlaskie, Opolskie, Lubuskie 107 to PLN 5.6 million in Mazowieckie. Higher total spending in Mazowieckie and Kujawsko-Pomorskie has been driven by greater service supply in those regions. In contrast, the highest unit costs are observed in the regions with relatively low service supply (Podlaskie, Warmińsko- Mazurskie) – see Table 9. These figures do not include out-of-pocket payments. Total number of and total cost of specialized services Figure 38.  (UO) in the social sector, 2017–2021 1 500 000 35 000 000 1 450 000 30 000 000 1 400 000 25 000 000 1 350 000 20 000 000 Services PLN 1 300 000 15 000 000 1 250 000 10 000 000 1 200 000 5 000 000 1 150 000 – 2017 2018 2019 2020 2021 Total Services Total Cost of Services Source: World Bank 2023, compilation based on 2021 MRPiPS-03 data. Services and spending in the category of specialized Table 9.  care, 2021 (excluding out-of-pocket payments) 2021 SPECIALIZED SERVICES ONLY OPS/CUS OPS/CUS USERS USERS TOTAL ANNUAL UNITS UNITS WHICH PER 100,000 ANNUAL SPENDING WHICH DO NOT POPULATION SPENDING, PER USER, PROVIDE PROVIDE PLN, MILLION PLN SUCH SUCH SERVICES SERVICES Dolnośląskie 19 150 281 9.7 1.10 3,907.8 Kujawsko-Pomorskie 22 122 597 29.1 4.65 7,794.1 Lubelskie 30 183 273 13.1 1.69 6,194.1 Lubuskie 5 77 27 2.7 0.22 8,194.2 Łódzkie 10 167 91 3.7 0.25 2,749.8 Małopolskie 36 146 230 6.7 2.02 8,773.0 Mazowieckie 36 296 1363 25.1 5.59 4,102.4 108 2021 SPECIALIZED SERVICES ONLY OPS/CUS OPS/CUS USERS USERS TOTAL ANNUAL UNITS UNITS WHICH PER 100,000 ANNUAL SPENDING WHICH DO NOT POPULATION SPENDING, PER USER, PROVIDE PROVIDE PLN, MILLION PLN SUCH SUCH SERVICES SERVICES Opolskie 7 64 154 15.8 0.24 1,585.6 Podkarpackie 17 143 80 3.8 0.78 9,802.6 Podlaskie 3 115 13 1.1 0.21 16,092.0 Pomorskie 29 94 258 11.0 1.18 4,558.9 Śląskie 45 122 1310 29.3 4.37 3,337.1 Świętokrzyskie 10 92 179 14.7 1.51 8,456.1 Warmińsko-Mazurskie 6 110 59 4.2 1.05 17,869.1 Wielkopolskie 24 202 329 9.4 2.32 7,064.2 Zachodniopomorskie 10 103 302 18.0 2.06 6,831.6 Poland OPS/CUS OPS/CUS users per total annual annual units which units which users 100,000 spending, PLN, spending per provide do not provide population million user PLN specialized specialized services services 309 2,186 5,546 14.5 29.26 5,276.5 Source: World Bank 2023, compilation based on MRPiPS-03 for 2021. In 2021, total spending on specialized services for persons with mental health conditions was PLN 148.38 million, a 34.8 percent cost increase compared to 2017. More recently the trend has seen an increase of 10.1 percent between 2019 and 2021. The total cost of specialized services granted to persons with mental health conditions and delivered in a home-based setting has been quite low, though nearly three times higher than the value of general specialized services. The cost has also declined slightly (by 2.1 percent) during the five-year period of analysis. Most regions saw a decline in the number of people using this type of service over this period. This trend can be attributed to a shortage of properly trained staff, lack of diagnoses, and gaps in mental health infrastructure at the local level. The average annual cost per user in Poland was PLN 10,362 (Table 10), and the highest per user spending was reported by Lubuskie, Dolnośląskie, and Podlaskie, which 109 have relatively low service supply. Out-of-pocket payments are not included. Services and spending in the category of specialized Table 10.  services for people with mental health conditions, 2021 (excluding out-of-pocket payments) SPECIALIZED SERVICES FOR PEOPLE WITH MENTAL HEALTH CONDITIONS REGION OPS/CUS OPS/CUS UNITS USERS USERS PER TOTAL ANNUAL UNITS WHICH WHICH DO NOT 100,000 ANNUAL SPENDING PROVIDE PROVIDE SUCH POPULATION SPENDING, PER USER, SUCH SERVICES PLN, MILLION PLN SERVICES Dolnośląskie 75 94 459 15.9 7.04 15,334.9 Kujawsko-Pomorskie 141 3 2405 117.1 28.25 11,745.1 Lubelskie 82 131 763 36.6 7.29 9,549.1 Lubuskie 17 65 62 6.2 1.08 17,374.2 Łódzkie 25 152 143 5.9 1.74 12,168.4 Małopolskie 91 91 810 23.8 8.78 10,838.1 Mazowieckie 162 170 1436 26.5 9.05 6,299.0 Opolskie 42 29 554 56.9 6.00 10,828.7 Podkarpackie 127 33 1342 63.4 11.31 8,426.7 Podlaskie 52 66 342 29.2 5.04 14,736.5 Pomorskie 100 23 1507 64.2 18.91 12,549.0 Śląskie 75 92 748 16.7 6.86 9,171.4 Świętokrzyskie 68 34 1405 115.3 9.84 7,003.7 Warmińsko- 35 81 491 34.8 5.54 11,272.9 Mazurskie Wielkopolskie 124 102 1389 39.8 17.66 12,713.6 Zachodniopomorskie 46 67 463 27.5 4.01 8,663.5 Poland OPS/CUS OPS/CUS units users per annual total annual units which which do not provide specialized provide specialized users 100,000 spending, PLN, spending per services for mental services for mental population million user PLN health conditions health conditions 1,262 1,233 14,319 37.5 148.38 10,362.3 Source: World Bank 2023, compilation based on MRPiPS-03 for 2021. 110 Additional programs that were made available during the five-year period of analysis include the following: ‘Personal assistant for the disabled’ and ‘Personal assistant z  to a person with disability’: In 2019–2022, more than 22,700 people with disabilities were supported from the resources of the ‘Personal assistant for the disabled’ program.65 In 2023, the two programs supported 1,401 municipalities and counties with a total of PLN 517 million,66 of this amount, 147 NGOs received a total of PLN 104 million.67 The Respite Care program: Following a slower than planned z  disbursement period in the first two years of the program, disbursements ramped up in 2021 and the target was exceeded – PLN 60.3 million versus the planned PLN 50 million – demonstrating a high degree of interest in the program. In 2023, 1,043 applications were approved for a total value of PLN 153.46 million.68 Another program, the ‘Respite care for caregivers of persons with disabilities’, supports caregivers of children with a certified disability, and caregivers of persons with a significant degree of disability or an equivalent certification. Between 2021–2023, PLN 88.141 million was allocated to the program. In 2023, funding under the program was granted to 77 NGOs for a total value of PLN 55 million.69 65 Ministerstwo Rodziny, Pracy i Polityki Społecznej. Personal Assistant Services As Social Support For Disabled People. KPS.430.11.2022 Nr ewid. 149/2022/P/22/033/KPS. https://www.nik.gov.pl/plik/ id,27418,vp,30233.pdf. 66 Ministerstwo Rodziny, Pracy i Polityki Społecznej. Lista rekomendowanych wnioskóww ramach programu MRPiPS "Asystent osobisty osoby niepełnosprawnej" ” [Personal assistant for a person with a disability] ‐ edycja 2023. https://niepelnosprawni.gov.pl/download/lista-wnioskow-rekomendowanych-aoon-edyc ja-2023-13.12.2022-1670945132.pdf. 67 Lista zatwierdzonych ofert w ramach Programu „Asystent osobisty osoby z niepełnosprawnościami” [Personal assistant for a person with a disability] – edycja 2023. https://niepelnosprawni.gov.pl/download/ lista-zatwierdzonych-ofert-aoozn-edycja-2023- 68 Lista rekomendowana wniosków Wojewodów na środki finansowe z Programu "Opieka wytchnieniowa" [Respite care] – edycja 2023. https://niepelnosprawni.gov.pl/download/lista-wnioskow-rekomendowanych- ow-edycja-2023-13.12.2022-1670945150.pdf. 69 Ministry of Family and Social Policy. “Respite Care for Caregivers to Persons with Disabilities.” https://zazyciem.gov.pl/strona/12314-opieka-wytchnieniowa-dla-opiekunow-osob-z-niepelnosprawnoscia. 111 FINANCING IN THE HEALTH SECTOR A. INPATIENT CARE Public spending on ZOL/ZPO facilities increased by 59.3 percent between 2017 and 2021. In 2021, total spending on inpatient LTC services in the health sector reached PLN 1.24 billion (Figure 39). This contrasts with a relatively small increase in patient volume of 5.5 percent over the same period 2017–2021. Out-of-pocket payments are not included. ZOL/ZPO services and spending, 2021 Figure 39.  (excluding out-of-pocket payments) 7000 180 users per 100,000 population 160 6000 beds, facilities, users 140 5000 120 4000 100 3000 80 60 2000 40 1000 20 0 0 Dolnośląskie Kujawsko-pomorskie Lubelskie Lubuskie Łódzkie Małopolskie Mazowieckie Opolskie Podkarpackie Podlaskie Pomorskie Śląskie Świętokrzyskie Warmińsko-mazurskie Wielkopolskie Zachodniopomorskie facilities users beds (year-end, 2020) per 100,000 population Poland beds 31,898 users per total annual annual spending (year-end, 100,000 facilities spending, PLN, billion per resident, PLN 2020) population 461 45,178 users 118.64 1.24 27,400 Source: World Bank 2023, NFZ for 2021. 112 B. HOME CARE Total expenditure increased by 10 percent over the period of analysis. The NFZ spent PLN 404.78 million on home-based nursing care in 2021, which is 10 percent more than in 2017, even though the population of service users shrank over the period. The top changes in spending were reported by Podlaskie (up 33.3 percent), Łódzkie (up 31.1 percent), and Lubelskie (up 28.1 percent). At the national level, unit cost (per user) was PLN 6,675, a 15.8 percent increase over the five-year period, and the biggest increases were once again reported by Podlaskie and Łódzkie. Out-of-pocket payments are not included (Table 11). Home-based nursing care: services and spending, 2021 Table 11.  (excluding out-of-pocket payments) HOME-BASED NURSING CARE REGION FACILITIES USERS PER 100,000 TOTAL ANNUAL ANNUAL POPULATION SPENDING, SPENDING PER PLN, MILLION USER, PLN Dolnośląskie 150 3,628 126.0 22.54 6,212 Kujawsko-Pomorskie 66 2,030 99.1 13.31 6,558 Lubelskie 70 3,550 171.0 23.92 6,737 Lubuskie 52 1,255 125.6 8.63 6,876 Łódzkie 75 3,106 128.5 18.80 6,054 Małopolskie 117 4,935 144.8 33.03 6,693 Mazowieckie 205 6,715 123.9 47.29 7,042 Opolskie 83 2,852 294.2 17.55 6,152 Podkarpackie 156 5,490 260.1 37.57 6,843 Podlaskie 29 1,336 114.7 8.58 6,422 Pomorskie 27 1,196 51.0 6.90 5,771 Śląskie 153 13,710 307.7 99.85 7,283 Świętokrzyskie 47 2,410 198.8 15.26 6,332 Warmińsko-Mazurskie 53 1,561 111.1 8.93 5,721 Wielkopolskie 134 4,514 129.4 27.56 6,105 Zachodniopomorskie 45 2,351 140.2 14.16 6,022 Poland facilities users users per 100,000 total annual spending, annual spending population PLN, million per user PLN 1,462 60,639 159.2 404.78 6,675 Source: World Bank 2023, compilation based on NFZ data for 2021. 113 In 2021, spending on home-based ventilation services for adults was PLN 250.9 million, a 28.6 percent increase compared to 2017. This was likely driven by the increase in the number of patients using the service, as the unit cost per patient decreased by 15.6 percent during this period. The information in Table 12 does not include the additional financial allocation for children and adolescents (under 18), which totaled PLN 36.78 million in 2021, so the average unit cost was PLN 47,030. Out-of- pocket payments are not included. Home-based mechanical ventilation: services and Table 12.  spending, 2021 (excluding out-of-pocket payments) HOME-BASED MECHANICAL VENTILATION SERVICES FOR ADULTS REGION FACILITIES USERS PER 100,000 TOTAL ANNUAL ANNUAL POPULATION SPENDING, SPENDING PER PLN, MILLION USER, PLN Dolnośląskie 7 764 26.5 27.75 36,321 Kujawsko-Pomorskie 6 558 27.2 20.80 37,284 Lubelskie 8 682 32.9 22.65 33,216 Lubuskie 3 251 25.1 7.24 28,835 Łódzkie 6 204 8.4 7.18 35,205 Małopolskie 9 1,202 35.3 30.13 25,068 Mazowieckie 12 761 14.0 19.17 25,197 Opolskie 5 165 17.0 5.38 32,578 Podkarpackie 5 419 19.9 12.66 30,211 Podlaskie 7 171 14.7 7.01 40,970 Pomorskie 3 208 8.9 8.39 40,324 Śląskie 17 1,242 27.9 34.01 27,385 Świętokrzyskie 9 289 23.8 8.66 29,969 Warmińsko-Mazurskie 10 336 23.9 11.67 34,747 Wielkopolskie 10 688 19.7 20.09 29,196 Zachodniopomorskie 15 180 10.7 7.43 41,284 Poland facilities users users per 100,000 total annual spending, annual spending population PLN, million per user PLN 132 8,116 21.3 250.94 30,919 Source: World Bank 2023, based on NFZ data for 2021. 114 FINANCING OF CASH BENEFITS Out of the total pool of cash benefits, seniors and persons with disabilities accounted for 72 percent of the total spending and 28 percent was disbursed to caregivers of persons with disabilities. In 2021, a total of PLN 16.88 billion was spent on cash benefits. Top spending lines were the nursing supplement (PLN 6.94 billion) and nursing allowance (PLN 2.35 billion) in the category of cash benefits payable to seniors and to persons with disabilities; and caregiver benefit (PLN 4.460 billion) in the category of cash benefits payable to caregivers. Cash benefits: recipients and spending by category, 2021 Table 13.  CLIENTS AND CAREGIVERS: TOTAL OF 4.1 MILLION PEOPLE Client population Caregiver population Total: 3,956,000 Total:  221,700 � Nursing supplement: 2,482,300 � Caregiver benefit:  191,000 � Nursing allowance: 911,600 � Special caregiver allowance:   21,900 � Supplementary benefit: 388,200 � Allowance for the caregiver:  8,800 � Permanent allowance: 173,900 CLIENTS AND CAREGIVERS: TOTAL OF PLN 16.88 BILLION Spending on clients Spending on caregivers Total:  PLN 12.19 billion Total:  PLN 4.69 billion � Nursing supplement:  PLN 6.94 billion � Caregiver benefit:  PLN 4.46 billion � Nursing allowance:  PLN 2.35 billion � Special caregiver allowance: PLN 0.16 billion � Supplementary benefit:  PLN 1.95 billion � Allowance for the caregiver: PLN 0.06 billion � Permanent allowance:  PLN 0.948 billion Source: World Bank 2023, based on MRPiPS and ZUS data for 2021. EU financing for LTC High spending on the nursing supplement and the caregiver benefit is driven by the large size of the population eligible to collect these (partly complementary) cash benefits. As for the amount spent on the caregiver benefit, it is linked to eligible population size and the benefit amount, which is set at the net minimum wage in Poland (Table 13). EU FINANCING FOR LTC Financing for LTC in Poland is also supported by various EU funds. The EU’s cohesion policy, supported by the ERDF and ESF, aims to address economic, social, and territorial disparities among member states. An analysis of projects funded during the 2014–2020 programming period revealed that the EU supported 1,076 LTC-related projects with a total value of PLN 1.64 billion, contributing to about 73 percent of the projects’ total value. Of the total funds for projects from the ERDF and ESF, 80 percent were financed from the ESF while the ERDF financed the other 20 percent (Figure 40). Figure 41 presents the total project value and the share of subsidies per each EU fund. Further analysis based on operational programs in place during 2014– 2020 indicates that by the end of 2023, owing to support from the EU funds, almost 142,000 people at risk of poverty or social exclusion were provided with care or assistance services, and over 90,500 places were supported where social services are provided. Over 1.4 million people were covered by the health program thanks to the ESF, and almost 321,500 people at risk of poverty or social exclusion benefited from support through a health service project. Because the implemented support focused on increasing the supply of social services, including their deinstitutionalization, and increasing access to health services, no definition of LTC was defined. For this reason, it is not possible to indicate exactly how many people were covered by this form of support. Publicly available documents regarding the next programming period in 2021–2027 show that approximately EUR 4 billion will be available in subsidies for care-related activities, particularly those covering long- term care. Although the estimated amount is only indicative, it can be noted that the scale of available funds can significantly complement national funds. 116 Breakdown of EU-funded projects (count and share of Figure 40.  total), by ERDF and ESF funding source, 2014-2020 863 projects (80%) 213 projects (20%) ERDF ESF Source: World Bank 2023, based on the database of EU-funded projects.70 Figure 41. Total value of projects and the amount of EU subsidies 1 000 000 000 897,000,272 900 000 000 760,456,382 800 000 000 741,894,462 700 000 000 600 000 000 PLN 500 000 000 441,310,569 400 000 000 300 000 000 200 000 000 100 000 000 0 total value of projects value of EU subsidy ERDF ESF Source: World Bank 2023.71 70  European Funds Portal. Portal Funduszy Europejskich. List of projects implemented from European Funds in Poland in 2014–2020. Lista projektów realizowanych z Funduszy Europejskich w Polsce w latach 2014- 2020. https://www.funduszeeuropejskie.gov.pl/strony/o-funduszach/projekty/lista-projektow/lista- projektow-realizowanych-z-funduszy-europejskich-w-polsce-w-latach-2014-2020/ 71 Source: Own compilation based on the database of EU-funded projects. Sourced from European Funds Portal List of projects implemented from European Funds in Poland in 2014–2020. https://www.funduszeeuropejskie.gov.pl/strony/o-funduszach/projekty/lista-projektow/lista-projektow- realizowanych-z-funduszy-europejskich-w-polsce-w-latach-2014-2020/. 117 KEY CHALLENGES AND SOLUTIONS FOR LTC IN POLAND In Poland, the system of LTC spans sectors, levels of government, care settings, programs, and funding sources; despite this complexity, there are six thematic solution areas that have been identified as having potential to improve the LTC system at large. The previous section aimed to provide an overview of the components of the broader system of LTC in Poland, including a description of benefits, the different organizational levels of benefit provision, the settings of care, and geographic variation in LTC services. This section also provided a light-touch description of human resources and financing for LTC. A deep dive on these two specific themes is provided in the following sections of the report, along with the other thematic challenge areas facing LTC in Poland. These challenges are described, and applicable solutions are proposed UNDERSTANDING CHALLENGES AND DEVELOPING SOLUTIONS The objective of the report is to identify recommendations that are necessary for Poland to address the identified key challenges facing LTC through the strategic review. These challenges therefore form the structure of this report, and are Governance, Financing, Human Resources, Quality, Private Sector, and Infrastructure. The key challenges facing LTC in Poland have been identified from three key sources: the experiences and perceptions of stakeholders in the LTC system; a systems-level analysis of LTC; and through the identification of challenges by national policymakers. The first and 118 fundamental source is the perspective of care recipients (patients, beneficiaries) and their families, as well as employees and people involved in the benefit system’s organization and delivery. To capture the opinion of these stakeholders, a survey was carried out in a representative sample of Poland’s adult population, in addition to qualitative research among various groups of LTC recipients, as well as social consultations. The second source for identifying LTC challenges in Poland is an analysis of various elements of the long-term care system in Poland using a systematic tool developed by the World Health Organization (WHO), and an analysis of available data on LTC in Poland.72 This assessment of LTC focuses on the areas of management frameworks, sustainable financing, information, monitoring and evaluation (M&E) systems, human resources, service provision innovation, and scientific research (Table 14). The next phase of this work is to define action plans for solutions, and the associated human resource and investment needs associated with their achievement. Therefore, this report does not seek to conduct feasibility analyses for each solution area. 72 WHO (World Health Organization). 2021. Framework for Countries to Achieve an Integrated Continuum of Long-Term Care. Geneva: World Health Organization. 119 National framework for achieving an integrated Table 14.  long-term care continuum in Poland, based on WHO guidelines, 2021 AREA NOT AVAILABLE PARTIALLY FUNCTIONAL FULLY FUNCTIONAL Governance (27 layers) 19/27 7/27 1/27 Sustainable Financing (8) 2/8 5/8 1/8 Information, Monitoring 8/18 3/18 7/18 and Evaluation Systems (18) Workforce (9) 2/9 6/9 1/9 Service Delivery (11) 8/11 2/11 1/11 Innovation and 13/14 1/14 0/14 Research (14) Source: World Bank 2023. While recent progress has been made in overcoming challenges around LTC, several areas require further improvement and solutions. Those that require building almost from basic levels are marked in red, those requiring further development are orange, and those already in operation, needing enhancement and further improvement are green. The most intensive areas include activities such as improving the components of an efficient LTC governance system, strengthening a data collection system, monitoring, building up a scientific base, as well as implementing elements for an efficient, coordinated system of LTC services. Detailed questions on which this assessment was based are included in an appendix to this report, along with a detailed description of methodology and data sources in the Methodology section in the appendix. 120 The third level of analysis centers around the main LTC objectives forwarded by the Ministry of Development Funds and Regional Policy (Ministerstwo Funduszy i Polityki Regionalnej, MFiPR) with the cooperation of MZ and MRPiPS: coordination and integration, deinstitutionalization, and human resources development, which were used to appraise and categorize several challenge areas. Based on these analytical processes and consultations, this report has comprehensively assessed the LTC system in Poland and presents the critical challenges facing its development. The three focus areas of reforms and the respective solutions are outlined below. Coordination/Integration: This reform area aims to achieve a strategic and integrated approach to care provision and governance. Person- centered care, that is conducive to independent living, is hampered by fragmentation between different sectors. Integrated and coordinated care should ensure that people move seamlessly through the continuum of care, and that care is adequately provided across a continuum of care needs, which includes integrating informal, home and community-based care, and, as needed, residential care. A coordinated system of care is also required to support the transition from institutionalized forms of care to community-based systems.73 The proposed solutions that address improved coordination, among others, include creating a unified body of LTC regulations; defining transparent eligibility for access to all types of care; mapping LTC resources and needs; designating LTC coordinators; developing data sharing agreement and LTC data collection legislation; conducting M&E of interventions that inform coherent strategic planning; developing analytics of service provision and demand; employing public awareness campaigns; coordinating the financing and legislation for LTC programs pursued by the government; and while the private sector is already 73 European Commission. 2022. Communication from the Commission to the European Parliament, the Council, The European Economic and Social Committee and the Committee of the Regions on the European Care Strategy. Brussels, 7.9.2022. https://eur-lex.europa.eu/legal-content/EN/TXT/ PDF/?uri=CELEX:52022DC0440 121 involved, ensuring those activities are coordinated, managed, and assessed more effectively. Labor market: LTC is a human resource intensive service, therefore the system hinges on adequately provided, well-trained, and supported caregivers. In many advanced economies,74 population aging has been outpacing the growth of the LTC supply. In these settings, the level of the workforce in LTC has stagnated or declined, even in countries where the LTC supply is typically higher.75 Poland’s population is one of the most rapidly aging in the EU,76 and with an already low supply of LTC workers, demand is projected to continue to far outstrip supply. Responding to this trend will require solutions that help attract, retain, and strengthen the LTC labor market, while measures are also needed to support informal caregivers and minimize disruption to their labor market status. LTC also necessitates more than just personal care, often requiring engagement in complex care tasks. Proper training, certification, and support is therefore imperative to ensure high-quality care. The proposed solutions that seek to address labor market development in Poland include increasing the remuneration of workers; boosting prestige through educational campaigns and financial and nonfinancial benefits; protecting workers against abuse; facilitating access to upskilling and training; and strengthening the provision and quality of informal caregiving through several holistic measures. Deinstitutionalization: Across the EU, hundreds of thousands of people living with disabilities, mental health problems, or in old age live in large segregated residential institutions.77 Evidence now shows that this type of care setting fails to deliver on providing person-centered care that 74 More than half of OECD countries. 75 OECD. 2021. “Long-Term Care Workers.” Health at a Glance: OECD Indicators. https://www.oecd-ilibrary.org/ sites/c8078fff-en/index.html?itemId=/content/component/c8078fff-en 76 Eurostat. “Population Structure and Ageing.” https://ec.europa.eu/eurostat/statistics-explained/index. php?title=Population_structure_and_ageing#:~:text=Regarding%20the%20share%20of%20 people,%25)%20had%20the%20lowest%20shares. 77 European Expert Group on the Transition from Institutional to Community-based Care. 2012. “Common European Guidelines on the Transition from Institutional to Community-Based Care.” https://deinstitutionalisation.com/wp-content/uploads/2017/07/guidelines-final-english.pdf 122 fulfils people’s right to inclusion, particularly by limiting people’s access to their communities.78 Strengthened community and home-based care options can therefore ensure individual well-being by offering care where its preferred. The proposed solutions that address deinstitutionalization include mapping existing LTC resources; conducting M&E of interventions, particularly those promoting deinstitutionalization; enhancing planning efforts toward deinstitutionalization, such as accelerating the development and implementation of local deinstitutionalization plans that support the enhanced delivery of local services; strengthening health literacy; implementing performance-based financing that can support the development of high-quality care with a focus on noninstitutional care; and developing housing solutions that support aging at home and in their communities. Several of the solutions outlined in this report address all three reform areas and seek to improve the existing system of care provision. An LTC legal act or amending the relevant acts of law forwards all three reform goals by defining the entitlements of individuals to various forms of care across different settings, defining informal caregivers, and ensuring coordination between actors across the continuum of care by clarifying roles and responsibilities. LTC coordinators too address all reform areas by supporting families access needed care services of all kinds, including day and home care, and by better coordinating a complex care system. Financing solutions – increasing financing from the state budget, conducting a Public Expenditure Review (PER), examining funding optimization and the use of financial mechanisms by the public, ensuring financing is allocated sufficiently and sustainably to different care settings, and regions are supported in pursuing recommended LTC interventions—is necessary for all reform goals. For example, deinstitutionalization will require 78 Ibid. 123 investment into the system by augmenting different types of care provision. Labor market development will be enhanced through increased staffing, training and benefits, and other retention activities. Investment will also be required to engage in the various coordination activities, including mapping care services and demand. Finally, quality solutions aim to secure the well-being, safety, and outcomes of care recipients. This has cross-cutting implications for deinstitutionalization, labor markets and coordinating care activities in line with quality outcomes. Assessing patients and their families’ opinions on LTC helps drive the quality vision forward, while conducting M&E of care provision using an integrated quality framework holds providers and decision- makers to account. Table 15 provides an overview of these challenges and classifies the solution area(s) applicable for each. Table 15. Key issues for LTC and solution areas NO. IDENTIFIED ISSUE LTC REFORM AREAS COORDINATION/ DEINSTITUTIONA- EMPLOYMENT/ GOVERNANCE INTEGRATION LIZATION LABOR MARKET There are multiple legal acts, 1. a complicated system of services, and ✕ a lack of a consistent definition of LTC. There are multiple definitions and levels of 2. ✕ eligibility criteria and dependency definitions. Current and future demands for LTC 3. ✕ ✕ ✕ services are challenging to estimate. There are opportunities to improve data collection, enhance the consistency of data formats, 4. regularly update the availability of detailed, ✕ comprehensive information and research, and improve M&E of LTC interventions. There is variation in care service 5. ✕ ✕ ✕ provision across regions. There is a limited understanding of LTC services and 6. ✕ ✕ how to access them from clients and their carers. 124 COORDINATION/ DEINSTITUTIONA- EMPLOYMENT/ FINANCING INTEGRATION LIZATION LABOR MARKET Expenditures on LTC are low compared 7. to other EU countries, with disparities ✕ ✕ ✕ in spending across levels of care. Sustainability of governmental 8. ✕ ✕ ✕ programs should be increased. COORDINATION/ DEINSTITUTIONA- EMPLOYMENT/ HUMAN RESOURCES INTEGRATION LIZATION LABOR MARKET There is variation in the availability and distribution 9. ✕ ✕ ✕ of personnel within and between sectors in Poland. The competences of select LTC 10. ✕ ✕ personnel need to be expanded. Informal care should be regulated and 11. maximized to improve the provision ✕ ✕ and quality of this type of care. COORDINATION/ DEINSTITUTIONA- EMPLOYMENT/ QUALITY INTEGRATION LIZATION LABOR MARKET The quality of formal care provided by 12. individual carers, care organizations and ✕ ✕ ✕ the care system should be increased. COORDINATION/ DEINSTITUTIONA- EMPLOYMENT/ INFRASTRUCTURE INTEGRATION LIZATION LABOR MARKET The housing market situation for seniors and persons with disabilities is inadequate, and there 13. ✕ is insufficient adaptation of housing for those in need and at risk of needing LTC in the near future. COORDINATION/ DEINSTITUTIONA- EMPLOYMENT/ PRIVATE MARKET INTEGRATION LIZATION LABOR MARKET Public institutions providing LTC fail to tap the potential of the private market; 14. ✕ and regulations and oversight of private care providers need improvement. PRIORITIZATION OF LTC SOLUTIONS This report proposes a comprehensive catalogue of policy solutions to the key challenges facing LTC in Poland. As part of the analysis, the World Bank has assessed the solutions in terms of their priority and sequence, based on surveys and consultations with stakeholders as well as discussions with national-level authorities. Among the basket of solutions, there is a subset that should be pursued immediately in terms of their high priority, impact on other solution areas, and feasibility. Solutions focused on a unified LTC definition, increased 125 financing, and development of an LTC quality framework are the three key areas to be implemented in the immediate future and seen as feasible for completion by 2026 (Table 16). A list of proposed solutions for the next 10 years, including recommendations for implementation in the next 2 years can be found in Table 17. Table 16. First phase solution areas and justification THEMATIC AREA SOLUTION REASONING Governance Create a unified body of LTC regulations, Developing appropriate and unifying LTC legislation will including an LTC definition or have an enormous impact across the LTC system and amend the relevant acts of law. many of the solution areas. It lays the foundation for common understanding of entitlements and operation of the LTC system across sectors and providers. Financing Increase LTC financing in Additional financing will be needed to increase the state budget. access to and quality of the LTC services. Human Develop a definition for Defining informal caregiving is resources informal caregiving. a critical first step in providing support and developing policies for this group. Quality Appoint an expert team to develop Specifying the quality of LTC is a cross-cutting area an LTC quality framework and KPIs. that will influence the well-being, safety, and health outcomes of those receiving care. Improving quality can also range from low-cost (if not free interventions), such as improving communication with care recipients and their families to more demanding solutions such as intensifying care (which would require more staff). Importantly, however, quality must be outlined to set a standard for LTC provided today. Include LTC quality definition, framework, Once quality and efficiency indicators are and KPIs in the relevant LTC acts of law. developed, they must be enshrined in the legal framework to become binding. *Emboldened solutions are those with highest priority The report has organized the solution areas by three phases for their implementation. First phase actions are foundational and can be achieved over a nearer time horizon (feasible for completion by 2026), they are denoted by the first phase column in Table 17. These are imperative for setting the foundations for further reforms. Financing and legislation are two enabling factors that allow the pursuit of other solution areas in this report, including human resource reforms, increasing access to services, and promoting coordination across the 126 system. These areas enhance the effectiveness of the existing system while paving the way for further reforms in the future. Quality is an area that must be pursued in parallel to ensure that no matter the service, care is being provided in a safe, effective manner that meets its goals. Similarly, private market and housing solutions enhance existing measures and are feasible in the near term. The second phase solutions are those that also have a shorter implementation time frame but should be pursued after or once the first phase activities have been commenced (feasible for completion by 2029). The third phase solution areas will require a medium-term implementation timeline (feasible for completion by 2031) and are informed by other activities that must be completed or are underway first. While a completion date can be set for some activities, they must be revised, updated, and maintained thereafter. Phases denoted here are not sequentially exclusive and can be begun in a staggered manner; for example, some activities of the third phase can begin in parallel with earlier phases but it must be noted that they are likely to take longer to implement and require some foundational elements to be established from earlier phases. The next step should be to develop specific action plans that outline the costs, human resources, implementing agency and time frame for the solution implementation. These activities should be done in a cross- sectoral manner. Table 17. Implementation phase for each solution area THEMATIC FIRST SECOND THIRD SOLUTIONS AREA PHASE PHASE PHASE GOVERNANCE Create a unified body of LTC regulations, including an LTC definition, 1 ✕ or amend the relevant acts of law. Define transparent eligibility criteria for access to LTC services and 2 programs for all users, with due consideration for various levels of care ✕ (that is, inpatient/residential, home and community care). Map LTC facilities at the local level, with a view to allowing 3 information sharing on LTC facilities operating in health and social ✕ sectors. Designate LTC coordinators e.g.at OPS/CUS and expand the role of 4 ✕ select PHC coordinators as contact persons for LTC matters. 127 THEMATIC FIRST SECOND THIRD SOLUTIONS AREA PHASE PHASE PHASE GOVERNANCE Develop template data sharing agreements for ministries, LGUs, and 5 ✕ service providers. Revise existing acts to ensure appropriate and coordinated LTC data 6 ✕ collection policies and guidelines in place. Ensure that the M&E of programs supporting LTC, including those 7 supported by EU funds, informs LTC interventions by identifying what ✕ has been successful and aligned with national and regional needs. Develop an interactive dashboard with demographic, care demand, 8 ✕ and service provision analytics for each region (voivodeship). Accelerate the development and implementation of plans (for 9 example, local deinstitutionalization plans) that support the ✕ enhanced delivery of local services. Ensure that strengthening communication and access to information 10 ✕ on LTC is part of the LTC coordinator’s role. Ensure effective public outreach using an awareness-building 11 campaign, a national government website, and local government ✕ websites. Continue to enhance the health literacy of the public regarding the needs of the aging population and persons with disabilities and 12 ✕ availability of care and LTC service offerings to raise awareness using available communication tools. FINANCING 1 Increase LTC allocation in the state budget. ✕ Conduct a PER to evaluate the effectiveness of public finances for LTC 2 and propose budgetary solutions to ensure the fiscal sustainability of ✕ the system. Ensure sufficient LTC funding at different service delivery levels (for example, central, regional, local) and at different service delivery settings (home, daycare and inpatient), including the possibility to 3 introduce publicly funded vouchers, managed at local government ✕ levels as demand-side subsidies to targeted groups, giving the opportunity to purchase LTC services on a well-regulated, private market. Introduce support mechanisms for LGUs which commit to develop 4 ✕ LTC interventions and follow strategic directions. Evaluate the existing copayment arrangement and prepare to implement a revised copayment mechanism for LTC services to 5 ✕ generate additional revenue without putting financial strain on vulnerable populations. Provide incentives and encourage the use of tools for individuals who are willing to plan for future LTC needs through health-related 6 ✕ investments and voluntary financial investments, such as savings, insurance, and similar schemes. Coordinate the financing and legislation for LTC programs pursued by 7 ✕ the government. Provide multiyear funding for LTC initiatives to ensure stability for 8 ✕ planning and resource allocation. Create feedback loops connecting LTC funding and performance 9 assessments; reward quality, excellence, and responsiveness in the ✕ context of evolving needs. 128 THEMATIC FIRST SECOND THIRD SOLUTIONS AREA PHASE PHASE PHASE HUMAN RESOURCES Ensure, where appropriate, that remuneration of LTC workers is raised 1 to support the supply of workers for care continuity across service ✕ settings. Incentivize LTC facilities to rely on complementary sources of labor— 2 ✕ migrants, family caregivers, NGOs. Step up efforts intended to standardize and formalize the profession 3 ✕ of medical caregiver. Boost prestige and attractiveness of care work—for example, through outreach campaigns, education, additional packages of nonfinancial 4 ✕ incentives such as mental health support, physiotherapy options, occupational courses/training, and professional development. Implement protection measures for care providers from violence and 5 ✕ abuse in all its forms. Facilitate access to upskilling and training for the LTC workforce, formulate a skills framework and career paths, and offer career 6 ✕ advancement and promotion mechanisms based on a common skills framework and rotation between LTC roles and settings. 7 Develop a definition for informal caregiving. ✕ Facilitate informal caregiving and mitigate negative labor market 8 consequences for carers, including family members, through pension ✕ credits, tax credits, work flexibility, and job guarantees. Provide financial and nonfinancial support for informal caregivers, 9 including family members, such as, care vouchers, education and ✕ training, physiotherapy, mental health support, and respite care. Introduce temporary and transition care to give families who have elected to become caregivers time to adjust their work patterns, 10 ✕ become trained in care, and adapt the home to the LTC beneficiary’s needs. QUALITY Appoint an expert team to develop an LTC quality framework and 1 ✕ KPIs in the relevant LTC acts of law. 2 Include LTC quality definition, framework and KPIs in the LTC law. ✕ Launch a national M&E mechanism applicable to LTC providers, 3 ✕ facilities, and organizations. Introduce user-engagement surveys to assess the experiences of 4 ✕ patients and their families within the LTC system. Create a publicly accessible database reporting the KPIs of public and 5 ✕ private LTC providers. Employ technological solutions to enhance data management 6 potentially with the real-time use of data, and to improve beneficiary ✕ care and LTC outcomes. Promote scientific research on LTC to improve services and the 7 ✕ system. 129 THEMATIC FIRST SECOND THIRD SOLUTIONS AREA PHASE PHASE PHASE INFRASTRUCTURE Continue the development of the housing stock for people with 1 ✕ disabilities and seniors. Continue regulating design standards for buildings and dwelling 2 units intended for people with disabilities and those intended for ✕ seniors; ensure that digital technologies and solutions are included. Extend greater financial support for home adaptations and access to assistive services and digital technologies to give seniors and people 3 ✕ with disabilities who prefer to live in their home an option to stay at home as long as possible. Collaborate with LTC coordinators (e.g., OPCS/CUS) to conduct 4 a needs analysis and help people to access funding for home ✕ adaptations. Conduct regular diagnostics of housing needs in local contexts and 5 manage the housing stock with due consideration for community ✕ needs. Align the planning processes to local conditions, access to transport 6 ✕ links and amenities—including social life, shopping, and health care. PRIVATE MARKET Routinely update a database of all (public and private where possible) 1 care services, including available capacity to facilitate searches of ✕ places and to make good use of supply. Give LTC coordinators access to the LTC facility database to enable 2 them to advise their clients about new openings and service ✕ availability. Improve and operationalize oversight and control mechanisms 3 applicable to private institutions in line with the requirements set out ✕ in quality standards for private and public providers. Continue to promote public-private and nongovernmental 4 ✕ partnerships and information sharing. The following sections of the report are organized according to the challenge areas that have been identified across sectors as critical for development of the LTC system in Poland. These areas have been determined through a triangulation of analysis of stakeholder perceptions, an analysis of the system, and dialogue with national-level policymakers Further, background research on ‘International examples of long-term care systems’ has been conducted to inform the solution areas of the report. This can be found in Appendix 5 to this report. For each critical area, there are one or more challenges outlined with solutions for each. This report was prepared with the support of the MZ, MRPiPS and commissioned by the MFiPR, as such, many of the 130 solutions pertain to these ministries for their action and implementation. However, others – notably those under Financing, Infrastructure, Private Market – will require involvement and leadership of other ministries and public agencies. Finally, the solution areas and challenges outlined in the next sections of the report are not entirely independent or distinct from one another. Certain challenges require more than one solution, for example, shortages of LTC staff requiring solutions pertaining to financial and nonfinancial incentives. While, other solutions, such as establishing LTC coordinators, address more than one challenge area. Hence, the following sections of this report set the challenge areas as an organizing principle for the purpose of this report, but with this limitation that some sections may be repetitive or are informed by earlier analyses in the report. 131 GOVERNANCE LONG-TERM CARE DEFINITION, A.  LEGAL ACTS, AND SYSTEM OF SERVICES This solution area seeks to address the lack of a consistent definition of LTC, multiple legal acts, and the complicated system of services. The challenge of delivering LTC in Poland is made increasingly complex due to multiple definitions, a complicated services system, variety of services provided, and numerous legal acts. This area is vital as definitions and legislation set the foundation for improving measures across several of the recommendations of this report. The lack of a single, consistent definition of LTC at the legislative level in Poland contributes to the complexity and fragmented nature of services. Variation in definitions for LTC has knock-on effects for the cohesiveness and clarity of the informational, legal, organizational, and financial aspects of LTC services. In the health-care sector, LTC services are defined as services provided to adults and children who are chronically ill but do not require hospitalization and require professional nursing, medical treatment, and rehabilitation.79 However, in the social system, which provides most of the services outside of health-care system, there is no clear definition of LTC.80 This creates ambiguity around the services’ scope and eligibility criteria for what we consider long-term care. The LTC services system in Poland is highly complicated and fragmented, with services dispersed across health care and social 79 Ministry of Health. Opieka długoterminowa w Polsce. https://analizy.mz.gov.pl/app/mpz_2020_dluga. 80 A somewhat simplified wording of LTC definition is included in a document entitled, “Senior Long-Term Care in Poland,” issued by the Ministry of Family and Social Policy in 2018, that is as follows: “all medical or social services that involve long-term nursing, therapies or personal care for chronically ill or dependent persons who do not require hospitalization.” Ministry of Family, Labor and Social Policy. Opanka długoterminowa nad osobami starchy w Polsce. https://archiwum.MRPiPS.gov.pl/download/gfx/mpips/pl/ defaultaktualnosci/5530/10219/1/opieka%20nad%20osobami%20starszymi.pdf. 132 care. This complexity is exacerbated by the availability of multiple types of monetary and in-kind benefits for both LTC recipients and caregivers of the elderly or persons with disabilities. In total, in 2021, there were seven different types of monetary benefits available, of which four were targeted to LTC recipients (nursing supplement, nursing allowance, supplement benefit, permanent allowance), and three to caregivers (care benefit, special care allowance, caregiver allowance). In-kind benefits included more than 20 types of services delivered both as part of the health-care system and social system – for example, DPS, OW, ZOL, ZPO, care services, and different governmental programs (see Figure 8 in the section ‘Long-term care system in Poland’). Efficient management and coordination between different benefits remains to be established. The LTC system in Poland is governed by many legal regulations. Two acts that are of particular importance for LTC in Poland are the Act of March 12, 2004, on Social Services81 and the Act of August 27, 2004, on Publicly Funded Health Care Services.82 The first Act falls within the competence of the MRPiPS and the other one within the MZ. LTC in Poland is also regulated by additional legislative acts, with a total of 70 additional regulations – 68 in force and two under development83 (Figure 42). Acts of law are perpetually changed, updated, and new ones are enacted, while others are abrogated.84 There are also many other documents discussing the development of LTC at the country level, including (among others) Healthy Future: Strategic framework for the development of the health care system for the years 2021-2027, with a perspective until 2030 and Annex No. 1 to this document in the form of a document entitled Deinstitutionalization strategy: health care for the elderly; the National Recovery and Resilience Plan (Krajowy Plan 81 Act of March 12, 2004, on social assistance. https://isap.sejm.gov.pl/isap.nsf/download.xsp/ WDU20040640593/U/D20040593Lj.pdf. 82 Act of August 27, 2004, on health care services financed from public funds. 83 A full list of all acts can be found in the appendix to this report. 84 World Bank commissioned survey, 2023. 133 Odbudowy i Zwiększania Odporności [KPO]), integrated strategies (‘Human Capital Development Strategy 2030’) and other documents such as the ‘Strategy for the development of social services, public policy until 2030 (with an outlook until 2035)’, or the ‘Strategy for People with Disabilities 2021–2030’.  Additional acts of law concerning LTC in Poland Figure 42.  (that is, excluding the Act on Social Welfare Services and the Act on Publicly Funded Health Care Services) Health care acts 28 Social care acts 23 Announcements and recommendations of the AOTMiT 14 Recommendations of the European Council 1 Others 2 Source: World Bank 2023, based on legislation review.  The limited alignment between self-government strategies and LTC needs remains a challenge. Not all local governments action plans are aligned with LTC requirements, such as establishing new care facilities in the health and social sectors, or measures aimed at adapting to the needs of persons with disabilities. No clear reporting system was found that would clearly connect numerous strategies with competitions for projects financed from EU funds. Analyzed strategic documents are static in nature, that is, they do not enable in-depth management analysis.85 The establishment of LTC regulations, therefore, plays a crucial role in addressing the inherent challenges stemming from the absence of a consistent definition for long-term care, coupled with the 85 World Bank commissioned survey, 2023. 134 ensuing lack of clarity within LTC services. The Act on LTC should primarily have a defining and coordinating function. Given the current legal regulations, it would not have to be the only document concerning the operation of LTC institutions, but rather a guidance document, linking institutions operating in both systems and setting basic—common—definitions. The level of detail and comprehensiveness of the law is dependent on the will of the bodies drafting it. The key element of the Act on LTC should be a definition of long-term care, applicable across both systems. This definition should be aligned with the definition provided by the Council of the European Union,86 or by the Social Protection Committee87 but it would encompass all LTC- related activities and services available in both health care and social care systems. Critical in this regard is the decision of the bodies drafting the Act as to which benefits and services, according to the definition adopted, are to be included or excluded from the LTC system – for example, cash benefits, pharmacological treatment, hospice and palliative care, and medical devices. Elements included in the long-term care definition in EU countries can be found in the International Examples as an appendix to this report. This Act should define, endorse or modify existing definitions for critical LTC stakeholders: caregivers and beneficiaries. Regarding system beneficiaries, those eligible for services can be identified in 86 Council Recommendation of December 8, 2022, on access to affordable high-quality LTC (2022/C 476/01): “Accessible, affordable and high-quality long-term care allows people in need of care to maintain autonomy for as long as possible and live in dignity. It helps to protect human rights, promote social progress and solidarity between generations, combat social exclusion and discrimination and can contribute to the creation of jobs." 87 Long-Term Care Report (2021). Trends, challenges and opportunities in an aging society. Social Protection Committee: "Long-term care is defined as a range of services and assistance for people who, due to mental and/or physical disability and/or disability lasting for a long period of time, depend on assistance for everyday activities and/or are in difficult life situation and require constant nursing care. Activities of daily living that require assistance may include self-care activities that a person needs to perform every day (activities of daily living, or ADLs, such as bathing, dressing, eating, getting in and out of bed or sitting on a chair, ambulation, toileting, and bladder and bowel control) or may be related to independent living (instrumental activities of daily living, IADL, such as preparing meals, managing money, shopping for groceries or personal items, performing light or heavy activities ) housework and using the telephone). 135 detail in the Act on LTC, or by the Act on LTC referring to specific laws defining those eligible for types of benefits applicable under each system. The Act should also define informal caregivers, including family caregivers. This latter definition is important because of the benefits and support channeled to this group—monetary (transfers, tax credits) and nonmonetary (respite care). It is possible to formulate a general definition in the Act on LTC, with references to specific provisions in various acts governing access to benefits, or ordinances regulating other forms of support such as respite care or nursing leave. The second function of the Act should be the coordination of services. To this end, the Act should indicate the types of institutions and types of benefits and services that are part of the long-term care system. In doing so, the Act could refer to laws governing both sectors. One important coordinating element would be to also designate bodies at the national level and, if possible, at the regional and local (municipal) levels, responsible for collecting information on the services provided, monitoring the demand, planning activities, and coordinating the provision of LTC services. Another element of the Act should address the issues related to quality management in LTC. As for existing standards, the Act may refer to existing regulations where these standards are established – for example, regarding equipment and minimum number of staff in relation to the number of patients/service recipients. In the case of areas where standards are not defined, such as care services, minimum guidelines in this regard can be formulated in the Act on LTC or in respective pertinent laws, for example, the Act on Social Assistance. It is also important to indicate at the statutory level the principles and method of measuring and monitoring the quality of LTC. However, detailed recommendations and guidelines may be specified in the relevant regulations 136 Matters concerning the financing of services may be included in the Act on LTC with reference to existing regulations in this matter. In contrast, specific changes in financing may be stipulated separately in Acts regulating the health and social sectors. The advantage of enacting the Act on LTC is that it would simultaneously tackle several of the problems addressed in the report: the issue of harmonizing definitions, introducing guidelines oriented toward improving the quality of services or supporting formal caregivers. There are many added benefits associated with the enactment of a new Act on LTC, such as strengthening cooperation between the health, social care, and senior policy sectors; increasing formal coordination of LTC management at the central and local levels; increasing coordination of the management of the various elements of the LTC; and defining a quality framework, accelerating the deinstitutionalization process, and reducing the fragmentation of care in line with the National Recovery Plan milestone: A69G. At the same time, depending on its comprehensiveness, the Act might not replace the solutions enshrined in sector regulations, but rather organize them, ensuring greater transparency of the LTC system, improved coordination, and quality of services. One alternative to enacting a single Act on LTC would be through incremental amendments to existing legislation in the health and social sectors. While one overarching LTC law would be beneficial for coordination purposes, with sufficient attention to clarity and harmonization of language, the same outcome could be achieved by amending the various existing Acts. This would require a holistic process of amendment of the existing legislation, ensuring that the various Acts speak to each other and clarify roles, without causing confusion. Such a solution would still have to address the various components that should be included in the LTC law (and elucidated in the previous paragraphs). As part of the development of an LTC law or amending existing legislation, Table 18 presents four key categories of 137 factors: strengths, weaknesses, opportunities, and threats (SWOT) that will influence this process. Table 18. SWOT analysis for enactment of Act on LTC in Poland STRENGTHS WEAKNESSES There is a supportive culture around the �  LTC planning and reform requires �  LTC reform agenda in the government. coordination between several government There are legal acts that set a precedent �  agencies which can add complexity. and foundation for a single Act on LTC. There are difficulties in selecting an institution �  There is strong alignment between Poland’s LTC �  responsible for coordinating work on the Act. reform agenda and that proposed by partners, There is also additional workload that �  including the EU, therefore there is already scope representatives of the health and aid and examples of this type of LTC legislation. ministries will be required to complete. OPPORTUNITIES THREATS Reforming the LTC system is broadly supported by �  Multiple stakeholders involved in the policy �  the public, hence a new Act should be a positive making and implementation of the LTC. signal on the government’s commitment to its Lack of coordination between stakeholders. �  aging population and is unlikely to face backlash. Long legislative process. �  There is available EU financing to propel LTC �  initiatives, such as those making progress on deinstitutionalization, that the Act will facilitate. GOVERNANCE SOLUTION 1: Create a unified body of LTC regulations, including an LTC definition, or amend the relevant acts of law. key area(s) addressed: coordination/Integration  LIGIBILITY CRITERIA FOR CARE B. E ACCESS The challenge brought about by multiple levels of eligibility criteria in the delivery of LTC in Poland is a significant issue. The issue stems, among others, from the lack of uniform and clear definitions for crucial terms such as ‘disability’, ‘dependency’, and ‘incapable of independent living’. These terms are used interchangeably and with varying 138 interpretations, creating inconsistency and confusion within the LTC system. In the health sector, no regulatory definitions for ‘disability’ and ‘dependency’ exist, although they are present in social sector terminology. The terms "disability" and "dependence" are not separately defined in health care regulations because they do not directly refer to the medical conditions that determine qualification for a specific type/ scope of health services and only the fulfillment of such conditions should constitute the basis for obtaining a specific health care provision.  xisting Definitions for Dependent Individuals or Persons with Disabilities Box 1. E According to the Act on Vocational and Social Rehabilitation and Employment of Persons with Disabilities,88 disability is defined as a permanent or temporary loss of social function due to permanent or long-term bodily impairment, rendering the person unable to work. A person with a disability is defined as someone facing permanent or temporary difficulties, restrictions, or inabilities related to social functions, particularly regarding gainful employment, provided they hold a relevant certificate. The Act on Supplementary Benefit for Persons without Independent Living89 states that the supplementary benefit is payable to adult individuals who cannot live independently, as established in a certificate that indicates complete loss of independent living, total inability to work and live independently, total inability to work on a farm and live independently, or total inability to serve and live independently. In the Act on Retirement and Disability Pensions,90 individuals with bodily dysfunction of such severity that they require continuous or long-term care and assistance with their activities of daily living are certified as unable to live independently. Also, the Act on Vocational and Social Rehabilitation and Employment of Persons with Disabilities defines ‘loss of independent living’ as bodily dysfunction of such severity that the affected person cannot satisfy their basic living needs, including self-care, mobility, and communication. 88 Act of August 27, 1997, on vocational and social rehabilitation and employment of persons with disabilities. https://isap.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=wdu19971230776. 89 Act of July 31, 2019, on supplementary benefits for people unable to live independently. https://sip.lex.pl/  akty-prawne/dzu-dziennik-ustaw/swiadczenie-uzupelniajace-dla-osob-niezdolnych-do- samodzielnej-18885415. 90 Act of December 17, 1998, on pensions and annuities from the Social Insurance Fund. https://sip.lex.pl/  akty-prawne/dzu-dziennik-ustaw/emerytury-i-renty-z-funduszu-ubezpieczen-spolecznych-16832385. 139 A contributing challenge to better defining eligibility criteria is amending the existing disability certification system. Currently, in Poland, disability can be assessed by (a) powiat teams for assessment of disability, as the first review; (b) voivodeship (regional) teams for assessment of disability, as the second review; and (c) district labor and social security courts, as a reporting body controlling the correctness of certifications granted by the teams. At present, assessments of disability are done by a multidisciplinary team and over multiple reviews; however, the majority of those consulted believe that this system needs to be placed under the purview of a single authority and that a distinction between disability and dependence needs to be made in assessments. Formal determination of assessing disability or the degree of disability is, as a rule, established in two review proceedings. The decision panel is attended by at least two specialists, including one physician. The second member of the panel may be a pedagogue, psychologist, social worker, career counselor, or other doctor. A disability certification is issued at the request of the interested party. A person may be granted a certificate of mild, moderate, or severe disability depending on the opinion of the panel. “Under the current state of law, health status assessment is not the only determinant of disability, as disability certification considers physical, mental, and social aspects of a person’s life. Therefore, presence of only one of the elements, for example, impairment of bodily functions (commonly equated with illness), does not necessarily mean that there is a disability. Moreover, the intensity of this factor does not directly affect the established disability or degree of disability if no significant limitations are caused in the person’s social or professional life because of its occurrence.”91 But public consultations commissioned by the World Bank revealed that 59 percent of participants believe the disability 91 Office of the Government Plenipotentiary for Disabled People. 2023. Unstitched Orzekające – procedury Orleanian, tryb i zasady. https://niepelnosprawni.gov.pl/art,13,instytucje-orzekajace-procedury-orzekania- tryb-i-zasady. 140 certification system needs to be changed. Among these participants, 74 percent think that a single institution with authority for providing LTC services in both the health care and social systems should be responsible for certification. Additionally, 54 percent of respondents believe that disability and dependency risks should be separated from each other (Figure 43). Should there be a change in the way dependency/ Figure 43.  disability of persons requiring LTC is certified? 8% No If so, how should it be accomplished? 74% A single certifying agency with influence over LTC dependency risk Separation of disability risk from 59% 54% 33% dependency risk No opinion Yes Source: Online survey – complementary to social consultations, World Bank 2023. Public consultations suggested that there needs to be improved accuracy and definition of the care needs of an individual, the certification system needs to be transparent and simplified, and determination of needs should be viewed by both sectors. Participants in the public consultations emphasized that the certification method should not only indicate the degree of disability but should also consider and accurately identify the care needs of a person with a disability and provide appropriate solutions. The certification system was deemed too convoluted and, according to the respondents, incapacity to work and disability were evaluated differently. The Barthel scale used for the care needs assessment 141 should be supplemented with the risk of neurodegenerative disorders (for example, Alzheimer disease) and an assessment of mental health. Apart from the disability certificate, the different eligibility criteria for benefits (both monetary and in-kind) also pose a challenge. Different cash benefits are granted by different authorities in specific groups of recipients. So too is the case with nonmonetary services, such as institutional, home, or day care. As individuals are defined in their eligibility at different intersections with benefits and sectors, it creates confusion for beneficiaries and providers on their entitlements. It leads to varying interpretations and potential gaps in the assessment of individuals’ eligibility for LTC services. This lack of clarity and consistency can hinder the equitable and effective delivery of LTC services in Poland, highlighting the need for a standardized and clear framework to address this challenge. Eligibility criteria need to be defined in correspondence with a needs assessment process and aligned with the different levels of care needs. Eligibility criteria used in other countries are shown in the appendix to this report: the International Examples of Long-term Care Systems, specifically from Germany, the Netherlands, Japan, Canada, and Denmark. The establishment of clearly defined eligibility criteria for LTC services and programs holds substantial potential for addressing coordination and integration issues in the LTC system. Transparent eligibility criteria play a pivotal role in ensuring that LTC services remain accessible to individuals who need it. Better defined eligibility criteria can translate to more efficient resource allocation as care providers and policy makers can deploy resources based on standardized criteria. Care can also be streamlined and coordinated across diverse care providers, thus working toward a system of patient-centered care. This empowers clients and patients to transition between varying care levels or providers without encountering abrupt shifts in eligibility standards. Eligibility criteria also support the patient in understanding their entitlement and improve the transparency of the benefit allocation system, including establishing a legal framework for the protection of 142 patients’ rights. This, in turn, will allow quality benchmarks to be designed in congruence with standardized eligibility criteria. Having clear eligibility criteria can also support the development of policies across sectors, including for example, determining people’s entitlements to financing support for housing adaptations. Better definitions of eligibility can make the process more efficient, and promote the provision of timely and pertinent care, while a transparent and easy to understand system of eligibility criteria inculcates confidence among diverse stakeholders, encompassing patients, families, care providers, and policy makers. GOVERNANCE SOLUTION 2: Define transparent eligibility criteria for access to LTC services and programs for all users, with due consideration for various levels of care (that is, inpatient/residential, home and community care) key area(s) addressed: coordination/Integration CURRENT AND FUTURE LONG-TERM C.  CARE DEMAND AND SUPPLY This solution area seeks to address issues in estimating current and future demands for LTC services. This cross-cutting challenge area undermines even the best strategic planning efforts. Knowing who needs care, where they are, and what type of care is required is a prerequisite for ensuring adequacy and accessibility of the LTC system, i.e., what and how much to supply. As the population continues to age, predicting future care demands is vital for allocating financial, human and physical resources. 143 Analyses of current and projected future demands for LTC services require strengthening. The challenge of estimating the current and future demands for LTC services in Poland is a complex issue. As Europe is aging, the demand for long-term care is rising. On average, 30.9 percent of people aged 65 or over living in private households required long-term care, according to the EU-22 2019 data.92 The number of people in the EU in need of long-term care is projected to increase from 30.8 million in 2019 to 38.1 million in 2050.  While it is difficult to precisely predict the likelihood of an individual in Poland needing LTC, considering the high prevalence of noncommunicable diseases, the demand is expected to be significant. Accurate projections are necessary to ensure that the country can adequately address the growing need for LTC services. Current estimates suggest that at least half a million people in Poland require LTC annually. In 2021, there were 432,035 patients receiving LTC services in Poland, of which the number of recipients in the social sector was nearly three times as high as those receiving LTC care in the health sector. Based on the number of persons who received LTC services in 2021, it should be assumed that at least half a million people will receive LTC annually. However, the 2023 survey commissioned by the World Bank suggests that the number could be even higher, with seven percent of adults in Poland (about 2.2 million) declaring that they are currently receiving care or assistance due to their health conditions, and this assistance is primarily provided by close family members who do not receive financial compensation (Figure 44). 92 European Commission and Social Protection Committee. (2021). Long-Term Care Report. Trends, Challenges and Opportunities in an Ageing Society. Available online: https://www.socialserviceworkforce. org/resources/long-term-care-report-trends-challenges-and-opportunities-ageing-society 144 Persons receiving selected LTC services in 2021 (as Figure 44.  a number and percentage of the adult population) Clients/patients using the public LTC 1.4% ; 432,035 (2021) system (social and health sectors together) Clients/patients using the private LTC 1% ; 20,894 (2021) system (for inpatient care) Survey respondents who declare that they use help from family/close ones due to 7.0% ; 2,155,062 (2023) their health condition Source: World Bank 2023. Although demand for LTC is more complex than just people living longer, based on current age and gender dynamics, care needs are projected to increase. Average life expectancy may be one of the key factors influencing the demand for LTC services, with regions with lower life expectancy and fewer elderly people (Figure 45) expected to have lower demand.93 However, the correlation between these factors and LTC use does not always match expectations, as regions with low life expectancy can also report a high demand for LTC services.94 93 World Bank. 2015. “The Present and Future of Long-term Care in Ageing Poland.” Policy Note for the Purposes of Long-Term Care Policy, 19. https://das.mpips.gov.pl/source/opiekasenioralna/Long%20term%20 care%20in%20ageing%20Poland_ENG_FINAL.pdf. 94 Ibid. 145 Share of the elderly in the population versus average Figure 45.  life expectancy Male life expectancy at birth Female life expectancy at birth 14.9% 20.2% 72.7 14.3% 80.1 20.5% 16.4% 22.4% 70.8 79.4 71.5 15.3% 15.0% 79.2 21.7% 21.5% 71.5 80.5 71.3 78.9 21.7% 15.4% 14.5% 71.6 21.4% 20.3% 80.0 15.3% 72.1 79.0 79.6 70.5 16.8% 24.6% 70.6 15.6% 23.1% 79.0 22.8% 16.4% 71.3 79.5 71.4 16.3% 17.0% 79.5 23.8% 22.6% 23.0% 72.4 16.7% 71.6 80.0 80.4 71.3 14.6% 78.9 14.6% 20.3% 20.4% 72.7 80.6 73.5 81.0 >= 72.2 >= 80.2 71.5 – 72.2 79.6 – 80.2 71.3 – 71.5 79.2 – 79.6 < 71.3 < 79.2 Percentage of men aged 65 and above Percentage of women aged 65 and above Source: World Bank 2023, based on GUS data 2023. Even with discrepancies between demographics and care demands, the number of hours of care required is still partly a function of gender and age. Projections show that the average number of hours needed, based on current gender and age derivations, will increase from 10.5 per month in 2022 to 13.2 hours per month in 2050 (Table 20). It also demonstrates significant regional variation: for instance, a man over 85, living in the northern region of Poland may need about 2 hours of care per day (around 63 hours per month), whereas a man of the same age would require less than a third of that amount in the northwestern region (19 hours per month). In 2030, there will be 10 percent more people over 50 years (an additional 1.5 million people) than in 2022, and the number of hours per month will increase by 6 percent. While it is not feasible to model the underlying drivers of the care demand at this level, the regional variation suggests other 146 elements influencing care demand beyond age and gender. Another key factor is the variations in disease pattern by geography, which is another critical element for tailored solutions. To provide care for these additional people, a 17 percent increase in the number workers providing home care will be needed compared to today, in absolute terms about 5,100 more workers.95 Table 20 shows the projected demand for care through 2060. Demand for care, in average monthly hours of care per Table 19.  person, by Poland’s NUTS196 regions in 2019 (definition of regions – GUS 2013) CENTRAL SOUTHERN EASTERN NORTHWESTERN SOUTHWESTERN NORTHERN REGION (PL1) REGION (PL2) REGION (PL3) REGION (PL4) REGION (PL5) REGION (PL6) Men 50–64 0.6 7.2 3.8 8.9 16.1 9.0 Men 65–74 4.9 12.3 10.7 11.1 7.4 14.7 Men 75–84 5.7 28.0 15.2 23.5 4.7 20.4 Men 85+ 44.2 32.5 38.6 19.0 35.6 62.7 Men 6.0 10.9 7.9 11.6 12.5 16.3 Women 1.4 3.5 2.4 3.3 3.4 3.6 50–64 Women 4.8 6.1 4.1 8.5 1.2 8.1 65–74 Women 10.8 40.5 30.1 10.5 5.2 33.6 75–84 Women 85+ 61.8 65.5 66.5 68.9 27.3 42.1 Women 8.1 10.9 14.9 12.4 4.4 12.3 Total 7.2 10.9 11.8 12.1 8.0 14.1 Source: World Bank 2023, based on the Survey of Health, Ageing and Retirement in Europe (SHARE) 2019. 95 Calculation methodology: currently there are approximately 30,000 long-term home care workers (22,000 in health care and 7,000 in social care). The increase in the 50+ population between 2022 and 2030 is 10 percent (14.370 million versus 15.824 million). At the same time, the percentage difference in the number of hours delivered is 6 percent (11.1:10.46 h). 1.1 x 1.06 = 1,166, or about 17 percent more workers. 96 Nomenclature of territorial units for statistics, Nomenclature des Unités territoriales statistiques (NUTS) 1 is the largest subnational territorial unit, above there is the 'national' level. 147 Projected demand for monthly hours of care by Table 20.  Poland’s NUTS1 regions in 2022–2060 (definition of regions – GUS 2013) REGION 2022 2030 2040 2050 2060 Central region Men 4.3 4.1 5.2 5.9 6.9 PL1 Women 8.7 8.6 10.7 11.3 12.9 Total 6.8 6.7 8.2 8.9 10.3 Southern region Men 12.2 13.0 13.4 14.3 15.9 PL2 Women 14.6 16.6 18.2 19.4 22.8 Total 13.5 15.0 16.0 17.1 19.7 Eastern region Men 8.5 8.9 9.7 10.8 11.9 PL3 Women 12.3 13.5 15.6 17.1 19.9 Total 10.6 11.5 12.9 14.2 16.3 Northwestern region Men 11.5 12.4 12.4 12.9 14.0 PL4 Women 10.4 10.3 13.2 14.4 15.8 Total 10.9 11.2 12.8 13.7 15.0 Southwestern region Men 12.7 12.4 13.6 12.9 12.7 PL5 Women 4.7 4.8 6.0 6.1 6.6 Total 8.2 8.2 9.4 9.2 9.3 Northern region Men 13.8 14.2 15.7 16.9 18.4 PL6 Women 12.1 13.8 14.8 15.7 18.1 Total 12.8 14.0 15.2 16.2 18.2 Average number of required hours per 10.5 11.1 12.4 13.2 14.8 month for both genders (national level) Percentage increase over — 6% 11% 6% 12% the previous period Source: World Bank 2023, based on SHARE 2019. Note: Definition based on GUS 2013. Understanding the care requirements of the population requires triangulation between different data sources and sector information, but this still provides an incomplete picture. According to the 2023 World Bank survey, when close family members provide care at home, it is often provided daily for around 1–3 hours per day. For formal care, the differences in the use of LTC services between the social and health care systems makes it a challenge to comprehensively assess their use. In the social system, 40.4 percent of people received home care, 32.9 percent of people received day care, and 26.8 percent of people received inpatient care. In the health care system, 60.6 percent of 148 patients received home care and 39.4 percent of people received inpatient care97 – see Figure 46. Comparative analysis of the number of people using Figure 46.  public sector LTC (excluding cash benefits) in 2021. 900 900 800 800 700 700 600 600 500 500 400 400 300 300 200 200 100 100 0 0 Social Inpatient Home Day Health Inpatient Home Care Care Care Care Care Care Care Number of beneficiaries (in thousands) Rate per 100,000 Total (Health and Social Sector) number of 432.0 beneficiaries (in thousands) 1,132.7 rate per 100,000 To project care needs across the population in Poland by region, more work needs to be done to understand the drivers of LTC needs. The old-age dependency ratio does not always correlate with the number of clients or patients receiving LTC services. Regional variations exist even when considering the old-age dependency rates. This makes it difficult to predict the exact demand for LTC based solely on demographic factors (Figure 47 and Figure 48). One notable dynamic in Poland is that the large gap in life expectancy at birth between genders shrinks over time. This reflects a high fatal burden, that is, years of life lost (YLL) of males and high non-fatal burden, that is, years of healthy life lost to disability (YLD) of females that have policy implications for elderly care. 97 Analysis of the number of patients receiving LTC services under the health-care system did not include the number of patients participating in the government's DDOM program, understood as home care, due to lack of access to reported data. 149 In Poland, the leading cause of YLD of females aged 80+ resulting in low health-adjusted life expectancy is dementia, which calls for special services that treat dementia patients. Therefore, gender plays a role in not only predicting the elderly shares of the population at local levels, it also informs the types of care required. This suggests that the drivers of different care needs must be considered comprehensively to assess the appropriate level and type of services to be developed. Old-age dependency ratio versus number of LTC Figure 47.  clients – social sector DEMOGR. 2021 NO. OF CLIENTS / PERSONS PER 100,000 Old-age dependency ratio Social sector, total 28.9 835.4 26.8 856.6 27.2 1251.6 30.4 927.2 28.3 964.3 28.9 677.3 28.2 710.4 26.8 838.0 822.8 28.8 806.7 33.0 785.7 873.0 30.3 30.4 32.7 1058.3 710.7 Source: World 29.6 30.8 1255.6 Bank 2023, max 26.9 max 852.1 own compila- 26.4 770.2 tion based on min min GUS 2023 data. Old-age dependency ratio versus number of LTC Figure 48.  clients – health sector DEMOGR. 2021 NO. OF PATIENTS / PERSONS PER 100,000 Old-age dependency ratio Health, TOTAL LTC (home + inpatient care) 28.9 297.3 26.8 147.21 27.2 223.43 30.4 232.63 28.3 237.29 28.9 239.32 28.2 251.77 26.8 271.02 219.94 28.8 33.0 273.16 315.5 30.3 30.4 287.7 Source: World 32.7 373.01 Bank 2023, max 29.6 30.8 455.53 451.61 max own compila- min 26.4 26.9 330.66 438.77 tion based on min GUS 2023 data. 150 Understanding service provision at the local level is essential to support planning for the efficient and targeted allocation of resources, including funding, workforce, and infrastructure development. Knowing what exists (including, for example, the list of LTC providers in the health care sector as part of the online Health Needs Map), and therefore potential gaps can help policy makers to set aside adequate funds for the expansion of LTC services, renovation of facilities, and the acquisition of necessary medical equipment. This can also enable the identification of facilities where there may be a shortage of health-care professionals, such as nurses, caregivers, and therapists. This information helps in recruiting and training the right number of personnel, which is vital to meet the growing demand for LTC services. Knowing the availability of services at local levels, authorities can also identify regions with disparities in LTC access and enhance the ability of policymakers to forecast required needs across regions once establishing robust information about baseline demand. GOVERNANCE SOLUTION 3: Map LTC facilities at the local level, with a view to allowing information sharing on LTC facilities operating in the health and social sectors. key area(s) addressed:coordination/integration, deinstitutionalization, labor market Even with several initiatives planned at regional levels, the public overwhelmingly consider access to long-term care services as having the highest importance, with many believing that existing services are insufficient. In 2023, the Regional Centers for Social Policy prepared plans for deinstitutionalization and social service development, emphasizing community-based initiatives targeting various groups, including seniors and persons with disabilities. Results from the World Bank 2023 survey conducted during public consultations show that 96 percent of respondents consider access to 151 LTC services as the most crucial measure for ensuring adequate support for the elderly and persons with disabilities. Additionally, 96 percent believe eligibility for LTC services should depend on the individual living situation and community circumstances of the dependent person. Concerning improvements to access, 78 percent of respondents suggest introducing new forms of care, followed by creating new LTC facilities, increasing staff, coordinating care services, and enhancing information about treatment processes and care options. Moreover, 91 percent of respondents advocate for improving access to equipment and technology supporting LTC, suggesting actions such as removing financial limits and expanding the list of eligible medical devices. Figure 49 shows that 65 percent of respondents believe that LTC services available in Poland are insufficient at present, and this number rises to 69 percent among respondents already using the LTC system. Thirty-six percent also negatively evaluate the access to information on receiving LTC services. These findings underline the pressing need for a more standardized and equitable approach to LTC provision, with a focus on improving access, addressing specific needs, and enhancing information dissemination. In your opinion, are the long-term care services Figure 49.  available in Poland sufficient (that is, meet the needs of people in poor health, persons with disabilities and the elderly)? 12% 12% 24% 3% 31% 3% Absolutely not 16% Probably not 21% Probably yes 41% Absolutely yes 38% I don't know, it's hard to say Respondent base: all respondents, Respondents: those who receive or deliver LTC services, n=1200. n=195 Source: Survey of a representative sample of Poland’s population, World Bank 2023.  152 Designating roles at OPS/CUS is imperative to reduce fragmentation, understand resourcing issues, and monitor progress on these areas. One of the key limitations in improving access to care and addressing care gaps at local levels is not having oversight of the varied providers and services being operated at specified levels. To assess this in a way that may inform redirection of resources and interventions requires understanding what the needs of the local-level residents are, whether those needs are being addressed by existing services, and if not, if this is because people are not aware of how to access information on available services or that they do not exist. Moving forward on these issues requires that a coordinator be in place – at least at the powiat level – who understands the LTC system and resources, can monitor and collect appropriate data, and improve information access systems to help to direct people to the right care provision. This would not require new staffing, but simply designating this responsibility as part of an existing appointment. Conceptually, the type of coordination role is not new to Poland. In primary health care, these roles have been established since October 2021. However, the role of coordinators for LTC is new and has not been formalized as part of the LTC system yet, although some LGUs have outlined this type of role in their local deinstitutionalization plans. In addition, where PHC coordinators are already in place, that is, those established in PHC as part of the PHC (POZ) Plus pilot program, they should have their role expanded to include contact with LTC coordinators to reduce fragmentation between health and social services. In other facilities where a PHC coordinator is not in place, a contact point for LTC coordination should be designated eventually. The PHC contact person is uniquely positioned to ensure improvements on care indicators, such as standardization of discharges from hospital settings. Creating a communication channel between health and social sectors will see the restoration of the social worker back into the health- care sector. The coordination between the two sectors at local levels should also promote community engagement through feedback mechanisms to help identify emerging needs and challenges, ensuring contextually sensitive care. 153 LTC coordinators understand the needs of their population and can coordinate with PHC coordinators, where they are in place, to ensure adequate information and access around LTC services. In Poland, the LTC coordinator and select PHC contact persons will play a crucial role in reducing variations in LTC service provision across their populations. They possess in-depth understanding of the unique LTC needs within their respective powiats, gminas, and health facilities enabling them to localize and customize care services to match their local population’s specific requirements. This begins with comprehensive needs assessments, delving into demographics, health profiles, and socioeconomic conditions to identify region-specific needs. Resource allocation is a central responsibility of these coordinators, and they strategically allocate resources to ensure that health-care facilities, staffing, equipment, and funding are directed to areas with the greatest need, guaranteeing that LTC services are accessible and adequate. LTC coordinators and PHC contact persons can leverage their local knowledge to develop customized solutions tailored to their region’s specific needs, while LTC coordinators can communicate strategic issues and care deficiencies to higher governance levels. GOVERNANCE SOLUTION 4: Designate LTC coordinators, e.g. at OPS/ CUS and expand the role of select PHC coordinators as contact persons for LTC matters. key area(s) addressed: coordination/Integration, deinstitutionalization, labor Market 154 D. DATA ON LONG-TERM CARE This solution area seeks to address the need to further improve collection and consistency of data related to performance, management, outcomes, and care decisions. In Poland, long-term care faces significant challenges related to poor data collection and data consistency. The publicly available databases and reports on LTC service provision lack a common denominator and format, complicating comprehensive analysis of LTC in the country. This issue hinders coordination of services, resource utilization, and future service planning, posing obstacles to effective management and decision- making in the sector.  The process for collecting data that could be used to inform strategic planning on LTC rests with several institutions in Poland; these data contain information on numbers of disabilities, population statistics, patient details, and distribution of LTC health services; however, they are not always routinely published or compatible. The main statistical office (GUS) annually collects and publishes data on population status and structure, including age cohorts such as individuals over 60 or 65 years. GUS also provides population forecasts. Additionally, the Office of the Government Plenipotentiary for Disabled People publish quarterly lists of individuals with official disability certifications or court rulings confirming disability status. This data contain detailed information on the reason for disability, age, gender, level of disability, education, and professional status. The number of people with disabilities is also collected as part of the general population census. While this data is publicly available, its usefulness is limited by the lack of consistent data standards and definitions. Regarding LTC within the health-care system, both GUS and the MZ collects data on LTC facilities. GUS offers data on inpatient LTC facilities, including the total number of facilities, beds, and patients, which is accessible to the public. MZ provides more comprehensive data that include demographic details of LTC patients, categorized by sex, age, diagnosis, care type, and service scope. 155 The ministry also collects data on the geographic distribution of LTC services. However, the ministry’s data, although updated annually, are not published in real time. Also, the Ministry of Interior and Administration (MSWiA) collects similar data but does not make the data publicly available. The MZ’s Health Needs Maps portal offers detailed information on the regional distribution of LTC health services, including inpatient, home and tele-care. Sources of health data include both MZ reporting forms and data reported to the NFZ from those under contract with the insurer.  The lack of a standardized format, unclear definitions, data duplication, and fragmentation of data across various sources, can be addressed through data sharing agreements between ministries, agencies, and care providers. First, data sharing agreements can establish a framework for the adoption of standardized data formats across all relevant entities, requiring consistent reporting of LTC data. This alignment with common definitions and variables promotes uniformity and clarity in data presentation. Concurrently, regulatory mandates can enforce unambiguous and precise definitions for LTC-related terms, minimizing the potential for misinterpretation and ensuring that reporting is unambiguous. Moreover, enhancing public accessibility to LTC data and increasing reporting frequency are integral components. Data sharing agreements can stipulate provisions for greater transparency, making LTC data accessible to the public, researchers, and policymakers. Data sharing agreements may also specify the obligation to report LTC data to international or regional databases such as those held by the OECD and Eurostat, reinforcing Poland’s role in international data sharing and benchmarking initiatives. Regulatory mandates underscore the importance of providing consistent and comprehensive data to these international bodies, ensuring that Poland’s LTC data aligns with global standards.  GOVERNANCE SOLUTION 5: Develop template data sharing agreements for ministries, LGUs, and service providers. key area(s) addressed:coordination/integration, deinstitutionalization 156 Complementary to LTC data sharing agreements, the development of appropriate regulations can support the minimization of duplication efforts and improve the collation and hosting of this data. Data sharing agreements can facilitate the consolidation of data while eliminating duplication. Data sharing agreements empower ministries, agencies, and care providers to collaborate in the creation of a central repository for LTC data. This repository serves as a single source for all LTC-related information, removing redundancies and ensuring data accuracy and currency. To facilitate this, policies and guidelines must be put in place to ensure that data can be collected and reported to this central repository, streamlining the data collection process and minimizing the need for separate data collection efforts by individual entities. This counters the issue of infrequent data updates and offers a more current perspective on LTC services. An entirely new data collection mandate and guidance does not need to be developed, existing applicable acts that allow for LTC data collection can be reviewed and amended considering these improved data sharing goals. Mandated data collection ensures regular reporting, keeping the data up-to-date and accurate. Data sharing agreements and regulatory mandates necessitate the sharing of relevant LTC data between these entities, promoting interagency cooperation and guidance on data collection and usage. This integrated approach enables a comprehensive overview of LTC in Poland, spanning population demographics, health care, social services, personnel, financing, and more. These mechanisms, data sharing agreements and data regulation, offer a comprehensive solution to the key issues and the challenges in LTC data in Poland. GOVERNANCE SOLUTION 6: Revise existing acts to ensure appropriate and coordinated LTC data collection policies and guidelines in place. key area(s) addressed:coordination/integration, deinstitutionalization 157 Data are collected on financial and human resources for LTC, but the process is disjointed, and it is difficult to delineate which resources pertain to LTC activities – this makes monitoring of LTC activities a challenge. Despite the annual availability of NFZ financial plans, it remains challenging to identify in detail cost components in LTC financing within the health-care system. MZ analyzes the cost structure associated with inpatient care and LTC home care but does not release detailed data to the public. The NFZ possesses data on individuals waiting for admission to LTC facilities, categorized into urgent and stable cases. The NFZ also has data on medical personnel employed in LTC facilities but does not share this information publicly. MZ’s Statistical Bulletin provides information on employment in LTC inpatient care, including various professional groups. The MSWiA collects staff data but does not publish the data. The Central Chamber of Nurses and Midwives (NIPiP) collects and publishes data on the number of nurses with specialist degrees in areas like long-term care nursing and qualification courses in the same field. The Center for Postgraduate Training of Nurses and Midwives annually publishes data on nurses who have earned specialist degrees in LTC and those who completed qualification courses – this data are publicly available. However, obtaining information on physicians working in long-term care is a significant challenge, as there is no medical specialization in the field of LTC, only the general number of doctors working in LTC is known. Therefore, to determine the number (or any other characteristics) of doctors practicing in the LTC field, information must be collected from various data sources including MZ reports, the Health Needs Maps website, Chamber of Physicians and Dentists, and LTC providers.  The social sector collects comprehensive data on LTC facilities and beneficiaries; however, there is neither sufficiently detailed information on workforce composition nor consistent data on financing at the state level. In the social system, GUS and the MRPiPS collect comprehensive data on LTC institutions, branches, and residents. 158 They collect clients’ rosters covering various categories, including the elderly, chronically somatically ill, chronically mentally ill, and individuals with intellectual and physical disabilities. The MRPiPS regularly publishes activity reports with detailed information on LTC residents, admissions, discharges, and funding sources. The scope of data collected reflects the tasks carried out in accordance with the provisions of the Social Services Act. But, based on this data, it is not possible to determine the exact number of clients across the sector in a single reporting year. The reports do not consider the movement of clients between different types of care. The reports also lack a breakdown of employee gender and age. The State Budget Execution Report from the Ministry of Finance (MF) provides detailed information on expenditures related to the operation of DPS and support centers, care services, and specialized care services. However, there are currently no publicly available data on state expenditures for other LTC services. GUS publishes annual reports in its ‘Family Benefits’ series, offering data on the cost of care benefits for individuals with disabilities. The Social Insurance Institution (ZUS) releases aggregate reports but does not provide detailed data to the public. Moreover, the definitions of identical or similar concepts differ. Thus, data reported by different institutions in the two systems are often not compatible with each other and do not provide a clear picture of the LTC system in Poland. International datasets collect some LTC data for comparative purposes, based on noncompatible national systems; however, they are not collected on a sufficiently frequent basis. However international comparisons can inform data collection approaches. On the international front, databases, such as those compiled by the OECD and Eurostat, offer extensive LTC indicators. Poland reports some data to these organizations, but staffing information is notably absent, as well as standardized cost data for LTC in the social sector. Eurostat collects data on various aspects of LTC services in European countries, but most of this data is collected once every five years. This infrequency makes it difficult to compare Poland against other EU countries and 159 inform national-level policy making. Aging and the related pressures on LTC are a new and increasingly important global phenomenon; as such, other countries have been compiling and updating data for LTC outcomes in their contexts. Best practices for data collection can therefore be informed by the approaches taken by other countries. For example, in the Netherlands there have been adaptations to existing care frameworks specifically for LTC settings. The use of these indicators has resulted in improvements in the delivery of long-term care, particularly among facilities with the lowest performance, providing evidence of the role of indicators in the implementation of quality improvement interventions.98 As part of the background research for the LTC agenda in Poland, a summary of ‘International Examples of long-term care systems’ has been developed and can be found in Appendix 5 to this report. The aging of the population and challenges related to good quality and appropriate LTC services poses added pressure on the additional initiatives and sources of funding, such as EU funds. Prioritization of LTC services is critical to support organizations and entities to harness their efforts and resources for the most critical areas, aligned to regional and national need; therefore, knowing what to prioritize requires proper M&E of interventions. Poland has seen quite a lot of innovation in pilots and programs designed to address different LTC outcomes, however more work is needed to understand which programs, including those financed by the EU, should be prioritized, scaled, and sustained. While M&E of programs by the EU does take place, it is difficult to ascertain what programs specifically support aging or LTC and to use the findings to inform LTC interventions. Conducting M&E of the various activities in line with what would successfully address these needs is key. More coordinated and multilevel oversight would allow for the 98 Zuidgeest, Marloes, Diana M. J. Delnoij, Katrien G. Luijkx, Dolf de Boer, and Gert P. Westert. 2012. "Patients' Experiences of the Quality of Long-Term Care among the Elderly: Comparing Scores Over Time." BMC Health Services Research 12: 1–10. 160 prioritization of these funds to the highest value and evidence-based activities—ultimately making the best use of the external financing. This would include identifying social innovations that have demonstrated promise, as these are likely to work toward solving LTC challenges fairly and efficiently, focusing on broader societal gains. Ensuring M&E of projects financed by national, regional, and EU funds focused on the goals of aging and long-term care can demonstrate impact and strengthen the design and investment case for future projects in these areas. Demonstrating the positive impact and successful execution of previously funded projects helps to build a track record of reliability and competence. GOVERNANCE SOLUTION 7: Ensure that the monitoring and evaluation of programs supporting LTC, including those supported by EU funds, informs LTC interventions by identifying what has been successful and aligned with national and regional needs. key area(s) addressed: coordination/Integration, deinstitutionalization  EGIONAL VARIATION IN STRATEGIC E. R PLANNING OF LTC DEVELOPMENT This solution area seeks to address variation in LTC development planning across regions in Poland. Regional differences are significant.99 The distribution of care type varies by region, for example just over 30 percent of care use in Malopolskie and Podlaskie is in home care settings, compared to over 50 percent in Kujawsko-Pomorskie. In health care, the differences are similar, with the proportion of home 99 World Bank commissioned survey, 2023. 161 care services ranging from 41 percent to 73.5 percent between regions. While the care use indicator also does not fully capture the availability of care services at the regional level, regional variations exist across various LTC resources including staffing, facilities, services, and financing (see the section ‘Long-term care system in Poland’). Figure 50 and Figure 51 present the varied dynamics in the LTC service mix across regions. Share of care use in each setting in the social sector, Figure 50.  by region SOCIAL CARE Inpatient care Home care Day care Poland 27.2% 39.3% 33.4% Mazowieckie 25.0% 41.5% 33.6% Śląskie 30.4% 38.8% 30.8% Wielkopolskie 24.4% 48.0% 27.6% Małopolskie 33.4% 31.1% 35.4% Dolnośląskie 27.4% 42.3% 30.2% Pomorskie 22.1% 45.7% 32.3% Kujawsko-pomorskie 22.8% 50.4% 26.8% Łódzkie 33.9% 34.0% 32.0% Lubelskie 25.7% 34.0% 40.4% Podkarpackie 27.1% 34.9% 38.0% Warmińsko-mazurskie 23.1% 34.8% 42.1% Zachodniopomorskie 28.5% 41.6% 30.0% Świętokrzyskie 24.0% 34.4% 41.6% Opolskie 32.6% 34.2% 33.2% Lubuskie 28.3% 39.2% 32.4% Podlaskie 31.1% 31.9% 37.0% Source: World Bank 2023, based on NFZ and MRPiPS data. Share of care use in each setting in the health sector, Figure 51.  by region HEALTH CARE Inpatient care Home care Poland 39.4% 60.6% Śląskie 26.5% 73.5% Mazowieckie 44.9% 55.1% Małopolskie 45.5% 54.5% Podkarpackie 36.8% 63.2% Dolnośląskie 46.9% 53.1% Wielkopolskie 31.5% 68.5% Łódzkie 49.9% 50.1% Lubelskie 36.0% 64.0% Kujawsko-pomorskie 46.8% 53.2% Świętokrzyskie 40.6% 59.4% Opolskie 32.6% 67.4% Zachodniopomorskie 35.4% 64.6% Pomorskie 58.7% 41.3% Warmińsko-mazurskie 39.5% 60.5% Podlaskie 45.1% 54.9% Lubuskie 44.8% 55.2% Source: World Bank 2023, based on NFZ and MRPiPS data. 162 Identifying and addressing resourcing gaps in care provision based on local needs are vital and should be supported by a standardized tool to support efficient decision-making. Reducing variation in LTC service provision across Poland remains key to addressing care outcomes of the population at large. By conducting comprehensive needs assessments that consider demographics, health profiles, socioeconomic conditions, and other local variables, Poland can gain a localized understanding of where resource gaps exist. Allocating resources based on local need will be fundamental to ensuring that LTC services are not only available but adequate and accessible. This assessment of resources should be done through the development and use of a standardized tool, such as an interactive dashboard with real- time analytics on demographics, care demand, and service provision for each region. This approach promotes equity by identifying and rectifying resource disparities in underserved areas or communities, ensuring that all regions have access to necessary LTC resources. Adaptability to changing demographics, particularly the aging population, is essential to address variations in LTC service provision effectively. Therefore, the strategy of identifying and addressing resourcing gaps based on local needs offers a data-driven, adaptable, and equitable approach, contributing to a more uniform, accessible, and high-quality LTC system throughout Poland. Developing estimates of unmet needs will also support the development of evidence-based policies to target the specific demographic compositions at local levels and support longer-term planning. Policymakers can thus use demographic information to create targeted, evidence-based policies that address the unique challenges faced by different regions. Accurate demographic data also assist in long-term planning. It provides a foundation for projecting future trends and making strategic decisions about the expansion or modification of health-care infrastructure and services while also enabling the calculation of projected costs based on anticipated future needs. The development of this dashboard can be partially informed by 163 governance solution 3, which pertains to mapping LTC facilities at the local level. GOVERNANCE SOLUTION 8: Develop an interactive dashboard with demographic, care demand, and service provision analytics for each region (voivodeship). key area(s) addressed:coordination/integration, deinstitutionalization A comprehensive review of Regional Development Strategies until 2030 provides evidence of variation in LTC development planning across regions in Poland. LTC measures planned by regions, outlined in these documents, have been categorized by the World Bank team into six thematic clusters, comprising 27 specific initiatives. The strategies reveal a significant diversity in LTC commitments among regions. None of the regions endorse all 27 measures, with Zachodniopomorskie and Dolnośląskie declaring the least (nine and eight, respectively), and Małopolskie, Podkarpackie, and Kujawsko-Pomorskie lead with 25, 24, and 23 measures, respectively (Figure 52) Mapping of regional aging agenda by the number of Figure 52.  aging-related measures planned in each region in Poland. max 19 min 21 9 18 23 14 14 20 22 8 20 14 22 17 24 25 Source: World Bank 2023, based on the review of all sixteen Regional Development Strategies until 2030.  164 Social integration and activation of seniors and fostering social and inclusive economy initiatives are the most-cited commitments, and the development of new facilities is among the least-cited commitments. The World Bank analyzed commitments to support aging communities, and while aging is broader and distinct from LTC, these commitments also cover LTC-related initiatives and act as an indicator to the degree to which aging is on subnational agendas. The most frequently declared measures across regions include social integration and activation of senior citizens (16 regions), fostering social and inclusive economy initiatives (16 regions), social integration and activation of persons with disabilities (15 regions), and labor market activation of persons with disabilities (15 regions). Conversely, measures such as digital education for persons with disabilities (3 regions), promotion of healthy lifestyles for persons with disabilities (4 regions), and new LTCFs in health and social sectors (4 and 5 regions, respectively) are less commonly prioritized. The thematic cluster of ‘education’ has the lowest priority, with 80 percent of measures not being on the agenda of more than 50 percent of the regions. The mapping of regional agendas underscores the variations in the commitment to specific measures.  Key strategic planning that must occur at local levels is the shift to deinstitutionalizing care. While LTC service access is relatively low in Poland, reliance on family support that is more characteristic of the Central and Eastern European countries is diminishing – due to this and because of lower pension rates, older people have been left without income or support, and are therefore more likely to be institutionalized.100 There is also a gender dimension, age is correlated with institutionalization, and therefore women tend to be institutionalized more than men. There is a broad political commitment, 100 European Expert Group on the Transition from Institutional to Community-based Care. 2012. “Common European Guidelines on the Transition from Institutional to Community-Based Care.” https://deinstitutionalisation.com/wp-content/uploads/2017/07/guidelines-final-english.pdf 165 at the European level, to transition from institutional to community- based care for all user groups. The physical separation from communities and families severely limits the capacity of those living in institutions to participate fully in their community and wider society. Strengthening these kinds of initiatives across regions and care providers can reinforce a shared vision for LTC and address distributional inequalities in access to care services and improve care delivery. Doing so relies on a process of assessment and developing a strategy and an action plan as critical to the process.101 A vital starting point is the development of subnational-level plans, for example, local deinstitutionalization plans, for how to improve their population care outcomes in line with broader LTC reform goals. The drafting of local- level plans can also support the collaborative efforts that take place through plan development and involve multiple stakeholders, such as government agencies, health-care institutions, and local authorities, to create comprehensive and integrated proposals. Critically, this relies on stronger cooperation between national and regional-level stakeholders. This solution area is therefore complemented by solution areas under Financing which pertain to introducing support mechanisms for LGUs which commit to develop LTC interventions and follow strategic directions (Financing solution 4) and creating feedback loops connecting LTC funding and performance assessments, reward quality, excellence, and responsiveness in the context of evolving needs (Financing solution 9). The local plans can also make use of the M&E outputs detailed in the solutions under Financing, Quality, and Private Market solutions. Considering the impacts of LTC interventions is an important element in planning future solutions, developing and appraising existing plans on a regular basis will help avoid pursuing inefficient efforts, especially those with unproven effectiveness. 101 European Expert Group on the Transition from Institutional to Community-based Care. 2012. “Common European Guidelines on the Transition from Institutional to Community-Based Care.” https://deinstitutionalisation.com/wp-content/uploads/2017/07/guidelines-final-english.pdf. 166 GOVERNANCE SOLUTION 9: Accelerate the development and implementation of plans (for example, local deinstitutionalization plans) that support the enhanced delivery of local services key area(s) addressed: coordination/Integration, deinstitutionalization, Labor Market INFORMATION ON CARE SERVICES F.  AND ACCESS FOR THE PUBLIC This solution area seeks to address the limited knowledge among the population relating to LTC services, particularly on how to access them by clients or patients and their carers. Limited understanding of services and how to access them by clients and their carers is a key issue highlighted by both public consultations and a survey conducted by the World Bank in 2023. During the consultations held in June and July 2023, care recipients consistently reported a lack of sufficient information to navigate the LTC system effectively. The information that is lacking comprises details about available cash and in-kind services. A subsequent survey commissioned by the World Bank emphasized the prevalence of confusion within the LTC system, with 65 percent of respondents expressing the need for better access to information on how to obtain local LTC support. Figure 53 illustrates the demand for support in navigating the LTC system, emphasizing the crucial role of access to information in providing care for elderly persons or individuals with disabilities. Participants in public consultations stressed the importance of enhancing communication and education efforts, proposing tools such as a national hotline or a publicly accessible information portal, that is, a website, to aid care recipients and their families in navigating the complex LTC system.  167 What kind of support is most needed to be able to Figure 53.  provide care for an elderly person or a person with a disability?   Coordination of long-term care services provided by various health and social institutions Creation of new long-term care facilities at or near the place of residence Support for family caregivers and private caregivers Access to information on how to get long-term care support locally or in the surrounding area Introducion of new forms of care, including day care, home care % 0 10 20 30 40 50 60 70 80 In qualitative research conducted by the World Bank, informal caregivers—family and friends involved in caregiving—reported issues in accessing information on available LTC services. These challenges included the absence of a uniform list of available services consistent across systems and a lack of clarity on eligible medical devices for reimbursement, such as wheelchairs. Although the list of medical devices available for request is publicly available (published in the Journal of Laws as an annex to the regulation of the Minister of Health on the list of medical devices issued on request), many participants reported learning from store employees about reimbursement possibilities for medical devices rather than through formal channels, adding to the confusion, especially when organizing services for individuals discharged from hospitals. In response to these challenges, participants in the consultations proposed the creation of an LTC coordinator role. This coordinator would facilitate communication and information exchange between service providers and care recipients, acting as a guide to navigate the LTC system for both patients and their care providers. This recommendation reflects the need for a centralized and supportive figure to bridge the information gap and improve understanding and access to LTC services for clients and their caregivers. 168 An LTC coordinator can act as a crucial bridge to tackle the issue of limited knowledge around LTC services, especially on how to access them. The designation of this role could take place at OPS/CUS with due consideration to the size of the locality they cover. At a minimum, an LTC coordinator role should be in operation at powiat levels. They can provide direct communication and guidance and help clients/ patients and their caregivers navigate the complexities of the LTC system. Their role extends to improving communication between service providers and care recipients, ensuring that resources are accessible and contextually sensitive to the unique needs of their locality. This role is recommended to be designated under the solution area titled, ‘E. Regional variation in strategic planning of LTC development’ and should extend to addressing issues in information deficits for the clients and carers in their locality. These solutions work in tandem with the communication strategy to effectively address the challenges faced by members of the public in navigating the LTC system. By offering hands-on support, enhancing knowledge, centralizing information, and tailoring resources to regional needs, these solutions contribute to a more informed, navigable, and efficient LTC system. Ultimately, they improve care provision and support for care recipients and their families, ensuring that they receive the assistance they require.  GOVERNANCE SOLUTION 10: Ensure that strengthening communication and access to information on LTC is part of the LTC coordinator’s role. key area(s) addressed:coordination/integration, deinstitutionalization There is a deficit in communication and information on the LTC system operations at the central and local levels. Communication issues regarding the LTC system were identified at both national and local levels during the consultations. The absence of a national information resource, 169 such as a hotline or website, to disseminate information about services was noted, and participants suggested that organizations providing financial support for the elderly or those with disabilities should improve communication about their offerings. LGUs were also urged to make information about available support services consistently accessible to interested parties. The key problem to be addressed, therefore, is the limited understanding of services and the lack of clear pathways for access, underscoring the urgency for coordinated efforts to improve communication and education in the LTC domain. A strong communication strategy can support improved dissemination of information on LTC through the following activities: an awareness campaign that can reach people where they live, a governmental website that acts as the central repository for information on rights in the LTC system, and local websites that provide community-specific information. The implementation of awareness campaigns plays a vital role in combating the lack of information on the LTC system. By disseminating key information about available services, eligibility criteria, and the process of navigating the system, these campaigns empower care recipients and their families with the knowledge they need to make informed decisions. This not only reduces confusion but also increases the confidence of patients and beneficiaries. A centralized governmental website acts as a comprehensive source of information regarding LTC services. It offers standardized and up-to-date information on services, eligibility, and how to access them. This addresses the inconsistencies in understanding, ensuring that care recipients have access to a uniform list of services. Furthermore, by providing transparent information on reimbursements and services, this governmental website helps to reduce the confusion that arises when individuals rely on third parties for such critical details. Additionally, local websites, specific to regions or municipalities, cater to the unique local needs of their respective areas. These websites offer localized information and resources, addressing regional disparities. They are a valuable resource for individuals seeking 170 care options when a family member is discharged from the hospital. By collaborating with LGUs, these websites can make vital information available to those in need, ensuring a more informed and organized approach to care provision. GOVERNANCE SOLUTION 11: Ensure effective public outreach using an awareness-building campaign, a national government website, and local government websites. key area(s) addressed:coordination/integration, deinstitutionalization Future expectations of care needs are influenced by health illiteracy. Health literacy among Poland’s population is low and is a crucial factor in understanding decisions about health and care (Table 21). The results of the World Bank survey also highlight the need for comprehensive awareness campaigns to educate the public on the growing care needs of the elderly and people with disabilities. Although 64 percent of respondents acknowledge the potential usefulness of information campaigns in raising awareness, only 17 percent believe it is the responsibility of their organization to conduct such outreach. Recognizing and addressing the health literacy challenges in LTC recipients is crucial to empowering individuals to prepare for future care scenarios. Proportion of those with limited health literacy by socio- Table 21.  demographic group, in Poland and select EU countries POLAND  AUSTRIA  BULGARIA  GERMANY  GREECE  IRELAND  NETHERLANDS  SPAIN Health status   Very poor  77.2  100.0  87.8  54.9  88.3  49.5  47.4  94.8  Poor  71.2  84.2  82.4  54.9  80.3  57.2  41.4  75.3  Chronic disease  More 54.3  78.5  83.3  58.5  73.8  45.3  32.6  69.5  than one Age  76 or 65.5  72.6  75.4  53.9  72.3  46.0  28.8  71.1  older  66-75  58.7  71.4  79.7  39.7  66.2  37.1  30.4  77.1  Socioeconomic Very low  59.8  78.5  79.7  58.8  79.5  64.0  49.9  84.3  status Low  63.8  59.4  62.10  63.9  57.4  53.3  48.4  59.2 171 Public campaigns and health literacy programs can help people take the necessary steps to prepare for possible future care scenarios. Adequate planning will not be possible if people are unaware of what may be required and how to navigate arranging or preparing for future health and care needs. Educational campaigns aimed at the general population can increase awareness of the challenges associated with aging and long-term care. These campaigns can also promote understanding of the available services and support systems, ensuring that people are better prepared for their own aging and caregiving responsibilities. Second, implementing programs that focus on health literacy related to aging well and LTC can empower individuals to make informed decisions about their own health and care needs. This knowledge can improve preventive care and early intervention, reducing the strain on informal caregivers.  GOVERNANCE SOLUTION 12: Continue to enhance the health literacy of the public regarding the needs of the aging population and persons with disabilities and availability of care and LTC service offerings to raise awareness using available communication tools. key area(s) addressed: coordination/Integration, deinstitutionalization 172 Summary of Governance Solutions SOLUTIONS WHAT IS BEING ADDRESSED KEY AREA LTC GOAL 1. Create a unified body of LTC A. There are multiple legal acts, Coordination/ Effective regulations, including an LTC definition a complicated system of services, and integration governance or amend the relevant acts of law. a lack of a consistent definition of LTC. Coordination/ Effective 2. Define transparent eligibility criteria B. There are multiple definitions integration governance for access to LTC services and programs and levels of eligibility criteria for all users, with due consideration for and dependency definitions. various levels of care (that is, inpatient/ residential, home and community care). 3. Map LTC facilities at the local level, C. Current and future demands for LTC Coordination/ Effective with a view to allowing information services are challenging to estimate. integration governance sharing on LTC facilities operating Deinstitutionalization, in the health and social sectors. Labor market 4. Designate LTC coordinators, e.g. at OPS/CUS and expand the role of select PHC coordinators as contact persons for LTC matters. 5. Develop template data sharing D. There are opportunities to Coordination/ Effective agreements for ministries, LGUs improve data collection, enhance integration governance and service providers. the consistency of data formats, Deinstitutionalization and regularly update the availability 6. Revise existing acts to ensure of detailed, comprehensive appropriate and coordinated LTC data information and research. collection policies and guidelines in place. 7. Ensure that the M&E of programs supporting LTC, including those supported by EU funds, informs LTC interventions by identifying what has been successful and aligned with national and regional needs. 8. Develop an interactive dashboard E. There is variation in care service Coordination/ Effective with demographic, care demand, provision across regions. integration, governance and service provision analytics Deinstitutionalization, for each region (voivodeship). Labor Market 9. Accelerate the development and implementation of plans (for example, local deinstitutionalization plans) that support the enhanced delivery of local services. 10, Ensure that strengthening F. There is a limited understanding Coordination/ Effective communication and access to of LTC services and how to access integration governance information on LTC is part of them from clients and their carers. Deinstitutionalization the LTC coordinator’s role. 11. Ensure effective public outreach using an awareness-building campaign, a national government website, and local government websites. 12. Continue to enhance the health literacy of the public regarding the needs of the aging population and persons with disabilities and availability of care and LTC service offerings to raise awareness using available communication tools. 173 FINANCING A. PUBLIC EXPENDITURES ON LTC This solution area seeks to address the low expenditures on LTC compared to other EU countries, and issues associated with disparities in spending levels of care. The challenge of low expenditures on LTC in Poland compared to other EU countries is multifaceted and evident in various aspects of the health-care and social systems. One of the clearest symptoms of low public expenditure is the extent of private out-of-pocket payments made by users of public LTC services. Patients and beneficiaries paid approximately PLN 1.4 billion toward LTC services in 2021, with PLN 1.1 billion coming from DPS beneficiaries and PLN 0.3 billion from ZOL/ZPO patients. On average, DPS residents paid a monthly out-of-pocket surcharge of PLN 1,173, while ZOL/ZPO patients paid PLN 1,129 per month. The costs of private, non-publicly funded LTC facilities could not be assessed due to the lack of data. All financing solutions must be explored for their feasibility within the legislative constraints of the government. The social and health sectors respectively receive differential levels of financing for LTC, and overall spend in Poland falls far below EU levels. In 2021, a total of nearly PLN 8.5 billion was allocated for LTC in the public sector. The bulk of this funding, more than PLN 6.5 billion, was assigned to the social sector, emphasizing its primary role in LTC, compared with PLN 1.9 billion allocated for this purpose in the health- care sector. The difference also results from the number of beneficiaries of care services in the social sector—a rate of more than three times that of the health sector. It is difficult to compare Poland’s LTC expenditure with other European countries due to differences in calculation methodologies. However, 174 when using conventional methods of estimating expenditures, Poland consistently spends less on LTC compared to the EU average. On average in the EU, public expenditure on LTC is projected to increase from 1.7 percent of GDP in 2019 to 1.9 percent in 2030, 2.5 percent of GDP in 2050, and 2.8 in 2070, with marked variations across member states (Ageing Working Group [AWG] reference scenario). These projections assume no policy change in relation to the current LTC systems in member states and that half of the projected gains in life expectancy are spent without disability. By these estimates, Poland is expected to see the highest increase in expenditure on LTC—a growth of nearly 200 percent between 2019 and 2070 (0.8 percent in 2019, 1.1 percent in 2030, 1.7 percent in 2050, and 2.4 percent in 2070102 (Figure 54). An assumption in determining cost rates is a lack of policy change, and while outside of the remit of this report, it should be noted that future LTC costs are a function of the investment in prevention – today. Strategies to increase LTC spend should be weighed in tandem with investments in prevention, especially cost-effective public health interventions. In terms of spending on preventative functions, Poland spends the second lowest among EU-27 countries.103 At the same time, preventive interventions have been shown as cost-effective for adjusting quality-adjusted life years (QALY).104 102 In this calculation it was assumed by the AWG that Poland spent 0.8 percent of GDP on LTC in 2019. 103 “Health Expenditure and Financing.” OECD.stat. https://stats.oecd.org/# (February 26, 2023), measured in current per capita purchasing power parities (PPPs). 104 Owen et al. 2012. “The Cost-Effectiveness of Public Health Interventions.” Journal of Public Health 34 (1): 37– 45. https://doi.org/10.1093/pubmed/fdr075 175 Expected increase in LTC expenditure during Figure 54.  2019–2070 as share of GDP based on AWG scenario Increase in LTC expenditure between 2019 and 2070 200% 8 180% 7 LTC expenditure (public) % of GDP 160% 6 140% 5 120% 100% 4 80% 3 2.4% 60% 2 40% 0.8% 1 20% 0 0 Poland Slovakia Luxembourg Malta Slovenia Denmark Ireland Hungary Finland Spain Austria Belgium Romania Czechia Norway Cyprus Portugal Netherlands Sweden Estonia Lithuania Italy France Germay Croatia Bulgaria Latvia Greece Increase between 2019 and 2070 % GDP (2019) % GDP (2070) Source: European Commission Directorate-General for Economic and Financial Affairs. 2021. The 2021 Ageing Report: Economic and Budgetary Projections for the EU Member States (2019-2070). Publications Office of the European Union. Reducing the financing gap would be transformative to the LTC system and would have broader benefits for the economy and society. The current estimates suggest Poland is spending less than the EU average while having one of the most rapidly aging populations in the EU. Without adequate financing, reforms across all solution areas are unlikely to reach their full potential or the scale necessary to satisfy the population’s current, not to mention future, needs. Investment in LTC not only improves the system and experience of care users, it also brings benefits to many different areas including labor force participation—by reducing the disruption to people’s working lives from care responsibilities; it can also reduce stress and burnout for family caregivers, which are predominantly women. All of this contributes to healthier, more productive societies. Bringing the financing up to the 176 level of other EU regions would require significantly increasing the amount of LTC spending in proportion to GDP. Simultaneously identifying a target spending amount based on comparable levels in other EU countries can help in the immediate term, while more sustainable and longer-term options are developed following a PER. A review of the current system of financing for benefits (including cash benefits) must be done to assess the efficiency and optimization of funding flows. Poland receives financing from EU funds that support LTC projects, several of which have not been sustained after the pilot period due to limited funds for their continuation by local authorities. Hence, increasing expenditure from the public purse will be more stable and sustainable, and reduce the government’s reliance on EU financing. To address immediate and urgent shortages in LTC supply, however, the most effective short-term solution is to increase LTC financing from the state budget. FINANCING SOLUTION 1: Increase LTC allocation in the state budget. key area(s) addressed: coordination/integration, deinstitutionalization, labor market The LTC system in Poland is underfunded and underdeveloped—this requires longer-term efforts to ensure the fiscal health of the system as well as to ensure high-quality and accessible care that can keep up with growing demand. As discussed under Financing solution 1, based on demographic projections alone the expenditure of the LTC system is set to grow by 200 percent by 2070. This is in a context where current provision levels are insufficient, waiting times are lengthy, and care responsibilities are falling on family members and social networks. To ensure the system can sustain itself, accommodate increasing demand for care and reducing inequalities in access, space will need to be made in the fiscal budget either by increasing revenue, reallocating resources, or identifying efficiencies with other sectors. While the latter options have appeal, the scale of the issue will require 177 substantial repurposing or raising of funds, and the exploration of new financing mechanisms. A thorough PER can help national policymakers better understand fiscal management and policy challenges, while proposing priority reform areas and setting the agenda for budgetary planning. By examining how public expenditure is allocated and managed, it is possible to assess the impact and the effectiveness of budget planning and execution. A review of the current system of financing for benefits (including cash benefits) must be done to assess the efficiency and optimization of funding flows. This includes evaluating the use of health taxes, including tobacco and sugar-sweetened beverage taxes for health spending. Projecting LTC needs in the medium- to long-term horizon is also an important exercise for determining the appropriate spending amount for Poland. As part of the PER, possible solutions for bridging the LTC financing gap could include changing the health, disability, and pension contributions; establishing an additional fund to secure LTC budget in the future; and developing additional public or private insurance options (strengths and weaknesses for different financing models for LTC from an international context, including different examples of cost arrangements can be found in the appendix).105 A cost-benefit analysis should be conducted to assess and increase the contributory rate for health or social sector benefits for the financial solvency of the system, but in a way that minimizes fragmentation of the service financing. FINANCING SOLUTION 2: Conduct a PER to evaluate the effectiveness of public finances for LTC and propose budgetary solutions to ensure the fiscal sustainability of the system. key area(s) addressed: coordination/integration, deinstitutionalization, labor market 105 Foresight Centre. 2021. “The Future of Long-Term Care. Development Trends up to 2035;” Newhouse, Joseph P. 1993. Free for All?: Lessons from the RAND Health Insurance Experiment. Harvard University Press. DOI: https://doi.org/10.7249/CB199. 178 The public also reported concerns about insufficiently financed benefits in the 2023 World Bank survey. Public opinion on the level of public funding for LTC in Poland is decidedly negative, with 57 percent of respondents expressing their dissatisfaction in the survey. Particularly critical views were expressed concerning financial support for family caregivers, benefits for people with disabilities and/or dependents, and access to free rehabilitation services (Figure 55). This dissatisfaction is also reflected among those providing or receiving LTC services, with 72 percent of this group expressing negative opinions. “Thinking of LTC services in Poland, what is your Figure 55.  opinion about...” Access to commercial rehabilitation services 32% 15% 48% 5% Access to commercial, home-based LTC services, e.g., a private caregiver 28% 22% 35% 16% Access to commercial, inpatient LTC services, e.g., a private facility 33% 22% 30% 16% Access to information about support options with regard to home- based LTC services 42% 27% 15% 16% Access to information about LTC options and availability 40% 27% 24% 9% Quality of LTC services in Poland 44% 25% 15% 16% Access to respite care – a service whereby the regular caregiver can 51% 19% 7% 23% take a break from their routine care-related duties Access to non-commercial, home-based LTC services, e.g., a nurse or 59% 21% 12% 8% a caregiver provided by social welfare agency (MOPS) Options for the caregiver of a person with disability to collect applicable cash benefits while also earning income from employment 59% 20% 11% 10% Financial support to adapt housing space to the needs of LTC patients 62% 15% 11% 13% Access to non-commercial, inpatient LTC services, e.g., a social welfare facility 65% 17% 9% 9% Size of government allocations to LTC 71% 15% 7% 7% Financial support for family caregivers 64% 18% 8% 10% Generosity of benefits payable to persons with disabilities and/or those who need assistance with activities of daily living 74% 10% 8% 8% Access to non-commercial rehabilitation services 77% 11% 8% 5% negative neutral positive I don't know, hard to say Source: Survey of a representative sample of Poland’s population, WB 2023.  179 To enhance public financing, the national-level financing system should incentivize local governments to increase financial outlays. The costs incurred by local governments could be linked to a subsidy from the central budget for specific LTC tasks – for example, care services, specialized care services, respite care, personal assistance. The level of this subsidy could be determined by an algorithm considering potential demand for services in each municipality such as size of the municipality, share of elderly in the population, or number of people with disabilities. Subsidies could apply to a defined basket of services currently included in government programs and municipalities’ own care tasks. Another option would be to provide LTC vouchers, financed from national and regional budgets, available for LTC beneficiaries to spend on a defined list of LTC services. Voucher utilization could be aided by the community-level support services and LTC coordinators. There should be a strong emphasis on interventions that further help deinstitutionalization, such as community-based care settings including day care and home care. Home and community care providers can be prioritized through competitive tendering, especially for social economy providers. The new financing model should also include clear incentives for quality, innovation, and accountability, encouraging integration between the health and social care sectors with clearly defined indicators for monitoring the use of subsidy financing. FINANCING SOLUTION 3: Ensure sufficient LTC funding at different service delivery levels (for example, central, regional, local) and at different service delivery settings (home, day care and inpatient), including the possibility to introduce publicly funded vouchers, managed at local government levels as demand-side subsidies to targeted groups, giving the opportunity to purchase LTC services on a well-regulated, private market. key area(s) addressed: coordination/integration, deinstitutionalization, labor market 180 While regional level financing is not available for all indicators, financing for services is highly varied, as is the distribution of EU financing. Under the LTC system overview, significant regional variation was observed when presenting expenditures for each service user under social sector home care services. On average, PLN 6,375.9 was spent per service user in 2021—ranging from PLN 4,252.7 in Śląskie to PLN 9,746.4 in Świetokrzyskie (Table 8). Similarly, specialized home care services show multifold differences between regions. The lowest per user spend is PLN 1,585.6 in Opolskie compared to the highest of PLN 17,869.1 in Warmińsko-Mazurskie (Table 9). This is also observed in health care services where data are available. The financing disparities are not only observed in public spending, EU financing is also unevenly applied to and distributed across Poland. Infrastructure is also differentially available in ZOL and ZPO facilities. For example, Opolskie only has one ZPO with 6 beds, while Śląskie has 1,344 beds in the region across 22 facilities. This is symptomatic, in part, of the availability of funds, but it also points to variation in the types of services that are available, the initiative of local authorities in seeking out cofinancing and strategic planning at this level. Thus, this solution area complements the solutions under ‘E. Regional Variation in Strategic Planning of LTC development’. Different incentives can be employed to motivate local authorities to pursue LTC interventions and engage the EU for cofinancing of LTC projects. The successful implementation of LTC solutions strongly relies on the participation of local governments. This is especially true for the initiation of projects, such as identifying the needs of their populations, coordinating with regional neighbors on complementarities, and searching the database of EU projects to identify initiatives that align with their region’s needs. Incentives to implement the recommended solutions may include targeted information and education packages to support local authorities to apply for EU funding; the creation of a database for sharing information on good practices implemented in the LTC area by other local authorities and cofinanced from EU funds; 181 and holding meetings organized by the ministries of health and social care with selected representatives of local governments, e.g. a joint commission of the government and local government. These joint meetings could discuss potential interventions and create opportunities for additional government support. While differences in utilization of EU financing are an issue, for the sustainability of LTC in Poland, it is also crucial that more stable fiscal space is made in the state and local government’s budget (Financing solution 1). FINANCING SOLUTION 4: Introduce support mechanisms for LGUs which commit develop LTC interventions and follow strategic directions. key area(s) addressed: coordination/integration, deinstitutionalization, labor market Even with public opinion highlighting the insufficiency of resources directed to LTC, there is no clear consensus on how services should be financed. As care demands on the public sector are increasing rapidly, to remain solvent the system must generate additional revenue, especially as the working-age population is set to decrease. Almost half of respondents (43 percent) are willing to copay for LTC, 30 percent of respondents do not support copayment, while 26 percent report no opinion. Thirty-four out of 90 respondents are willing to pay 40 percent of the cost of private care per hour, assuming one hour of care costs PLN 50 (Figure 56). 182 Willingness of respondents to copay for LTC and Figure 56.  percentage of the costs of care respondents willing to pay out of pocket Willing to copay for LTC? Share of LTC copayment that respondent is willing to pay 0%-5% 4% 30% 6%-10% 11% No 11%-20% 18% 43% Yes 21%-30% 16% 31%-40% 7% 26% >40% 34% I don't know Source: Survey of a representative sample of Poland’s population, World Bank 2023. Through the PER, copayment arrangements should be evaluated as one potential way to improve revenue while protecting service affordability for financially constrained clients. This option can be implemented by introducing fixed copayment amounts, particularly for those who can afford it, without significantly burdening less-affluent populations. Adjusting copayment levels can help balance the funding disparities by ensuring that individuals who can afford to pay more contribute proportionally, reducing the burden on municipal budgets. By transparently and equitably revising copayment levels, the government can demonstrate a commitment to fair burden-sharing, addressing the public’s concerns regarding funding. An equitable copayment system is essential to maintain public trust and alleviate concerns about LTC financing. While a copayment system is already in place in Poland and is therefore practical to revise, alternative options that minimize financial hardship and can innovatively finance the system can be explored through the PER. Additionally, encouraging a public-private mix in financing LTC can diversify funding sources. This can include incentives for private insurance, investments, and contributions. Any solution should be appraised for its financial impact and ensure that care remains affordable and accessible. 183 FINANCING SOLUTION 5: Evaluate the existing copayment arrangement and prepare to implement a revised copayment mechanism for LTC services to generate additional revenue without putting financial strain on vulnerable populations. key area(s) addressed: coordination/integration, deinstitutionalization, labor market Currently, there is a mixed market of care provision in Poland, hence individuals are still involved in procuring care to varying degrees, especially in the social sector. Complementary to copayment systems and to allow individuals to have more choice in their care provision, supporting individuals to prepare for future care costs is an important way to ensure they are properly protected if they require care support. Similar to what is available for those who save for retirement or in case of an adverse event, more tools should be available to support individuals make the most out of their savings. Further, while preventive actions and health-related investments are low-cost ways to offset potential care dependency, 41 percent of respondents to a survey by the World Bank said they were not making any effort to stay healthy, fit, and/or independent for as long as possible. In addition, it was found that people are not sufficiently planning for their futures. Fifty-five percent of people aged over 65 had never spoken to their family or friends about issues relating to aging and future care needs; this proportion is 71 percent for people aged 45–64. Encouraging individuals to financially plan for future LTC and engage with health prevention measures to avoid or delay needing LTC at a later stage of life can complement public financing for LTC. Incentives can be introduced to promote savings or investments in LTC insurance, encouraging personal responsibility for LTC costs. When citizens are actively involved in planning for their long-term care, they may feel more positively about the current LTC financing structure. New programs—either saving or insurance-based—should 184 be designed so that participation is affordable and appropriate coverage is provided irrespective of the individual’s socioeconomic and socio-demographic characteristics. FINANCING SOLUTION 6: Provide incentives and encourage the use of tools for individuals who are willing to plan for future LTC needs through health-related investments and voluntary financial investments, such as savings, insurance, and similar schemes. key area(s) addressed: coordination/integration, deinstitutionalization, Labor Market   NCREASE SUSTAINABILITY OF B. I GOVERNMENTAL PROGRAMS  This solution area seeks to increase the sustainability of governmental LTC programs. Since 2015, targeted programs have been introduced to support the activation of—and services for—older people and people with disabilities. Some of these programs continue to be in place—such as Senior+, others were introduced later and have been operating on an annual basis until today—these include Care 75+, Respite Care, and the Assistant for person with disabilities. There are also programs that operated for two years or so and then discontinued, for example, the Care services for people with disabilities. Programs operate on an annual basis, and each year LGUs can apply for funding. In principle, programs are designed to plug gaps in service provision, increase the overall number of services provided, introduce innovative solutions, and promote new types of care targeted to specific recipients, such as unpaid family carers. Inequalities arise from the fact that some local authorities might not have the capacity to apply for additional funding and therefore provide fewer or more limited services compared to others. 185 Programs that address specific target groups or are limited in service scope or timespan should therefore be better embedded into the LTC system: to do this requires an appropriate legal framework and dedicated financing. Presently in Poland, LTC is provided as a bricolage of services. To begin to improve the system and identify gaps requires understanding the current system components and integrating these services under a single umbrella. A crucial enabling factor is the enactment of an Act on LTC, aimed at restructuring the existing and fragmented system. This proposed legislation would address definitions, service accessibility, quality standards, institutional responsibilities, staff development, database systems, new technologies, and their financing. While drafting of such an Act can be done in the short term, its implementation, including staff preparation, reporting systems, and tools like Care Protocols, necessitates sustained, long-term systematic efforts. To integrate these programs will likely require greater dedicated public and private resources. FINANCING SOLUTION 7: Coordinate the financing and legislation for LTC programs pursued by the government. key area(s) addressed: coordination/integration, deinstitutionalization, labor market In the longer term, organizing services under annual programs results in inequalities between different local settings and creates instability. The aforementioned programs are often implemented over short time frames and instability arises in part from these programs being planned on an annual basis. Local authorities, while expected to develop deinstitutionalization and social services’ provision plans, face uncertainty regarding whether and which type of services they will be able to apply for and provide each year. In practice, the government allocates program funding regularly, which means there has been somewhat consistent financing directed to increase overall LTC funding. However, as the funding cycles are annual it means this practical 186 consistency still gives way to uncertainty for implementers. To counteract this issue, programs can be either supported for multiple years or select solutions should be formalized as part of the regular mandate of OPS or CUS and funded from the general budget. This rethinking of financing commitments is necessary to increase the availability and sustainability of solutions that have been in place for several years and have demonstrated positive results, and to promote additional care solutions. Multiyear funding would therefore be instrumental in bringing much needed stability to LTC initiatives. By committing funds for several years, the LTC system gains a reliable financial foundation, allowing for better long-term planning and the assurance of sustained resources. This stability helps to streamline administrative processes, reduces the need for frequent fund-seeking efforts, and enhances the focus on delivering quality care. With multiyear funding, LTC providers can allocate more resources to staff training, infrastructure development, and service improvements, resulting in better care outcomes for the elderly population. Adequate funding should be provided not only for service provision but also for research, data collection, and analysis in this area. FINANCING SOLUTION 8: Provide multiyear funding for LTC initiatives to ensure stability for planning and resource allocation. key area(s) addressed: coordination/integration, deinstitutionalization, labor market To ensure the best LTC services are adopted, evaluations are necessary. As is the case in Poland many short-run projects provide critical services to at-need populations. However, in general the purpose of short-run programs is often to pilot or test out select interventions for their effectiveness in a given community or locality. Therefore, evaluating interventions and determining which should be scaled and 187 sustained should be more systematic and performance based. This will improve the intentionality with which projects receive funding and incentivize worthwhile interventions. Sustainable funding, in the form of performance-based financial support, can thus promote this accountability. Programs that undergo independent evaluations and receive favorable assessments should be rewarded with sustainable funding. This approach encourages LTC providers to maintain high standards and continually enhance their services to meet the evaluation criteria. The accountability element ensures that funding is allocated to programs that consistently deliver quality care and acts as a powerful incentive for improvement. One option for rewarding performance is strategic purchasing. Through the PER (Financing solution 2), expenditure on LTC will be evaluated for its effectiveness, and strategic purchasing can be explored for the allocation of finances from central and local budgets. Strategic purchasing refers to allocating resources based on information about the provider, such as who their target population is, what kind of services they provide, and how effective they are at providing care. It employs an evidence-based process for defining services for purchase, by whom and how they should be paid for.106 Moreover, it fosters adaptability within the LTC system, allowing it to evolve according to changing needs and best practices. For case examples, see the experiences of Sweden and the Netherland experiences with financial incentives for LTC in the international examples in the appendix to this report. Programs excelling in evaluations can be expanded or replicated, while those underperforming can be restructured or phased out, promoting a dynamic and responsive LTC system. 106 WHO. 2019. “Purchasing Health Services for Universal Health Coverage: How to Make It More Strategic?” WHO/UCH/HGF/PolicyBrief/19.6 188 FINANCING SOLUTION 9: Create feedback loops connecting LTC funding and performance assessments, reward quality, excellence, and responsiveness in the context of evolving needs. key area(s) addressed: coordination/integration, deinstitutionalization, labor market  Summary of Financial Solutions FINANCIAL SOLUTIONS WHAT IS BEING KEY AREA LTC GOAL ADDRESSED 1. Increase LTC allocation in the state budget. A. Expenditures on LTC Coordination/ Effective is low compared to Integration, financing 2. Conduct a PER to evaluate the effectiveness of public other EU countries, with Deinstitutionalization, finances for LTC and propose budgetary solutions disparities in spending Labor Market to ensure the fiscal sustainability of the system. across levels of care. 3. Ensure sufficient LTC funding at different service delivery levels (for example, central, regional, local) and at different service delivery settings (home, day care and inpatient), including the possibility to introduce publicly funded vouchers, managed at local government levels as demand-side subsidies to targeted groups, giving the opportunity to purchase LTC services on a well-regulated, private market. 4. Introduce support mechanisms for LGUs which commit to develop LTC interventions and follow strategic directions. 5. Evaluate the existing copayment arrangement and prepare to implement a revised copayment mechanism for LTC services to generate additional revenue without putting financial strain on vulnerable populations. 6. Provide incentives and encourage the use of tools for individuals who are willing to plan for future LTC needs through health-related investments and voluntary financial investments, such as savings, insurance, and similar schemes. 7. Coordinate the financing and legislation for B. Sustainability of Coordination/ Effective LTC programs pursued by the government. governmental programs Integration, financing should be increased. Deinstitutionalization, 8. Provide multiyear funding for LTC. Labor Market 9. Create feedback loops connecting LTC funding and performance assessments, reward quality, excellence, and responsiveness in the context of evolving need. 189 HUMAN RESOURCES  A. DISTRIBUTION OF LTC PERSONNEL This problem area seeks to address the availability and variation in the distribution and composition of personnel within and between sectors in Poland. One influencing factor shaping the availability and varied distribution of personnel is the lack of a coherent institutional framework. Notably, regulations and employment requirements for LTC service providers differ between the health and social sectors. This is partly a consequence of the division of responsibilities of LTC services into the two sectors. In social inpatient settings in DPS, where the Ordinance of the MRPiPS outlines staffing requirements for DPS facilities, the majority of DPS staff (97 percent) are full-time salaried employees. The majority of DPS facilities enforce specific staffing regulations, other LTC service providers in the social sector lack stringent requirements. This includes OW, where core staff comprise psychologists, occupational therapists, and physical therapists, and OPS, employing caregivers without strictly defined qualifications. In contrast, the health sector, which is regulated by the MZ, enforces minimum pay rates and qualifications for specific medical positions involved in LTC services. However, the health sector has seen slight declines in staffing over the analyzed period (see section on Human Resources for LTC for sector-specific figures). Across care settings, the patient workload per LTC worker is difficult to estimate, but available data suggest there is a disproportionate number of LTC beneficiaries per worker in home care settings in the social sector compared to the health sector. In 2021, a total of 6,918 LTC staff were employed in home care provided by the social sector, while as many as 22,221 were employed by the health-care system—over three times as many (see Figure 28 for social sector figures – Human Resources for LTC section). 190 Figure 57. Nurses in LTC health sector in Poland Nurses – NFZ health care professionals Number of patients per one nurse 18 392 18 520 19 225 19 535 19 538 6.02 5.95 5.71 5.52 5.79 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021 Region Nurses 2021 vs. Region Patient/ 2021 vs. 2021 2017 staff 2017 ratio 2021 Śląskie 2475 146 Śląskie 8.13 -0.33 Mazowieckie 2359 69 Zachodniopomorskie 6.98 -0.57 Małopolskie 2211 184 Warmińsko- 6.64 -0.73 Dolnośląskie 1772 -14 mazurskie Podkarpackie 1710 28 Opolskie 6.46 -3.40 Wielkopolskie 1263 6 Wielkopolskie 6.08 0.07 Lubelskie 1132 123 Łódzkie 5.85 -0.50 Łódzkie 1129 180 Lubelskie 5.79 -0.25 Pomorskie 898 15 Kujawsko-pomorskie 5.79 0.46 Świętokrzyskie 862 53 Mazowieckie 5.78 0.00 Kujawsko-pomorskie 847 -18 Podkarpackie 5.42 0.09 Opolskie 684 184 Świętokrzyskie 5.25 -0.58 Podlaskie 623 67 Małopolskie 5.10 -0.20 Zachodniopomorskie 559 22 Lubuskie 5.01 0.14 Lubuskie 541 77 Dolnośląskie 4.68 -0.01 Warmińsko- 473 24 Podlaskie 4.44 -0.34 mazurskie Pomorskie 3.85 -0.25 Source: World Bank 2023, based on NFZ data.  The LTC health workforce is characterized as mostly female and with an average age of 52 years. In the formal LTC workforce in Europe, including both social and health-care workers, women outnumber men nearly 9 to 1.107 The dynamic in Poland reflects the situation in Europe more broadly. Data obtained by the World Bank from the NFZ show that there are significantly more women than men employed in LTC in the health sector. In 2021, the average age of LTC employees in the health-care sector was approximately 52 years (Figure 58). Workforce data received from the MRPiPS for the social sector did not enable the 107 EC and OECD data, 2021 191 identification of either the age or gender of persons employed in the provision of long-term care. Age and gender of LTC personnel in the health sector, Figure 58.  2017–2021 Women Men Total Nurses Number of nurses  Average age  19,225  19,535  19,538  20 000 18,392  18,520  60 53.6  53.2 52.8 52.4  51.9 50 15 000 40 10 000 30 20 5000 10 0 0 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021 Geriatricians  Number of geriatricians   Average age  500 60 301 288 53.9 53.4 53.4 52.1 51.6 400 277 279 50 258 40 300 30 200 20 100 10 0 0 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021 Medical caregivers Number of caregivers    Average age  5000 4,514  3,999  60 4000 3,534  48.4 48.2 48.0 47.9 47.5 50 3000 40 2,558  2,049  2000 30 20 1000 10 0 0 2017 2018 2019 2020 2021 2017 2018 2019 2020 2021 Source: World Bank analysis, based on NFZ data.  192 Emigration of health workers is a concern; however, estimating the levels is difficult given a lack of data on emigrating medical workers. The Supreme Audit Office, in its 2016 report, highlighted the lack of reliable tools to monitor emigration of health-care workers out of Poland and cited a lack of understanding of the true extent of this phenomenon. This is partly due to the lack of consistent mechanisms for collecting statistics and monitoring the movement of medical workers. The available data are mainly based on the number of certificates issued by professional chambers, which entitle their members to practice in other EU countries. Information gathered by national professional chambers shows that since 2004, when Poland joined the EU, 7–9 percent of doctors and nurses have opted to apply for such certificates. However, the analysis of data from professional chambers for 2004–2020 finds a declining trend in emigration in recent years. This trend can be explained by two main factors: the increase in domestic wages during this period and the aging of individuals that make up this workforce, as migration intentions are negatively correlated with age and work experience. Using comparable indicators in the EU, Poland’s staffing for LTC is low. The number of LTC patients per nurse working in LTC in the health sector in Poland is relatively low compared to other European countries. Based on data provided by the NFZ, in 2021, Poland had an average of 5.8 LTC patients per nurse (Figure 57). For the social sector, there is a lack of data to conduct a similar analysis. According to OECD data, the lowest rate of nurses for inpatient care was recorded in Switzerland (1.8 per nurse) and the highest in Estonia (29.3). The lowest rate for home care was recorded in Portugal (10.2) and the highest in Slovakia (as many as 554 patients per LTC nurse) (Table 22). Poland is not listed in the table as data on this indicator are not available from the OECD database. 193 Number of LTC patients per nurse in inpatient and home Table 22.  care (health sector only) in select Euorpean countries – Poland data are not available in the OECD dataset COUNTRY LTC LTC LTC RATIO RATIO PATIENTS PATIENTS LTC RATIO RATIO (2022 OR CLIENTS CLIENTS EMPLOYEES (ANY (65+) (ANY AGE) 65+ EMPLOYEES (ANY (65+) MOST (ANY (65+) AGE) AGE) RECENT AGE) YEAR) Denmark 149,949 126,138 10,195 14.7 12.4 n.a. 38,908 5,016 n.a. 7.8 Estonia 19,982 14,785 264 75.7 56.0 15,308 12,173 522 29.3 23.3 Finland n.a. n.a. n.a. n.a. n.a. 63,847 50,833 5,576 11.5 9.1 Germany 4,001,344 3,039,859 171,254 23.4 17.8 897,677 721,569 224,980 4.0 3.2 Hungary 205,547 160,353 14,186 14.5 11.3 76,174 54,956 19,471 3.9 2.8 Ireland n.a. n.a. n.a. n.a. n.a. n.a. n.a. 6,935 n.a. n.a. Italy n.a. n.a. n.a. n.a. n.a. 423,876 n.a. 31,872 13.3 n.a. Luxembourg 10,662 7,004 906 11.8 7.7 5,402 4,759 1,404 3.8 3.4 Netherlands 382,160 262,175 22,000 17.4 11.9 205,120 135,340 50,000 4.1 2.7 Portugal 16,992 14,208 1,668 10.2 8.5 33,801 27,826 4,906 6.9 5.7 Slovakia n.a. n.a. n.a. n.a. n.a. 39,623 29,944 2,371 16.7 12.6 Slovenia 47,663 30,006 86 554.2 348.9 20,520 16,643 2,479 8.3 6.7 Switzerland 440,747 309,094 33,605 13.1 9.2 89,285 84,368 49,323 1.8 1.7 Source: World Bank analysis, based on OECD data.  Quantitative data is missing for benchmarking wages across sectors for jobs with similar roles, however, focus groups revealed perceived inequalities by staff. Long-term care in Poland is provided by various professional groups, including nurses, doctors, medical caregivers, non- medical caregivers, workers providing care, educational and support services; social workers, rehabilitators, therapists; and a host of administrative employees. Social consultations and surveys conducted by the World Bank suggest that LTC workers in the social sector not only have lower professional prestige, but their remuneration too is worse than their colleagues from the health-care sector. And although the competences of employees of these two sectors may be different, which may be the reason for this disproportion, particular dissatisfaction is heard in the professional group of nurses who, although equally educated, employed in DPS earn much less than equally educated nurses employed in medical entities (ZOL, ZPO). Therefore, the problem concerns primarily long-term inpatient care— 194 DPS does not have the status of a medical entity, and therefore nurses employed in the social welfare system are not given the wage increases guaranteed by law by the MZ. To attract and retain LTC workers, it is vital to solve the problem of adequacy of remuneration to the type of work performed and a clear division of work and professional duties between the social and health sectors. Policymakers should focus on ensuring that LTC workers receive competitive salaries on par with their counterparts in the health-care sector. Increasing wages where needed will not only attract new talent to the LTC sector but also help to retain experienced professionals who might otherwise be lured to similar but better-paying jobs in health care. This move supports equity and recognizes the value of LTC workers’ contributions to society.  In a profession that faces a myriad of disincentives for uptake, raising the salaries of workers is an uncomplicated solution to part of the workforce shortage problem. Long-term work can be physically intensive, often requiring unsociable hours, with difficult working conditions, and characterized by low career growth and prestige. A survey by the World Bank saw LTC workers cite these challenges in their profession. In particular, social workers said their wages were particularly low especially in the context of demanding workloads, travel to high-risk neighborhoods, and their caregiving of sometimes troubled clients. Hence considering the nature of the work and ensuring, at a minimum, remuneration evaluations should make sure that there are not disparities between similar job types, but also paying attention to what would be needed to retain and attract workers to the occupation. These issues require more substantive transformation in the work arrangements for LTC workers. One of the most direct ways to improve the attractiveness of this work, and therefore address workforce shortages in LTC, is to raise the remuneration of workers. Competitive compensation is a powerful incentive to attract new individuals to these professions and retain those already employed in the sector. Higher salaries not only make the profession more appealing but also acknowledge the critical role 195 LTC workers play in supporting the elderly and vulnerable populations. Increasing wages can help to mitigate the challenges of understaffing and high turnover rates, leading to better continuity of care and improved quality of services. Adequate compensation can also alleviate financial stress on workers, resulting in higher job satisfaction and a more motivated and dedicated workforce.  HUMAN RESOURCES SOLUTION 1: Ensure, where appropriate, that remuneration of LTC workers is raised to support the supply of workers for care continuity across service settings. key area(s) addressed: coordination/integration, deinstitutionalization An analysis by the World Bank forecasts demand for health, social, and informal care sectors based on predictions of future care needs; the analysis finds that overall care requirements will be nearly 40 percent higher by 2060. Based on the care hours required for different demographic profiles in the Survey of Health, Ageing and Retirement in Europe (SHARE), the average number of care hours per month was estimated for the period 2022–2060, using the population forecast by GUS in 2023. The percentage change in care hours then assumes a consequential and parallel rate of change in the required numbers of staff (Figure 59). The estimated number of staff required in both sectors is projected against a baseline of 2022 data. Additionally, the number of informal caregivers was calculated with data from the 2023 World Bank survey: approximately 9 percent of respondents declare that they offer care to their close ones — that is about 2.77 million informal caregivers (Figure 60). The data show that a significant number of informal caregivers would be required to sustain the current care provision levels. The ability to meet the projections for the informal caregivers will be immensely challenging, given declining rates of the working-age population and the already strained caregivers in Poland today. The potentially lower availability of informal caregivers is likely to 196 put increasing demand on formal care provision of the health and social sectors; in this scenario, even more LTC staff would be required above the projected levels. Possible mitigating factors of the care requirement projections include improvements in innovation-based efficiency— influencing the caregiving supply side—or improved health outcomes of the population—influencing the care demand side; however, these also require significant policy effort. Forecasted average monthly care demand of older Figure 59.  adults (in hours) in Poland. 20 45% 18.3 18 16.2 40% 15.2 16 35% 13.2 14.2 14 30% 12 25% 10 20% 8 15% 6 10% 4 2 5% 0 0 2022 2030 2040 2050 2060 Male Female Total Percentage change of monthly care hour needs in Poland, compared to 2022 Source: World Bank analysis, based on SHARE data 2023. Human resources required for care provision Figure 60.  in the formal and informal sectors 3,851,274 4 000 000 3,411,500 3 500 000 3,197,347 2,982,766 3 000 000 2,770,793 2 500 000 2 000 000 1 500 000 1 000 000 43,565 46,898 50,272 53,639 60,553 500 000 24,533 26,410 28,310 30,206 34,100 0 2022 2030 2040 2050 2060 Health sector Social sector Informal Source: World Bank analysis, based on MRPiPS and NFZ data 2023. 197 When only considering demographic trends, the informal caregiver pool is estimated to decline by almost 60 percent by 2060 (see section Human Resources C. Provision and quality of informal care). Figure 60, shown previously, presents the number of caregivers required by 2060, which is far above the projected availability, see Table 23. This suggests that much higher rates of the working-age population would need to choose to become LTC workers than at current levels to address needs, in a context of increasing pressure on the LTC system due to the lower availability of informal care. It is difficult to assess the extent of the migrant workforce in LTC, but Poland sees many more workers emigrating there and a generally positive perception of migrant workers. In Europe, the only country that has been able to enumerate the number of migrant care workers is Austria due to its mandate on registering all care workers.108 Estimates for Poland suggest that every fifth migrant worker is employed in a household, which would give a total number of about 100,000 migrant household workers: this is broader than but inclusive of care workers. In Poland, migrant workers can be legally employed by households. However, a general lack of regulation and oversight can increase the risk of abuse of the carers and affect the quality of services.109 Paying for the employment of migrant carers’ is also more feasible for higher- income households as available cash benefits are low and insufficient to cover the costs of migrant carers’ employment, services, while services are also more likely to be obtained in big cities.110 While the exact number of migrants working in LTC is unclear, migrant workers make up a sizable share of the overall labor force111 and in a recent poll, Poland’s respondents reported a relatively high public acceptance of migrant workers.112 Most respondents perceive the employment of third- 108 Sowa-Kofta et al. 2019. “Long-Term Care and Migrant Care Work: Addressing Workforce Shortages While Raising Questions for European Countries.” Eurohealth Observer. 109 Ibid. 110 Ibid. 111  European Commission. 2023. “Poland: Almost 1.3 million Foreigners Work Legally in Poland.” https://migrant-integration.ec.europa.eu/news/poland-almost-13-million-foreigners-work-legally 112  European Commission. “Poland: Poll Shows Relatively High Public Acceptance of Migrant Workers.” https:// migrant-integration.ec.europa.eu/news/poland-poll-shows-relatively-high-public-acceptance- migrant-workers_en 198 country nationals (TCNs) in Poland to be beneficial for individuals and the companies employing them (83 percent) as well as for the Polish economy (72 percent). Common nationality groups among TCNs in Poland include Ukrainians, Belarusians, Moldovans, Indians, and Nepalis; however, Poles were more aware of the increase in trends of Ukrainian migrants.113 The relatively high level of acceptance among Poles regarding the employment of foreigners may contribute to better integration of migrants working in Poland.114 Incentivizing and augmenting the LTC workforce from sources such as the community, the private sector, migration, and through leveraging technology, can help to address workforce shortages and improve the continuum of care. Complementary sources of staffing can come from the community, by attracting migrant workers, collaborating with the private sector, and leveraging technology to explore options for remote workers to deliver care. As workforce shortages persist, it is important to consider external human resources to meet the growing demand for LTC services. Policies should be put in place to facilitate the integration of human resources into the existing LTC workforce. A key benefit of doing so is that formal public sector workers can be trained and incentivized to collaborate with families and other types of caregivers to ensure care is aligned with the needs of the individual and that there is continuity and confidence in the care plan. Providing comprehensive training and support for these external resources is essential to ensure that they meet the required standards of care. Training programs can include language and cultural competency training for migrant workers and quality assurance measures for private sector partnerships. Programs such as Neighborhood Services, which can offer paid services to other members of the community, subject to supervision from a local OPS center or 113 Ibid. 114  European Commission. “Poland: Poll Shows relatively High Public Acceptance of Migrant Workers.” https:// migrant-integration.ec.europa.eu/news/poland-poll-shows-relatively-high-public-acceptance- migrant-workers_en 199 community service center, have the potential to tap into a trusted and localized pool of people willing to participate in caregiving. Technology also has the potential to support the existing pool of the LTC workforce by facilitating a more efficient delivery of care or by substituting for routine tasks of caregivers, thus freeing up time for more complex care provision and human-centered care. Technology can also be used to help with spatial distribution of care, by allowing remote workers to supplement caregiving in different communities. By effectively using external resources, Poland can bridge the workforce gap more efficiently.  HUMAN RESOURCES SOLUTION 2: Incentivize LTC facilities to rely on complementary sources of labor—migrants, family caregivers, NGOs. key area(s) addressed: coordination/integration, deinstitutionalization There is recorded interest from individuals to train as medical caregivers, but until recently, the profession was not legally regulated. In the case of the medical caregiver specialty, data from the Ministry of National Education (MEN) show that the number of schools providing training in the profession of medical caregiver and the number of people being trained has steadily increased each year. In the 2015/2016 school year, the number of schools offering education in this profession was 396, while the number of students was 13,970. In 2021/2022, these had risen to 454 schools and 21,787 students, respectively. As the National Association of Medical Caregivers points out, based on data from the MEN, despite strong interest in the field, only about one-third earn a professional diploma. However, these statistics may be underestimated, as currently there is no register of medical caregivers. Until recently, the profession of medical caregiver was not legally regulated in Poland. Lack of statutory regulation meant that medical caregivers could be employed in other, lower-level positions, for example, as a patient assistant. The profession of medical 200 caregiver was included in the Act of August 2023 on certain professions (Journal of Laws, item 1972), as well as in the Ordinance of the Minister of Health of July 10, 2023, on qualifications required of employees in particular types of positions in non-business medical facilities (Journal of Laws, item 1515), which provides for the position of medical caregiver and senior medical caregiver. Medical caregivers are underemployed in the LTC sector, sometimes working in lower-level positions; a simple yet effective solution is to continue efforts to standardize the profession and outline the scope of duties. Continued work on standardization of the profession of medical caregivers will have knock-on effects in terms of the ability to better regulate this profession, make it more attractive as a prospective career path, and allow for ease of recruitment of these types of positions by using a standardized title and job role. One of the first steps in enhancing this professional category is through retitling the position as ‘care professional’ to reflect the skills required for LTC provision and to better match care professionals to positions of appropriate grade and complexity levels. This would allow the better formulation of skills requirements, roles, and remuneration policies concerning this position. It would also enable the monitoring of the numbers of care specialists operating in the LTC system. HUMAN RESOURCES SOLUTION 3 Step up the efforts intended to standardize and formalize the profession of medical caregiver. key area(s) addressed: coordination/integration, deinstitutionalization Workforce projections in the LTC sector are currently unavailable, making it difficult to anticipate future gaps; while using the number of those enrolled in relevant studies suggests an increase in labor supply, it is unclear how many will enter LTC. Available workforce projections pertain to the overall number of nurses and doctors as well 201 as medical caregivers. In the 2015/2016 academic year, 5,935 people enrolled in undergraduate nursing, while in 2021/2022 the number increased almost twofold, to 11,408. The number of universities offering to train future physicians in 2023/2024 will increase to 36, which is 12 universities more than in the previous academic year. The total number of available places for medical studies is approximately 11,627; the number of slots in full-time studies increased by 13 percent compared to the 2022/2023 academic year, while the number of slots in extramural studies has decreased. Moreover, according to data from the National System for Monitoring the Economic Lives of University Graduates (ELA), as many as 93 percent of medical degree graduates in Poland are employed in the health-care sector. The Supreme Chamber of Nurses and Midwives (NIPiP) has documented that only 60 percent of nursing degree graduates pursue employment in the profession. Therefore, a serious concern is that while the number of graduates in medical studies, nursing, and medical caregiving is increasing, the disparity in salaries, lack of regulation for medical caregivers, and workforce migration continue to pose significant challenges for the LTC sector in Poland. This is in a context where by 2030, there will be 10 percent more people over 50 years (an additional 1.5 million people) than in 2022, and the number of care hours required per month is projected to increase by 6 percent. To care for the greater numbers of older people, 17 percent more home care workers will be needed than currently—approximately 5,100 more workers.  Elevating the prestige of LTC professions can enhance their appeal as long-term career choices. Low prestige is often cited as a barrier for participating or pursuing a role in LTC provision. Providing opportunities for upskilling and continuous training is critical for keeping LTC workers abreast with best practices and enhancing their qualifications. In addition, offering benefits such as physiotherapy and mental health support for workers can improve their overall well-being and job satisfaction. These career development opportunities not only attract individuals to LTC professions but also encourage them to remain in the 202 sector over the long term. By fostering a sense of professional growth and advancement, the LTC sector can build a stable and dedicated workforce that delivers high-quality care to those in need.  HUMAN RESOURCES SOLUTION 4: Boost the prestige and attractiveness of care work—for example, through outreach campaigns, education, and additional packages of nonfinancial incentives such as mental health support, physiotherapy options, occupational courses/ training, and professional development. key area(s) addressed: labor market Long-term care workers can be subject to difficult working conditions, and most concerning is the risk of violence and abuse. Evidence from other advanced economies suggest that LTC workers face heightened risks of violence and abuse in their workplace. In the United States, the health and social assistance sector sees the highest risk of non-fatal violence, but this is seen as a global phenomenon.115 WHO estimates that between 8 percent and 38 percent of health workers suffer physical violence at some point in their careers. Many more are threatened or exposed to verbal aggression. Most violence is perpetrated by patients and visitors.116 In the survey commissioned by the World Bank in Poland, aggression was experienced primarily by nurses and medical carers in public ZOL, ZPO, and family structured LTC facilities, less frequently in DPS LTC facilities. These workers have resorted to training in self-defense—sometimes at their own expense— or relying on other staff to step in. Hence those providing care in home- based settings could be at elevated risk as they often work in isolation. In a study on home care aids in the US, 22 percent had suffered verbal abuse in the 12 months before the survey, and the risk factors included 115 Gerberich. 2019. “Verbal Abuse Against Home Care Aides: Another Shot Across the Bow in Violence Against Health Care and Other Workers.” Occupational and Environmental Medicine 76: 593–594. 116 WHO. “Preventing Violence Against Health Workers.” https://www.who.int/activities/preventing-violence- against-health-workers 203 patients with dementia, homes with too little space for the aide to work and unpredictable work hours.117 It is important to ensure that vulnerable groups are not being subject to abuse which is less likely to be reported because the workers are less visible in the system. This includes migrants who may not be familiar with available services or those migrants in an irregular situation who feel that they can safely report the abuse experienced to the police without fear of being returned to their country of origin.118 A suite of interventions can mitigate violence in the workplace. First, including or amending legislation around workplace violence can mandate better oversight and control of this at the facility and health- care setting, encouraging the adoption of policies at the workplace level, and monitoring its implementation in terms of standards setting. It is also important that home-based workers are protected; this can be improved by establishing proper reporting protocols. Hence this is a cross-cutting area to be considered under legislation and quality. Other communication activities such as building awareness of this issue and requesting the collection of information on the incidence and impact of this kind of violence.119 Resourcing issues can exacerbate violence, so having sufficient staffing and support can help individuals respond to and prevent an adverse event. HUMAN RESOURCES SOLUTION 5. Implement protections measures for care providers from violence and abuse in all its forms. key area(s) addressed: labor market 117 Karlsson, et al. 2019. “Home Care Aides’ Experiences of Verbal Abuse: A Survey of Characteristics and Risk Factors.” Occupational and Environmental Medicine 76: 448–454. 118 European Union Agency for Fundamental Rights. 2019. “Protecting Migrant Workers from Exploitation in the EU: Workers’ Perspectives.” https://fra.europa.eu/en/publication/2019/protecting-migrant-workers- exploitation-eu-workers-perspectives#publication-tab-1 119 International Labour Organization, International Council of Nurses, WHO, and Public Services International. 2002. “Framework Guidelines for Addressing Workplace Violence in the Health Sector.” Joint Programme on Workplace Violence in the Health Sector. 204  OMPETENCES OF SELECT LTC B. C PERSONNEL This solution area seeks to address the limited competences of select LTC personnel. The challenge posed by the limited competences of select LTC personnel in Poland is a significant concern, as highlighted by public consultations conducted by the World Bank. During social consultations with NGOs, facility representatives, carers, and patients, workforce training was ranked as the third most crucial measure to enhance LTC organization in the country. Nearly 50 percent of participants believed that there was little that could be done at the organizational level to improve LTC functioning. The regulation that currently supports the employment of medical caregivers in a long-term care team does not have established standards, and therefore does not prescribe or endorse the competences for providing care. The current Ordinance of the MZ on guaranteed care and nursing benefits within LTC, enacted on November 22, 2013, stipulates that medical caregivers may provide services in the scope of their competence within a long-term care team. However, the permissive language (‘may’) implies that LTC facilities are under no obligation to hire them as part of their LTC teams, whereas nurses are included under staffing requirements. The key area to be addressed is the limited competences of selected LTC personnel, especially medical caregivers, due to the absence of stringent regulations governing their roles and responsibilities within the health- care framework. Efforts have been made to expand some of the competences of medical caregivers, but these may be undermined if the expanded competences are not enshrined in law. The Ordinance of the Minister of Education and Science, enacted on January 27, 2021, introduced amendments that expanded the competences of medical caregivers. These included activities such as collecting venous and capillary blood 205 and other materials for laboratory tests, performing subcutaneous injections, or administering drugs to a sick and dependent person ordered by a doctor or nurse. Although a medical employee has a statutory obligation to develop professionally during a five-year educational period, the absence of a specific law regulating the professional path of medical caregivers may hinder the effective utilization of these expanded competencies in the existing LTC system. At the time of writing, the MZ is working on a draft regulation on a detailed list of professional activities of persons performing certain medical professions (MZ 1644), which specifies a detailed list of professional activities to which persons performing medical professions covered by the above are authorized to perform, considering the knowledge and skills acquired during education enabling obtaining qualifications in these professions An attractive and clearly outlined career path that is matched with opportunities for personal development and progression will see individuals self-invest to develop the skills needed to provide quality LTC services. As a starting point, it is essential to create opportunities for the existing workforce to upskill and receive further training. This can be achieved by offering professional development programs that focus on the specific needs and competencies required in LTC. Competency frameworks should be developed to clearly define the skills and knowledge expected at various levels of care provision, from junior to senior management roles and specialized positions. By offering clear career paths and guidance on how to progress within the field, employees are more likely to invest in their professional development. Upskilling and training opportunities, along with clear career paths, motivate employees to continuously improve their skills. This not only improves the competence of the workforce but also provides a sense of purpose and motivation for individuals working in LTC.  206 To make a meaningful impact, the workforce requires structural changes, which include the formal setting of standards. An effective way to ensure that LTC workers are adequately trained and competent for their roles is to establish mandatory certification and professionalization standards. This means that individuals entering the field or already working in LTC must meet specific educational and training requirements to practice. These requirements should be appropriate for the level of care they provide, whether it is basic caregiving or specialized medical services. Mandatory certification and professionalization set consistent standards for entry into the field. Professionalization helps raise the overall quality of the LTC workforce, ensures consistent standards, fosters public trust in the services provided, and improves the prestige of the profession. By implementing these measures, Poland can significantly improve the competences of its LTC workforce. To maintain high standards of care in LTC, it is necessary to mandate continued professional development (CPD) requirements. This involves ongoing training and education to keep LTC workers updated with the latest developments and best practices in the field. CPD should align with the previously mentioned competency frameworks, ensuring that LTC professionals are well-equipped to provide quality care. Rotation of workers across facilities, types of care, and supervision settings will also foster a culture of oversight and professional development that would positively maintain and develop professional competencies in line with standards. This comprehensive approach will help mitigate the challenges related to limited competences within the LTC sector, ultimately leading to better quality care and a more professionalized workforce.  HUMAN RESOURCES SOLUTION 6: Facilitate access to upskilling and training for the LTC workforce, formulate a skills framework and career paths, and offer career advancement and promotion mechanisms based on a common skills framework and rotation between LTC roles and settings. key area(s) addressed: labor market 207 PROVISION AND QUALITY OF C.  INFORMAL CARE This solution area seeks to regulate and maximize the provision and quality of informal care; this is especially important given that Poland is characterized by a high degree of reliance on informal care provision. Providing regulations and maximizing the provision and quality of informal care in Poland is a complex issue deeply rooted in cultural perceptions and social expectations. Despite the presence of nursing and care services within the publicly funded health and social systems, LTC in Poland predominantly remains a familial responsibility. Indeed, traditional family roles are firmly ingrained in citizens’ perceptions, with the family serving as the primary support and care network. In a 2017 survey of European values, nearly 74 percent of respondents in Poland agreed or agreed strongly with the statement that adult children have the duty to provide long-term care for their parents.120 The 2023 survey commissioned by the World Bank echoes these sentiments, emphasizing that 54 percent of respondents expect their family to be primarily responsible for their care in case of slight health deterioration, and increasing to 69 percent in the event of a significant health deterioration. State health care and social assistance institutions are considered a secondary choice (Figure 61). Additionally, 80 percent of participants in social consultations reinforced the family’s role as the cornerstone of responsibility for care and assistance in case of sudden deterioration, with government institutions seen as a secondary option. 120 EVALUE. 2017. “Atlas of European Values.” https://www.atlasofeuropeanvalues.eu/maptool.html 208 In your opinion, who should be responsible for care Figure 61.  and assistance to you in your daily activities in case of a sudden deterioration in your health (mild, moderate, severe)? 80% 70% 60% 50% 40% 30% 20% 10% 0% Mild Moderate Severe Family Government Myself Source: World Bank 2023, Survey of a representative sample of Poland’s population.  Defining informal care is a foundational step toward addressing the challenges posed by the reliance on family caregivers, limited caregiving capacity, and low health literacy. To implement the structural changes required to fulfil the solutions for informal caregivers, there needs to be a definition of who is an informal caregiver so that this is consistent in policy, at care coordination in health-care settings, for coordinating with a formal care team, navigating the carers benefits, and so forth. Having a definition also facilitates recognition, support, and collaboration between informal caregivers, health-care systems, social care systems, and society at large, ultimately improving the quality of care and the well-being of care recipients and caregivers. Importantly, defining who is a caregiver can support better outreach to, enumeration, and mapping of these individuals. Therefore, they can be better reached in terms of support and policy targeting. 209 HUMAN RESOURCES SOLUTION 7. Develop a definition for informal caregiving. key area(s) addressed: deinstitutionalization, labor market The expectation that the family or a member of one’s local community should take on care responsibilities is further emphasized by people’s desire to be cared for at home. The World Bank survey found that 68 percent of respondents would prefer to be assisted in their own homes. These preferences are consistent across demographics, with both men and women, as well as people of all age groups, indicating their homes as their preferred location for care. Inpatient facilities are the preferred choice of only 15 percent, while 8 percent prefer outpatient facilities (Figure 62).  If your health were to deteriorate significantly in the Figure 62.  next two years and long-term care was necessary, how would you want that care to be arranged? At home 68% At an inpatient facility 15% I don’t know, it’s hard to say 9% At an outpatient facility 8% Other 0% Source: Survey of a representative sample of Poland’s population, World Bank 2023.  The preference for receiving care by a family member or friend is not envisioned, planned, or communicated with realistic future care needs in mind. There is a significant gap in awareness and communication within families regarding LTC needs. Almost 80 percent of respondents have never discussed their LTC needs with their families 210 (Figure 63), with men and those under 45 being least likely to engage in such conversations. Reasons cited for not discussing care needs include a belief that it is not yet necessary (50 percent) or that it will never be necessary (28 percent). Moreover, 47 percent of respondents stated that they would only need any potential support after they reach the age of 80, and according to 12 percent, such assistance would not be needed at all in the future. Given that the average healthy life expectancy in Poland is about 61 years, the vision of Poland’s society that care needs appear only in their 80s is not reflected in reality. Have you ever talked to your family or friends about Figure 63.  the issues related to aging and your future care needs? 3% 21% Yes, it has been discussed No, it has never been discussed I don’t know, I don’t remember 76% Source: Survey of a representative sample of Poland’s population, World Bank 2023.  In addition to being expected to provide care, families are set to face an even higher burden of care demands in the future. Based on demographic changes in the population structure based on GUS data, the projections consider the decline in the total population and the increase in the elderly dependency ratio (Table 23). In the scenario where declines in the total population and the aging of the population are modelled (scenario 3), the availability of informal carers is estimated to drop to 41 percent of what is currently available today by 2060. 211 Table 23. Projections of the availability of informal carers 2023 2030 2040 2050 2060 SCENARIO 1: Total population changes Change in total population, compared to 2022 100% 98% 93% 88% 82% Projected number of informal caregivers 2,770,793 2,718,205 2,586,828 2,435,752 2,268,911 (benched to population decline) SCENARIO 2: Old-age dependency changes Change in dependency ratio of older 100% 115% 130% 173% 199% people, compared to 2022 Projected number of informal caregivers (benched 2,770,793 2,406,274 2,125,504 1,598,171 1,390,707 to changes in old-age dependency rates) Change in the availability of informal 100% 87% 77% 58% 50% caregivers (benched to the changing old-age dependency rates), compared to 2022 SCENARIO 3: Total population and old-age dependency changes Projected number of informal caregivers 2,770,793 2,360,605 1,984,383 1,404,921 1,138,804 (benched to changes in old-age dependency and total population changes) Change in the availability of informal caregivers 100% 85% 72% 51% 41% (benched to the changing old-age dependency rates and total population changes), compared to 2022 Source: World Bank analysis, based on MRPiPS and NFZ data 2023. As the care burden is set to increase, informal caregiving will continue to be highly disruptive to people’s working lives, and therefore it is vital that negative impacts are mitigated, financial hardship is reduced, and the attachment to the labor market is maintained. Offering tax credits or financial incentives to informal caregivers can alleviate some of the financial burdens associated with providing care. This can incentivize family members to take on caregiving roles, making it more feasible for them to provide care without excessive financial strain. Pension credits and other forms of financial assistance are key options that can be provided through the social sector (see International Examples in the appendix for an example of using pension credits for caregivers). On maintaining an individual’s labor market attachment, flexible work arrangements and job security guarantees could enable informal caregivers to balance their work responsibilities with caregiving duties. Such an arrangement would also be better for labor markets as the transaction costs of people 212 losing their jobs and trying to reenter the labor market can be high. Another solution is job guarantees which ensure that there is a place in the labor market for reentry after caregiving duties. This can help caregivers maintain their income and job security while caring for their loved ones, reducing the financial pressure that may lead to reluctance in providing care. HUMAN RESOURCES SOLUTION 8: Facilitate informal caregiving and mitigate negative labor market consequences for carers, including family members, through pension credits, tax credits, work flexibility, and job guarantees. key area(s) addressed: deinstitutionalization, labor market Informal caregiving is widespread and sees many adults struggling to balance their professional and caregiving lives, with little regulatory oversight and in a context where the care burden is set to increase. The informal caregiving landscape in Poland is largely facilitated by family members, with 9 percent of respondents (which corresponds to almost 2.7 million of the adult population) stating that they provide care to a chronically ill, disabled, or elderly person. Informal caregivers, predominantly those in middle age, often find themselves in caregiving roles unexpectedly, leading to challenges in balancing their professional and personal lives. The World Bank’s 2023 survey found that noninstitutional LTC services are predominantly provided by informal caregivers, and a significant portion of them are unpaid, but motivated primarily by a sense of duty. Also, given the size of the informal caregiving pool, an absence of regulations means that the quality of informal care is not being monitored or improved through formal means. Indirect costs associated with informal caregiving, such as psychological strain, changes in professional performance, and damage to one’s physical health, highlight the considerable sacrifices made by informal caregivers. Demographic changes, longer lifespans, and societal shifts contribute to an increasing care burden, rendering the 213 family incapable of meeting all the necessary care needs. The GUS- projected indicators of potential support, parental support, and caregiving capacity will change dramatically (Table 24). Addressing the key area of providing regulation and maximizing the provision and quality of informal care requires a multifaceted approach, including the development of formal care, improved communication within families, and educational campaigns to enhance public awareness and understanding of LTC needs. Indicators of potential support, parental support, Table 24.  and caregiving capacity in 2017–2050 YEAR OLD-AGE-DEPENDENCY PARENT SUPPORT CAREGIVER RATIO (PER RATIO (ELDERLY PER 100 RATIO (PER 100 100 PEOPLE AGED 80+) WORKING-AGE PEOPLE) PEOPLE AGED 80+) 2017 25.0 468.9 243.0 2018 26.1 453.8 234.8 2019 27.2 439.0 226.8 2020 28.1 432.7 223.3 2021 28.9 434.0 223.9 2023 30.9 436.0 224.2 2030 34.4 363.5 186.0 2050 51.8 226.7 115.9 Source: World Bank analysis, based on GUS and BASiW data, 2023.  There is much that can be done in-kind to support informal caregivers with the physical and emotional health toll. Informal caregivers often face physical and emotional challenges. Offering physiotherapy services can assist caregivers in managing physical demands, such as lifting and assisting with mobility. Mental health support can help caregivers cope with the emotional stress associated with caregiving, reducing burnout and enhancing the quality of care provided. Respite care programs offer temporary relief for caregivers, allowing them to take breaks and attend to their own needs. This ensures that caregivers do not become overwhelmed and can continue providing care effectively.  214 Most informal caregivers feel unprepared for the responsibility of providing care when it is needed. Therefore, offering structured training programs for informal caregivers can equip them with the necessary skills and knowledge to provide quality care, while care vouchers can empower better choice over care assistance. This can include support for basic health-care training, understanding specific medical conditions, and knowing how to provide assistance effectively. As mentioned under financing solution 3, care vouchers should be explored as a way to subsidize care choices for targeted groups—managed by LGUs (see international examples in the appendix for more information on how care vouchers have been used in Finland, France, Belgium, and Germany). Increasing health literacy among informal caregivers can also better help caregivers understand and manage the health needs of those they care for. This includes recognizing signs and symptoms of health events, adhering to medication regimens, and accessing appropriate health-care services when needed. This will ultimately improve the well-being of carers and the quality of informal care received by the cared for. HUMAN RESOURCES SOLUTION 9: Provide financial and nonfinancial support for informal caregivers, including family members, such as care vouchers, education and training, physiotherapy, mental health support, and respite care. key area(s) addressed: deinstitutionalization, labor market In a survey conducted by the World Bank, informal caregivers reported a feeling of being left to their own devices, with little support. The sense of lacking government/system support is particularly strong in family caregivers who take care of their loved ones unassisted, without support from other family members. They are exhausted, they do not collect benefits and they are not aware of any respite care options. None of the respondent family caregivers had considered taking care of a family member before it became necessary, 215 and they had no choice but to reorganize their life and rearrange their routine. The situation is described as quite difficult for the respondents, if only because of their professional activity and the need to find the time and continue to attend to their own family. Taking up caregiving was something they did under the pressure of the moment and was not a deliberate plan for the future. The transition into a caregiving role is a particularly important time to provide support to informal caregivers. Where someone suddenly requires care, such as through experiencing an acute phase of a disease, this can be a particularly overwhelming time for the friends and family who step in to provide care. There is therefore a need to support people to transition effectively into a caregiving situation. The new care recipient should be supported by a formal caregiving team, in cooperation with the LTC coordinator or designated PHC contact person. The family or friends should then receive support from this formal care team as the responsibility for the loved one shifts to them. There should be sufficient support to allow the designated informal carers to make the necessary arrangements at work or in their personal lives. In addition, the family and friends should be given adequate training during this period, so that they feel comfortable and equipped to take over whatever care responsibilities are required of them. As the physical environment of the care recipient will greatly influence their care outcomes and the ability of their carer to work, the necessary home adjustments should also be put in place. The support of LTC coordinators will be indispensable in this regard. HUMAN RESOURCES SOLUTION 10: Introduce temporary and transition care to give families who have elected to become caregivers time to adjust their work patterns, become trained, and adapt the home to the LTC beneficiary’s needs. key area(s) addressed: deinstitutionalization, labor market  216 Summary of Human Resource Solutions HUMAN RESOURCE SOLUTIONS WHAT IS BEING KEY AREA LTC GOAL ADDRESSED 1. Ensure, where appropriate, that remuneration A. There is variation Labor market, Effective of LTC workers is raised to support the supply of in the availability and Coordination/ Human workers for care continuity across service settings. distribution of personnel Integration, Resources within and between Deinstitutionalization 2. Incentivize LTC facilities to rely on sectors in Poland. complementary sources of labor— migrants, family caregivers, NGOs. 3. Step up efforts intended to standardize and formalize the profession of medical caregiver. 4. Boost the prestige and attractiveness of B. The competences of Labor market Effective care work—for example, through outreach select LTC personnel Human campaigns, education, and additional packages need to be expanded. Resources of nonfinancial incentives such as mental health support, physiotherapy options, occupational courses/training, and professional development. 5. Implement protections measures for care providers from violence and abuse in all its forms. 6. Facilitate access to upskilling and training for the LTC workforce, formulate a skills framework and career paths, and offer career advancement and promotion mechanisms based on a common skills framework and rotation between LTC roles and settings. 7. Develop a definition for informal caregiving. C. Informal care should Deinstitutionalization, Effective be regulated and Labor market Human 8. Facilitate informal caregiving and mitigate maximized to improve Resources negative labor market consequences for carers, the provision and quality including family members, through pension credits, of this type of care. tax credits, work flexibility, and job guarantees. 9. Provide financial and nonfinancial support for informal caregivers, including family members, such as care vouchers, education and training, physiotherapy, mental health support, and respite care. 10. Introduce temporary and transition care to give families who have elected to become caregivers time to adjust their work patterns, become trained, and adapt the home to LTC needs. 217 QUALITY A. QUALITY OF FORMAL LTC This solution area seeks to increase the quality of formal care provided by individual carers, care organizations and facilities, and the care system. The enhancement of formal care quality is crucial for ensuring the well-being of individuals receiving LTC services. Quality of care is defined as the degree to which services improve the likelihood of desired outcomes, and in the context of health services quality is increasingly understood as being effective—providing evidence-based health-care services to those who need them; safe—avoiding harm to people for whom the care is intended; and people-centered—providing care that responds to individual preferences, needs, and values. Whereas standards are the defined levels of a service that should be in place to attain quality outcomes.121 According to the International Organization for Standardization (ISO), standards are best understood “as a formula that describes the best way of doing something.” 122 Standards are just one component of quality assurance, they require other actions including training, awareness and communication, monitoring, and feedback and updating.123 In Poland, quality of care and the standards for ensuring this quality of care need to be improved. The emerging cooperation between the social care and health-care sectors in LTC delivery emphasizes the need to address aspects of LTC quality in both sectors simultaneously. In defining a quality framework for LTC in Poland, it is important to consider its four main components: social care, health care, formal care, and informal care. It is therefore necessary to include both social and health sector representatives in the work of developing the framework. The proposed framework and corresponding key indicators for assessing the quality of LTC in Poland 121 WHO. 2024. “Quality of Care. Health Topics.” https://www.who.int/health-topics/quality-of-care#tab=tab_1 122 ISO. “Standards.” https://www.iso.org/standards.html 123 WHO, World Bank, and OECD. 2018. “Delivering Quality Health Services: A Global Imperative.” https://doi. org/10.1787/9789264300309-en 218 are presented in Table 25, based on solutions from international examples. In addition to those presented in the table, the following should also be considered when developing the quality framework and corresponding evaluation indicators: national requirements for the type, number, and qualification of staff; furnishing standards for LTC facilities; and how to allow as many good quality LTC providers as possible to enter the market. Key framework and corresponding key indicators for Table 25.  assessing the quality of LTC to be considered in Poland DIMENSION INDICATOR SOURCE Individualized care plans   These plans include a detailed assessment of the Health Information and Effectiveness needs of LTC recipients and the support required to Quality Authority (2016)124 satisfy their needs and improve their quality of life. Regular assessment of the health and well-being of care   beneficiaries Health Information and Health and well-being of LTC users can be promoted and Quality Authority (2016) Health and well-being verified through regular assessment based on surveys or validated questionnaires. Igarashi et al. (2020)125 Number of hospital admissions and readmissions for   inpatient treatment All relevant information used to plan and deliver   Health Information and Use of information effective, safe, and person-centered LTC services Quality Authority (2016)   Number of follow-up appointments  Fragmentation of care index (FCI) Collaboration between the social and health-care Continuity of care sectors should be measured to identify, address and Accreditation Canada126 coordinate services across the continuum of care. This includes, among other things, ensuring that LTC users participate in follow-up appointments. Staff caring for LTC recipients are properly trained.   LTC recipients in institutional care have 24-hour access to   Capacity and a nurse. Quality Framework availability of staff LTC users in institutional care have 24-hour access to   Responsible Care (2007)127 a doctor. LTC users are legally protected from abuse by staff.   Informal caregivers (unpaid family members,   Maintenance of among others) are identified. Igarashi et al. (2020) family well-being Informal caregivers (care provided by unpaid family   members) have access to social and health-care support. Source: World Bank 2023. 124 Health Information and Quality Authority. 2016. “Your guide to the National Standards for Residential Care Settings for Older People in Ireland.” https://www.hiqa.ie/sites/default/files/2017-01/National-Standards-for-Older-People-Guide.pdf. 125 Igarashi A, Eltaybani S, Takaoka M, Noguchi-Watanabe M, Yamamoto-Mitani N. Quality Assurance in Long-Term Care and Development of Quality Indicators in Japan. Gerontology and Geriatric Medicine. 2020;6. doi:10.1177/2333721420975320 126 Accreditation Canada. 2015. An Overview of Accreditation Results: Alberta. https://www.scc.ca/sites/default/files/publications/ASB_ POV_ASB-Program-Overview_v0_2015-06-30.pdf/. 127 ACTi, Organisation of Care entrepreneurs, et al. 2007. Quality Framework Responsible Care: Nursing, Care and Home Care. https://static-content.springer.com/esm/art%3A10.1186%2F1472-6963-10-95/MediaObjects/12913_2009_1232_MOESM1_ESM.PDF. 219 The developed framework and quality indicators should be standardized as much as possible for providers of similar services. This solution could help eliminate disparities in quality of care between different LTC facilities and create a level playing field for all providers. It will ensure that each care recipient receives care of specified quality, which promotes equality and fairness. Quality frameworks and indicators should also be uniform for private and public providers, with quality standards and mechanisms covering the full range of LTC services across settings, and across all typers of providers, regardless of ownership. To develop an integrated quality framework and KPIs for Poland, an expert team should be appointed who can draw on existing national documents, international best practices in quality frameworks (including information in Appendix 5: International examples—relevant for Poland), and by consulting with stakeholders, where necessary. QUALITY SOLUTION 1: Appoint an expert team to develop an integrated LTC quality framework and KPIs in the relevant LTC acts of law. key area(s) addressed: coordination/integration, deinstitutionalization Oversight for LTC spans government agencies and levels, and no unified definition exists for LTC quality that is applicable to both sectors. The responsibility for LTC service oversight lies with national and regional government institutions, each with their own specific inspection authority determined by legal provisions. Inspection bodies include voivodes, the Department of Inspection of the NFZ, and the National Mechanism for Prevention of Torture (KMPT) attached to the Office of the Commissioner for Human Rights. However, at present, Poland’s legal system lacks a unified definition of LTC quality applicable to both the health and social sectors. The Act of November 6, 2008, on accreditation in health care and the recently enacted Act on quality in health care and patient safety regulate health care quality and although they do not 220 exclude LTC facilities, the primary focus is on therapeutic activities. Similarly, the Act of March 12, 2004, on social assistance addresses inspections of social facilities without explicitly defining LTC quality. The quality of LTC must be regulated by law to ensure that all stakeholders such as central and regional governments, care coordinators, care facilities, and individual caregivers are obligated to comply with it. Incorporating the quality framework and indicators into LTC regulation is therefore fundamental. This means defining and enforcing specific benchmarks that LTC providers must meet in terms of care quality, safety, and patient rights. Legal regulation of the quality framework and indicators will ensure that providers consistently deliver a high level of care. In addition to enforcing, leveraging financing mechanisms to incentivize quality assurance should also be explored, for example, in the form of paying for performance, as discussed under the Financing solutions section. By making adherence to quality a legal requirement, providers are incentivized to maintain and improve the quality of their services. QUALITY SOLUTION 2: Include the LTC quality definition, framework, and KPIs in the LTC law. key area(s) addressed: coordination/integration, deinstitutionalization LTC facilities are not inspected in a systematic manner—but of the few that have been inspected, irregularities have been identified in half of them.128 Although the Regulation of the MRPiPS dated December 18, 2020 on supervision and control in social assistance indicates that "comprehensive inspections in the entity subject to 128 Detection of irregularities may result from the very nature of the inspection, which is aimed at detecting them 221 inspection are carried out at least once every four years according to the inspection plan." 129, the frequency of inspections carried out for medical entities is not limited by specifying their number, but only the conditions and procedure for conducting inspections and documentation of inspection activities.130 Based on the above, it is difficult to talk about the systematic nature or regularity of the inspections. The World Bank’s analysis of inspections carried out from 2017 to 2021 reveals a low number of inspections carried out in LTC facilities. Only about 8 percent of LTC health-care facilities and 18 percent of LTC social care facilities were controlled annually in those years—the low number of controls may partly be a result of the COVID-19 pandemic during that time. The analysis of inspections carried out from 2017 to 2021 identified irregularities including systemic issues, gaps in patient records, legal compliance, inadequate living conditions, unmet medical care standards, staff shortages, improper use of coercion, and violations of residents’ rights. These irregularities were found in more than half of the inspected facilities, although only a small number of facilities were inspected. Table 26 presents a selection of inspection data; it only presents information from the voivodes’ inspections; and does not include NFZ and KMPT inspections. 129  Regulation of the Minister of Family, Labour and Social Policy of December 18, 2020 on supervision and control in social assistance. https://isap.sejm.gov.pl/isap.nsf/download.xsp/WDU20200002285/O/ D20202285.pdf 130 Ministra Zdrowia. w sprawie ogłoszenia jednolitego tekstu rozporządzenia Ministra Zdrowia w sprawie sposobu i trybu przeprowadzania kontroli podmiotów leczniczych [method and procedure carrying out inspections of medical entities]. https://isap.sejm.gov.pl/isap.nsf/download.xsp/ WDU20150001331/O/D20151331.pdf 222 Number and results of voivodes’ inspections over Table 26.  the period 2017–2021 TYPE OF FACILITY HEALTH SECTOR (ZOL, ZPO, DDOM) SOCIAL SECTOR (DPS, 24-HOUR CARE FACILITY) REGIONS SHARE OF SHARE OF NUMBER % NUMBER % NUMBER OF INSPECTIONS NUMBER OF INSPECTIONS OF INSPECTED OF INSPECTED INSPECTIONS WITH INSPECTIONS WITH FACILITIES* ANNUALLY FACILITIES* ANNUALLY IRREGULARITIES IRREGULARITIES Dolnośląskie  68  4  1.2%  100%  — — — — Kujawsko-Pomorskie  42  5  2.4%  —**  — — — — Lubelskie  37  3  1.6%  100%  81  95  23.5%  49.5%  Lubuskie  15  18  24.0%  — 50  16  6.4%  — Łódzkie  41  2  1.0%  50.0%  118  66  11.2%  54.5%  Małopolskie  52  14  5.4%  — 167  141  16.9%  — Mazowieckie  113  72  12.7%  72.2%  282  380  30.0%  71.4%**  Opolskie  21  14  13.3%  71.4%  68  40  11.8%  — Podkarpackie  40  23  11.5%  — 104  12  2.3%  — Podlaskie  21  14  13.3%  14.3%  50  68  27.2%  63.2%  Pomorskie  35  6  3.4%  0.0%  148  209  28.2%  40.7%  Śląskie  73  36  9.9%  — 230  169  14.7%  7.7%  Świętokrzyskie  22  21  19.0%  — 76  64  16.8%  70.3%  Warmińsko-Mazurskie  17  12  14.1%  25.0%  86  125  29.0%  — Wielkopolskie  42  14  6.6% 71.4% 142 61 8.6% 59.0% ****  Zachodniopomorskie  35  5  2.9% 0.0% 76 66 17.4% 69.7%  Total Total   Average Average   Total Total   Average Average  674  263  7.8% 52.1% 1,678 1,512 18.0% 54.0% Sources: *World Bank compilation based on KRDO (National Register of Care Facilities), status as of June 14, 2023; due to the lack of access to data from this registry from 2021 or any other publicly available registry, the results should be treated with caution as the number of facilities may have changed. Note: ** No data available; ***Only pertains to ad hoc inspections; n=185; **** Own compilation based on information provided in Public Information Bulletin (BIP). KMPT inspections raised concerns about issues related to patient safety and rights, and cited staff training as critical for preventing these issues from occurring. During 2017–2021, KPMT carried out inspections in 86 LTC facilities: Care and Treatment Facilities (ZOL), 18 inspections; Social Welfare Homes (DPS), 30 inspections; and facilities providing 24-hour care, 38 inspections. The KMPT inspections delved into issues related to direct coercion, medication administration, living conditions, and residents’ rights. Post-inspection recommendations emphasized the need for increased staff training, especially regarding 223 the Istanbul Protocol,131 and addressing issues like professional burnout. The voivode inspections, covering various aspects of facility operations, highlighted irregularities such as operating without proper documents, incomplete records, staff shortages, exceeding resident limits, and neglecting residents’ rights. NFZ inspections, which focused on health-care services, uncovered irregularities like incomplete medical records, gaps in internal documentation, staff shortages, and irregularities in health services provision.  Inspections of LTC facilities revealed several issues relating to the quality of care provided by personnel. Staffing shortages were a recurring problem, with facilities often lacking the necessary caregiving and medical personnel. Moreover, there were instances where employees did not possess the required licenses and lacked proper training. The use of nonstandard forms of coercion, often without legal basis, raised concerns about the safety and well-being of residents. Medication administration practices were also flagged, including unauthorized personnel administering drugs and using deceptive methods. Access to specialized equipment that could support the provision of care, particularly for physical therapy, was noted as a challenge, coupled with low awareness of available funding options. Recommendations emphasized the need for increased training, especially covering items such as the Istanbul Protocol, to address identified shortcomings.  Certain irregularities were discovered in LTC organizations during inspections, shedding light on organizational challenges. Operational issues were prevalent, with facilities found to operate without proper documentation. Record-keeping problems included gaps in medical and internal records, unlawful clauses in contracts, and missing 131 Office of the High Commissioner for Human Rights.The Istanbul Protocol. https://www.ohchr.org/en/ publications/policy-and-methodological-publications/istanbul-protocol-manual-effective-0. 224 residents’ signatures. Staffing challenges, including shortages and inadequately qualified personnel, were found to be recurrent. Living conditions often fell short in terms of hygiene, sanitation, and adherence to disability accessibility standards. Inspection outcomes highlighted high irregularity rates, with over 50 percent of facilities consistently found to have issues. Voivode inspections covered a broad spectrum, including the condition and equipment of facilities, records, staff qualifications, and residents’ rights. Formal caregivers also expressed concerns about patients’ loneliness affecting their intellectual function. The regulatory landscape for LTC in Poland has notable gaps. There is no unified definition of LTC quality applicable to the health and social sectors. Regulatory oversight, while present in health care, primarily focuses on therapeutic activities and more on implementation of inputs around care standards and excludes LTC facilities. Various bodies, including voivodes, the NFZ, and the KMPT, are responsible for inspecting LTC facilities. Counteracting the identified irregularities through regular inspections of as many LTC providers as possible, possibly all of them, and a comprehensive understanding of LTC quality is crucial to achieving the overarching goal of improving the well-being of people receiving long-term care in Poland.  225 Box 2. Most common irregularities in voivodeship inspections The voivodes’ inspections considered a wide range of aspects of the facility’s operation, including the condition and equipment of the facility, the number and qualifications of staff, access to medical care services, and respect for the rights of residents. Main irregularities reported during voivodeship inspections are as follows: Running facilities without appropriate documents: for example, with a lack of 1.  permission from the voivode. Incomplete documentation: for example, failure to maintain a register of 2.  benefits, and failure to inform relevant units about significant organizational and legal changes. Staff shortages and lack of appropriate qualifications: for example, performing 3.  medical activities without qualifications, failure to meet the employment levels, and lack of specialized training. Exceeding the admission limit: for example, too many residents staying in the 4.  facility, discrepancies in the actual number of beds and the number reported to the register authority. Failure to respect the rights of the wards: for example, violation of the rights to 5.  dignity and intimacy, restriction of freedom, unauthorized use of direct coercion, and after the death of the wards, inappropriate respect for the bodies. Inappropriate equipment of the facility and unsatisfactory technical condition 6.  of the building: urgent renovation and modernization required; poor condition of the rooms; lack of standards met; lack of appropriate equipment; lack of common rooms such as the dining room and laundry room; lack of or faulty call and alarm system; or inappropriate adaptation of the facility to people with disabilities. Unmet standard of services: mismatch of the type and frequency of care and 7.  medical services to the health condition of the patient; lack of assistance in obtaining due services; and admission of people requiring more specialized care, for example, psychiatric care. 226 Once the framework of quality indicators is legally regulated, it is necessary to establish a mechanism for LTC quality control and monitoring and evaluation to ensure consistent and comprehensive oversight of LTC providers. Regular inspections help effectively monitor and evaluate the performance of LTC providers, including the quality of care they offer. Inspections should be conducted regularly and consistently and should cover all LTC providers in the country. Appointing an authority/representative to monitor and evaluate LTC service providers may ensure consistent oversight of their activities across the country. However, it is important that this authority/ representative has the capacity to inspect both social and health sector service providers. Indeed, the scope of work of such a body/ representative would include conducting regular inspections, enforcing quality indicators, and coordinating efforts to improve LTC quality. With centralized operations, it will be easier to quickly resolve problems, standardize practices, and hold service providers accountable. QUALITY SOLUTION 3: Launch a national M&E mechanism applicable to LTC providers, facilities, and organizations. key area(s) addressed: coordination/integration, deinstitutionalization To continuously pursue quality improvement, understanding the experiences of carers and their families in the system is critical. In the surveys commissioned by the World Bank, service users and their families provided insights into the functioning of the care system and areas where they see room for improvement. Informal caregivers, based on media reports and customer experience of their friends, were reluctant to use the support of government institutions due to the way those facilities treat their residents. Some respondents admit that, while visiting the facilities, they could hear staff shout at residents, they saw people lodged in overcrowded halls (16 people in one room), and there was an unpleasant odor in the air. In respect to agency workers, 227 informal caregivers perceived some of those who provide LTC services on behalf of LTC agencies as lacking empathy and patience, and offered a low pay, which additionally dampens their motivation. Some family caregivers have had poor personal experience with personnel sent from agencies: one caregiver was not physically able to take proper care of the client; another one failed to turn up as scheduled; others were smoking in the client’s home. Furthermore, families perceive the waiting lists as excessively long for residential facilities, so they apply just in case (as they cannot predict how the patient will feel in the future, one day s(he) may require professional care around the clock). All these issues should be captured in user surveys to ensure that services are up to standard. For example, in the Netherlands, an existing framework (Consumer Quality index, CQ-index) was adapted to LTC settings. The CQ-index collects experiences of residents, representatives, and clients based on ten dimensions: (1) care plan and evaluation, (2) shared decision-making, (3) communication and information, (4) physical well-being, (5) competency and safety of care, (6) living environment, (7) participation and autonomy, (8) mental well- being, (9) safety and living environment, and (10) availability and continuity of care. The use of these indicators has resulted in improvements in the delivery of long-term care, particularly among facilities with the lowest performance,132 providing evidence of the role of indicators in the implementation of quality improvement interventions. See the International Examples in the appendix for information on the CQ-index.133 In Poland, as part of M&E of services, routine surveys should be conducted among patient groups and their families to ensure that care is meeting standards and incorporating preferences and opinions of this group of stakeholders. 132 Zuidgeest M, Delnoij DM, Luijkx KG, de Boer D, Westert GP. Patients' experiences of the quality of long- term care among the elderly: comparing scores over time. BMC Health Serv Res. 2012 Jan 31;12:26. doi: 10.1186/1472-6963-12-26. PMID: 22293109; PMCID: PMC3305532. 133 Triemstra, M., Winters, S., Kool, R.B. et al. Measuring client experiences in long-term care in the Netherlands: a pilot study with the Consumer Quality Index Long-term Care. BMC Health Serv Res 10, 95 (2010). https://doi.org/10.1186/1472-6963-10-95 228 QUALITY SOLUTION 4: Introduce user-engagement surveys to assess the experiences of patients and their families within the LTC system. key area(s) addressed: coordination/integration, deinstitutionalization Public perception of LTC quality in Poland is mixed, with 90 percent considering it to be important, but 43 percent expressing a negative view of current quality.134 Participants in public consultations emphasized what they considered as the key aspects of quality: a personalized approach, an adequate number of qualified staff, professionalism, standardized services, efficient organization, broad access, and sufficient financing (Figure 64). Qualitative research, commissioned by the World Bank, of formal and informal caregivers in 2023 saw respondents raised concerns about the inadequacy of intellectual and physical activity for patients, the limited access to specialized equipment, low awareness of available funds, and the loneliness of patients affecting their intellectual function.135 To improve LTC quality, regular evaluations of the care recipient’s perspective were suggested as the primary tool (Figure 65). Figure 64. How should LTC quality be understood? Individualized approach 26% Qualified staff 19% Professionalism 17% Standardization of the services 16% Efficient organization of the care system 15% Widespread access to this type of assistance 5% High level of financing (including staff salaries) 2% Source: Online survey -– complementary to social consultations, World Bank 2023.  134 World Bank commissioned survey, 2023. 135 World Bank survey, 2023. 229 What kinds of tools can be used to improve the Figure 65.  perceived quality of long-term care in Poland? Regular evaluation of long-term care from the perspective of the care recipient (regular collection of quality of life 81% care surveys and analyzing their results) Regular evaluation of long-term care from the perspective of the person implementing the services (regular 61% collection of job satisfaction surveys and analyzing their results) Other (accessibility, systemic financial solutions, family satisfaction, certification of facilities, supervision and 14% monitoring, periodic review of procedures, upgrading of skills, information) Source: Online survey – complementary to social consultations, World Bank 2023.  Creating a publicly available database that lists public and private care facilities, along with their care types, capacity, and staff numbers, offers transparency to clients and their families as well as policy makers. Comparing care providers and accessing publicly available information on their performance is available in several countries. For example, in the United States, an official government website posts ratings of service providers across a range of services, including nursing homes, rehab services, home health services, long-term care hospitals, and more. Indicators on the public website include staffing, quality, and results of health inspections with stars representing relative performance.136 For home health services there is a quality rating and a patient survey rating, although this is not available for each agency. However, the minimum data set (MDS) collects more data which provide a standardized assessment, see the data scope for long-term care in residential facilities in the International Examples in the appendix. In England, the Care Quality Commission (CQC) is the independent regulatory body of health and social care services. They register, conduct 136 United States Government. “Care and Compare.” https://www.medicare.gov/ 230 inspections, and publish the findings on their website. The public can search for a provider in their area and see how they perform across different domains, Safe, Effective, Caring, Responsive, and Well-led. The assessments are Inadequate, Requires Improvement, Good, and Outstanding.137 A similar database in Poland will enable individuals to make informed choices about LTC providers, promoting competition based on quality. Clients can compare facilities and select the one that best meets their needs. In turn, this allows for the sharing of results of quality inspections, making them accessible on the public database to allow clients to better understand the quality of care they are offered. Clients can then factor these results into decisions about which LTC provider to choose. This transparency holds providers accountable for their quality of care and encourages continuous improvement. However, the publishing of care indicators should be done with proper context and analysis so they can be interpeted correctly. QUALITY SOLUTION 5: Create a publicly accessible database reporting the KPIs of public and private LTC providers. key area(s) addressed: coordination/integration, deinstitutionalization The broader organizational and technological system around LTC services contributes to be insufficiently measured and of suboptimal quality. The World Bank analysis showed that inspections were carried out in few of the facilities; less than 12 percent of facilities were inspected each year, depending on the sector. Common irregularities included systemic problems, documentation errors, inadequate living conditions, and unmet standards of medical care. The review proposed assessing the quality of LTCs in terms of maintaining dignity, health, nutrition, physical and intellectual activity, preventing social isolation 137 Care Quality Commission (CQC), https://www.cqc.org.uk/about-us 231 and providing a safe environment. Technological adoptions can support many of these quality enhancements. For example, proper record management and continuum of care for people between sectors can be improved through electronic records. Social isolation could be reduced by connecting older and disabled people with loved ones more often, while also providing intellectual stimulation. The system through which care is delivered could also become more automated, with improved communication channels between providers in teams and across sectors and facilities. Appraising and revising Poland’s Digital e-Health Center Strategy for 2023-2027 in the context of aging and LTC can support the leveraging of technology for reform goals. Technology plays a crucial role in the Long-Term Care in Poland - Vision Document. Technological innovations can better facilitate aging in place, where care recipients and older people can be monitored remotely, and their caregivers can be given the tools to remain connected to public services. This would empower older adults to maintain their independence, autonomy, and familiar surroundings, while ensuring they have access to the necessary support when needed. Technological advances can also be used to support memory care, improve monitoring of conditions, and minimize risks, such as technology that identifies fall risks.138 The technologies include wearable physical sensors, wearable chemical sensors—that can collect molecular data, and non-wearables such as diabetic testing strips, and smart clothing and assistive robotics, among others.139 Like most countries in the EU, Poland has a digital health innovation (DHI) strategy, a DHI institution, and DHI funding. DHI strategies must carefully consider the long-term vision of health care, which includes long-term care. This strategy should be evaluated with an aging lens to 138 Gschwind, Y. J., S. Eichberg, A. Ejupi, H. de Rosario, M. Kroll, H. R. Marston, M. Drobics, J. Annegarn, R. Wieching, S. R. Lord, and K. Aal K. 2015. “ICT-Based System to Predict and Prevent Falls (iStoppFalls): Results from an International Multicenter Randomized Controlled Trial.” European Review of Aging and Physical Activity 12: 1-1. 139 Chen, C., S. Ding, and J. Wang. 2023. “Digital Health for Aging Populations.” Nat Med 29: 1623–1630. https:// doi.org/10.1038/s41591-023-02391-8 232 assess whether key groups of carers and care recipients are properly benefiting from the strategy. As part of technological solutions development, attention must be paid to the digital literacy of the population to ensure technology can be integrated across the care continuum. This should comprise part of digital health strategies and pay attention to the elderly and people with disabilities in terms of usability and the needed infrastructure to ensure operability and coverage of these innovations. Innovations can be informed by investment in research and development (R&D), see Quality solution 7. This solution complements the quality assurance and monitoring of new standards by bringing in new technologies that could enhance quality of care. These technologies would enhance the effectiveness of care monitoring and provision through measures such as electronic health records, telemedicine, and assistive devices. Further, new technologies can improve systems level management of the care provision system as they can improve data management, communication, and patient monitoring, leading to more efficient and higher-quality care. Future plans can explore more innovative ways to deliver care and improve LTC outcomes by drawing on emerging technological advances. QUALITY SOLUTION 6: Employ technological solutions to enhance data management, and potentially with the real-time use of data, and to improve LTC beneficiary care and LTC outcomes. key area(s) addressed: coordination/integration, deinstitutionalization Further investment is also needed in Poland to develop academic research, including on LTC. There are several themes that should be explored to support LTC and the aging-related agenda: the healthy aging of the population; active aging, including preventing loneliness and activation in the labor market; the implementation of new 233 technologies for the care of the elderly and disabled—what can be implemented, what is acceptable; the determinants of cooperation between various institutions for the purposes of care; ways to strengthen the involvement of local institutions in care; and financing— types, models, and acceptable levels of copayment for care.  QUALITY SOLUTION 7: Promote scientific research on LTC to improve the services and the system. key area(s) addressed: coordination/integration, deinstitutionalization Summary of Quality Solutions QUALITY SOLUTIONS WHAT IS BEING KEY AREA LTC GOAL ADDRESSED 1. Appoint an expert team to develop an A. The quality of Coordination/ High quality integrated LTC quality framework and KPIs. formal care provided integration, of LTC by individual carers, Deinsitutioanlization 2. Include the LTC quality definition, framework, care organizations and KPIs in the relevant LTC acts of law. and the care system 3. Launch a national M&E mechanism applicable should be increased. to LTC providers, facilities, and organization. 4. Introduce user-engagement surveys to assess the experiences of patients and their families within the LTC system. 5. Create a publicly accessible database reporting the KPIs of public and private LTC providers. 6. Employ technological solutions to enhance data management, patient care, real-time use of data, and to improve LTC outcomes. 7. Promote scientific research on LTC to improve services and the system. 234 INFRASTRUCTURE HOUSING SITUATION FOR SENIORS A.  AND PERSONS WITH DISABILITIES This solution area seeks to address the weak housing market situation for seniors and persons with disabilities, and insufficient adaptation of housing for those in need and at risk of LTC. As the size of the elderly population in Poland increases, the need to fix the issue of poor-quality senior housing, which affects an elderly person’s health outcomes, becomes more pressing. Not only do poor living conditions pose issues for the health of the elderly, but they also exacerbate economic situations by increasing healthcare and social security expenses. The living conditions of seniors have a profound impact on their overall quality of life, given their potentially limited mobility and the relatively higher amount of time spent indoors. Most senior citizens in Poland reside either independently or with their families in their own homes, making the condition and suitability of their housing a key determinant of their health and well-being. Although housing policy is outside of the remit of the health and social sectors, it is a key intervention area for strengthening LTC deinstitutionalization and improving care outcomes for the elderly, hence recommendations and diagnostics outlined here should be considered with the involvement of the appropriate ministry or agency. The stock of public sector housing for seniors is limited, with many seniors residing in privately provided housing. Despite relatively good housing conditions for seniors, the success of senior housing programs is impeded by senior attitudes, housing ownership structures, and a lack of established practices for organizing and supporting senior housing. Seniors predominantly reside in buildings owned or provided by the private sector, which is less conducive to public intervention. 235 Several programs in Poland, such as the ‘Accessibility Plus’ program for 2018–2025, the social and municipal housing program, and the social rental housing program, aim to address the inadequate adaptation of housing for those at risk of long-term care. These initiatives represent crucial steps toward creating a more inclusive and accommodating housing environment for vulnerable populations.  Issues facing housing for people with disabilities include inadequate supply of public sector housing and a lack of transparent criteria for allocation of the housing units. An audit by the Supreme Audit Office (NIK) dated April 4, 2023, found that there is still an insufficient amount of available public sector housing without architectural barriers for people with disabilities. The audit covered 35 local government units from seven regions, including 19 cities with county rights and 16 units managing municipal housing resources. The cities have tried to increase availability of housing for persons with disabilities mainly by retrofitting existing buildings and building new ones without architectural barriers. However, despite these measures, there is still a housing shortage, resulting in long waiting times. New buildings are usually adapted to the needs of people with disabilities, but older buildings require upgrades such as installing lifts or widening doors. The audit also found some irregularities in the allocation process for housing units, including nontransparent criteria for evaluating applications and errors in verification procedures. Lease agreements were concluded for fixed term and open-ended periods, but in some cases the termination dates of the agreements were not monitored, leading to apartments being occupied by people without a legal title. Nevertheless, most cities maintained the housing stock in good condition, although there were also cases of negligence concerning technical inspection of buildings, which could endanger residents.  With growing numbers of seniors in the population, ensuring a supply of affordable and appropriate housing for older people and those with disabilities is becoming urgent. In addition to existing 236 efforts, ramping up the development of housing specifically designed for seniors and individuals with disabilities can be supported by incentives for local governments which focus on creating accessible and age-friendly housing options. By encouraging the construction of such housing, the availability of suitable living spaces for seniors and people with disabilities can be expanded. In addition, exploring the expansion of non-traditional housing options, such as intergenerational living models and assisted living services should also be considered to ensure a continuum of housing covering a range of low to intermediate needs. INFRASTRUCTURE SOLUTION 1: Continue the development of the housing stock for people with disabilities and seniors. key area(s) addressed: deinstitutionalization Many elderly people and people with disabilities reside in accommodations that are not suited to aging or safe living; at the same time, there is an insufficient supply of housing adapted to the needs of persons requiring LTC in the private market. When considering the broader population, households with the elderly are more likely to possess property or cooperative housing rights and are less inclined to seek housing through the commercial rental market. Several common challenges are associated with these living arrangements, including the high cost of living, barriers to mobility due to accessibility issues, and restricted access to public transportation networks. Senior citizens also often reside in old buildings constructed between 1960 and 1990,140 with some of them lacking thermal retrofitting or elevators, posing challenges particularly for those on higher floors. Insufficient adaptation of housing for 140 GUS. 2019. Opracowanie metodologii i przeprowadzenie badania skali działań termomodernizacyjnych budynków mieszkalnych wielomieszkaniowych, “Developing a Methodology and Conducting a Study of the Scale of Thermal Modernization Activities in Multi-apartment Residential Buildings.” 237 individuals requiring additional care, such as seniors and those with disabilities, presents a multifaceted challenge within the housing market. The existing measures within housing and social policies must be expanded to address the specific needs of these groups, moving beyond conventional interventions like night shelters. Enhancing the housing segment with assisted and training housing is vital for fostering inclusivity. Establishing and enforcing design standards, including around digital technologies, for buildings intended for seniors and people with disabilities is crucial. These standards should cover aspects such as accessibility, safety, and comfort, ensuring that housing units are equipped to meet the unique needs of this segment of the population. By regulating design standards, the government can guarantee that newly constructed housing is built with the well-being of seniors and individuals with disabilities in mind. The integration of digital technologies and related solutions into design standards is paramount. This involves incorporating features that support smart homes, telehealth, and digital tools that enhance the quality of life and care for seniors and individuals with disabilities. Digital solutions can facilitate remote health-care monitoring, improve accessibility, and promote independence.  INFRASTRUCTURE SOLUTION 2: Continue regulating design standards for buildings and dwelling units intended for people with disabilities and those intended for seniors and ensure that digital technologies and solutions are included. key area(s) addressed: deinstitutionalization Currently, several governmental, local, and NGO programs are being implemented to support housing for people with disabilities, but issues around access and sufficiency need to be addressed. 238 In 2019, a ten-point support plan for people with disabilities was presented to the public. As part of this plan, the MRPiPS introduced a package of solutions titled, ‘My Home’, with the primary goal of providing appropriate housing conditions for people with disabilities. Within this framework, three programs were to be launched regarding care and accommodation centers (COM), barrier-free buildings, and barrier-free apartments. The last one provides for rent subsidies and cofinancing of the costs of adapting apartments to the needs of people with disabilities. Relevant programs were approved in the support plan for 2019 but were not included in such plans in subsequent years. As of 2021, the support plan only included the program for COM. The issue of supported housing is also included in the Strategy for People with Disabilities for 2021–2030. It is assumed that the supported housing service will be regulated at the statutory level and unified with the training or supported housing included in Section 53 of the Act on Social Assistance. The unified formula relates to supported housing, divided into training type (temporary), and supported type (for an indefinite period). According to the Strategy, appropriate actions are to be implemented by the end of 2025. However, the solutions introduced have been assessed by the Ombudsman as imperfect, because the possibility of using training or supported housing is time-bound and therefore does not meet the practical housing needs of individuals or families. The solutions are also not systemic. Access to this form of support is limited due to insufficient financial resources, the time of granting them, and territorial restrictions related to the activity of the local government unit.  Providing further financial support for home adaptation is a key strategy to enable individuals with LTC needs to remain in their homes for as long as possible. This support can cover physical alterations and digital technologies. Assistive services and digital technologies can improve self-care and independence of the elderly and people with disabilities. This should be part of a comprehensive, integrated needs assessment process. Physical changes may include 239 installing grab rails, ramps, wider doorways, or accessible bathrooms to enhance mobility and safety. Digital technologies, such as fall alarms and remote calling systems, can be integrated to provide immediate assistance in case of emergencies, ensuring the well-being of residents. This financial aid helps individuals maintain their independence, safety, and comfort in their familiar home environment, creating more accessible and deinstitutionalized LTC.  INFRASTRUCTURE SOLUTION 3: Extend greater financial support for home adaptations and access to assistive services and digital technologies to give seniors and people with disabilities who prefer to live in their home, an option to stay at home for as long as possible. key area(s) addressed: deinstitutionalization Funds are available to support housing, but amounts can be low and limited in scope and location. There are currently no solutions that would provide rent subsidies in apartments on the secondary market. The possibility of cofinancing from the State Fund for the Rehabilitation of the Disabled (PFRON) for the elimination of architectural barriers does not cover all barriers existing in the apartment, and the pool of funds allocated for this task is limited. For these reasons, many interested parties do not receive funding. Other activities in the field of supporting housing for people with disabilities include the Act of July 20, 2018, on state aid for housing expenses in the first years of apartment rental. However, the solutions are available primarily in large and medium-sized cities, and the level of rents may exclude the poorest people from this opportunity. On May 9, 2022, PFRON approved the ‘Independence-Activity-Mobility!’ program. Although solutions within the program seem to respond to many of the demands of people in need, they are not addressed to all people with disabilities. They are intended only for people with a certificate of severe disability and, in the case of people with hearing disabilities, a certificate of moderate disability. The ombudsman also raised concerns that people who are 240 over 65 years at the time of applying do not end up accessing the support they need.  Assessing the needs of individuals and helping them to access financial support for home adaptations by LTC coordinators is a vital component of addressing housing inadequacies. These professionals can evaluate the specific requirements of each person, create a customized plan, and guide people through the application process for financial assistance. By offering expert guidance and support, LTC coordinators can ensure that individuals receive the resources they need to modify their homes according to their unique LTC-related needs. This approach empowers people to continue living in their homes with the necessary adaptations.  INFRASTRUCTURE SOLUTION 4: Collaborate with LTC coordinators (e.g., OPS/CUS) to conduct a needs analysis and help people to access funding for home adaptations. key area(s) addressed: deinstitutionalization Some specific solutions for developing senior housing have been pursued, but efforts have not been able to address the problem at- scale. The aging population adds another layer to the challenge, necessitating systemic reflection on the need to consider senior housing as a resource spatially, environmentally, and technically tailored to the elderly. Yet currently, state policies addressing senior housing are fragmented. A future-oriented approach should involve constructing housing adapted to an aging population, incorporating features like railings, low thresholds, ramps, and elevators. But not much has been done in this regard. The Ministry of Development and Technology provided design standards for disability-friendly buildings and senior housing in 2017, and some developers offer housing for seniors or individuals with disabilities—but at unaffordable prices. A 2018 report from the Institute for Urban and Regional Development emphasized 241 the need to improve the quality of seniors' housing in Poland, highlighting issues such as outdated buildings, inadequate thermal retrofitting, and undersized apartments. To implement more holistic solutions for developing housing, more needs to be done to first assess the availability and quality of housing for people with disabilities and the elderly. Gmina-level integrated registries can help match the needs of the population with the available stock of appropriate housing. These registries can collect data on socio-demographics of the population, the local environment, social care, and health care to support strategic planning. These registries can aid in better planning and coordinating care services for seniors and individuals with disabilities. Complementary to this, appropriately understanding whether the needs of the population can be met is supported through the development of a housing system that reports the degree to which units are suitable to different levels of LTC needs—at a minimum whether the buildings are suitable for people with disabilities and/or seniors. By having a comprehensive understanding of the local population's needs and available resources, more effective care solutions can be developed and implemented. INFRASTRUCTURE SOLUTION 5: Conduct regular diagnostics of housing needs local contexts and manage the housing stock with due consideration for community needs. key area(s) addressed: deinstitutionalization The prevalence of single-person households is rising, especially among those aged 80 and above. According to Eurostat (2021), approximately 31.4 percent of Poland’s 80+ age group live alone, and demographic projections suggest a rapid increase in their numbers. This demographic shift raises pressing concerns related to ensuring that these individuals receive adequate care within their living 242 environments. In most households, people aged 60 and above continue to reside in their privately owned homes or apartments, with roughly 12 percent residing in the social rental sector. Therefore, it is more important than ever that seniors and people with disabilities are embedded in their communities and are living in areas that provide for their needs. Figure 66. Percentage of people aged 65 plus living alone 60 50 49.3 44.6 40 38.3 37.0 35.1 33.8 30.7 32.5 30 28.6 28.4 25.4 24.9 22.5 20.8 20 10 0 65+ 65-79 80+ Male Female Rural Urban EU POL Source: Eurostat 2021. The development of appropriate housing is only one part of the issue; these houses must also be considered in the wider environment in which they are located. This means taking a broader look at the communities and environments in which elderly and disabled reside. Adequate investment in public spaces—age-friendly and disability- inclusive environments should be considered to promote longevity for residents of their communities. This solution therefore focuses on regulating house planning to ensure that it considers the local environment, transport links, and access to facilities such as community centers, shopping areas, and health-care facilities, as fundamental. Proper house planning can create living environments that are 243 conducive to the well-being of seniors and individuals with disabilities, fostering independence and community engagement. This can involve zoning regulations that encourage mixed-use developments and elderly and disability-friendly neighborhoods. INFRASTRUCTURE SOLUTION 6: Align the planning processes to local conditions, ensuring access to necessary transport and amenities, including social life, shopping, and health care. key areas: deinstitutionalization Summary of Infrastructure Solutions INFRASTRUCTURE SOLUTIONS WHAT IS BEING KEY AREA LTC GOAL ADDRESSED 1. Continue the development of the housing A. The housing market Deinstitutionalization Strong stock for people with disabilities and seniors. situation for seniors and housing persons with disabilities market for 2. Continue regulating design standards is inadequate, and LTC clients for buildings and dwelling units intended there is insufficient for people with disabilities and those adaptation of housing intended for seniors; ensure that digital for those in need and technologies and solutions are included. at risk of needing LTC. 3. Extend greater financial support for home adaptations and access to assistive services and digital technologies to give seniors and people with disabilities who prefer to live in their home, an option to stay at home for as long as possible. 4. Collaborate with LTC coordinators (e.g., OPS/ CUS) to conduct a needs analysis and help people to access funding for home adaptations. 5. Conduct regular diagnostics of housing needs in local contexts and manage the housing stock with due consideration for community needs. 6. Align the planning processes to local conditions, ensuring access to necessary transport links and amenities—including social life, shopping, and health care. 244 PRIVATE MARKET A. PUBLIC-PRIVATE PARTNERSHIPS IN LTC This solution area seeks to address the issue of public LTC institutions failing to tap the potential of the private market, and to improve regulation and oversight of private care providers. The coexistence of public and private LTC facilities in Poland comes with challenges that are rooted in the low coordination of these sectors. One notable issue arises from the lack of official information on the utilization of private providers by public LTC institutions. While public statistics capture the number of facilities providing round-the-clock inpatient care, there is a dearth of data regarding the engagement of private providers in home-based LTC services. This information gap impedes a comprehensive understanding of the dynamics between public and private sectors in meeting the demands of LTC patients. There are several mechanisms through which private sector providers can participate in service delivery to LTC patients, with private provision taking place in facilities or through individually provided services. Private sector providers can be contracted by public institutions such as OPS or CUS. In this case, private LTC service providers are awarded a contract in accordance with public procurement law, with bids submitted by private sector entities or NGOs. Also, private service providers can deliver home-based and inpatient LTC services on an out-of-pocket basis when they charge clients and client families directly. In this model, LTC services are part of their business activities or statutory activities. There is no official list of private providers that offer home-based LTC services, so the size of this sector is unknown. It is more common for private providers to provide services in large urban areas. Care in the form of home-based assistance may be provided by private individuals or unregistered private providers, 245 and in this type of provision there is a grey economy largely dominated by women of retirement age or migrants from Ukraine or Belarus. In Poland, it is possible to legally hire a non-EU citizen for LTC service delivery, provided the prospective employee has notified the local labor office. On that basis, the non-EU migrant worker can stay in Poland for up to six months. With this type of arrangement, compensation is paid to the caregiver directly by the client or client’s family. Information on private providers can be gathered through their registrations with voivodeships, but certain types of privately provided care are not easy to enumerate or monitor. Private providers can register with the regional branch of central government authorities, and basic data, such as their address and capacity (such as number of beds), is published by voivode (regional) governors and included in the MRPiPS annual statistics on social services. In 2021, Poland had 704 registered private LTC facilities. Altogether, they had 27,154 beds and housed 20,894 people. These private providers tend to be smaller than those in the public sector; on average they can accommodate about 30 patients/clients (Table 27). Mazowieckie leads the regions in the number of private providers of 24/7 LTC services (140), followed by Śląskie (94) and Pomorskie (85). Pomorskie and Opolskie reported the highest ratio of users of private providers per 100,000 inhabitants. The regional variation in the distribution of private providers underscores the need for a coordinated approach to ensure equitable access to LTC services across different parts of the country. While data exist on 24/7 providers, there is no official list of private providers that offer home- based LTC services. Hence the size of this sector is unknown, but a known characteristic of private provision is that it is more commonly provided in large urban areas. Therefore, establishing a publicly accessible database of private providers across the country could be a solution to foster greater collaboration, enabling public institutions to make informed decisions about engaging private services based on their capacity and expertise. 246 Number of residents in 24-hour care facilities run by Table 27.  registered private providers in 2021 RESIDENTS BED OCCUPANCY REGION FACILITY COUNT BED COUNT RESIDENT COUNT PER 100,000 RATE (%) INHABITANTS Dolnośląskie 63 2,315 1,883 81.3 65.3 Kujawsko - Pomorskie 23 772 574 74.4 27.9 Lubelskie 21 685 495 72.3 23.7 Lubuskie 9 277 221 79.8 22.0 Łódzkie 34 1,090 956 87.7 39.4 Małopolskie 52 2,001 1,665 83.2 48.9 Mazowieckie 140 6,100 4,491 73.6 82.9 Opolskie 32 1,164 974 83.7 100.1 Podkarpackie 17 673 466 69.2 22.0 Podlaskie 22 842 651 77.3 55.7 Pomorskie 85 2,894 2,373 82.0 101.2 Śląskie 94 3,756 2,983 79.4 66.7 Świętokrzyskie 18 826 629 76.2 51.6 Warmińsko-Mazurskie 27 1,059 675 63.7 47.9 Wielkopolskie 41 1,479 1,070 72.3 30.6 Zachodniopomorskie 26 1,221 788 64.5 46.9 Poland 704 27,154 20,894 76.9 54.8 Source: World Bank 2023, based on MRPiPS-05 data for 2021. The routine updating and management of a live database that shares information on available capacity in public and private care facilities can accelerate progress toward enhanced coordination of LTC services. The digital platform can act as a centralized repository of up- to-date information on care providers, helping public institutions to identify and collaborate with private providers to meet the growing demand for LTC services. The database can be hosted at voivode offices with the eventual creation of a weblink to provide information to clients and for building consumer awareness. This flexibility allows clients to access care promptly. By streamlining the matching process between clients and facilities, this database can help ensure efficient allocation and timely provision of care services, enhancing the overall quality of LTC.  247 PRIVATE MARKET SOLUTION 1: Routinely update a database of all (including public and private, if possible) care services, including available capacity to facilitate searches of places and to make good use of supply. key area(s) addressed: coordination/integration Information about the services provided by the private sector is also limited. Private market institutions have the potential to complement the public LTC system and address its shortcomings. However, the absence of a systematic approach to regulating and monitoring private sector operations poses challenges for ensuring the quality of services. To know more about the cost, type, and quality of services delivered by private providers, the World Bank contacted 325 registered private LTC providers. However, there was little uptake or response from private providers to the outreach; this suggests that stronger oversight and engagement with these providers is necessary to better harness this sector. Such an intervention would be worthwhile as the effectiveness of the public LTC system could be enhanced by leveraging the private sector's capacity, especially in areas where public sector resources are limited. When it comes to the provision of care services by municipalities, outsourcing the services to private providers is already common practice. In addition to commercial providers, there are several nonpublic actors operating in the LTC system which adds complexity to coordinating and monitoring services. In addition to private providers, NGOs such as the Polish Red Cross, Caritas, and numerous organizations operating locally are involved in LTC service delivery. Social economy entities, including social enterprises, are also becoming more and more active in this area. The involvement of non-public sector actors, ranging from for-profit enterprises to NGOs and social enterprises, adds complexity to the coordination challenge. In this landscape, the integration of private and public LTC services requires 248 careful consideration of regulatory frameworks, quality assurance measures, and mechanisms for transparent communication and collaboration. Addressing these coordination issues is crucial for optimizing the collective potential of both public and private sectors in delivering effective and comprehensive LTC services to meet the diverse needs of the population.  Empowering LTC coordinators (OPS/CUS) by providing them access to the live provider database offers a straightforward solution to the problem of underutilized private LTC providers in Poland. With this database at their disposal, care coordinators can play a pivotal role in advising clients and their families on the best care options available. They become informed advocates for the clients, helping them navigate the LTC landscape. This direct link between care coordinators and the database ensures that clients are matched with care facilities that meet their specific needs and preferences, fostering client choice and empowerment while maintaining quality standards.  PRIVATE MARKET SOLUTION 2: Give LTC coordinators access to the LTC facility database so that they can advise their clients about new openings and service availability. key area(s) addressed: coordination/integration One way that private inpatient facilities are regulated is through the issuance of permits for their operation. The provisions set forth in the regulation of the MRPiPS of August 28, 2020, on issuing and revoking permits for private business activities of inpatient LTCFs apply in this context. According to the regulation, the regional (voivode) governor considers the application for a permit within 14 days from the date of completion of the inspection of the facility. When considering an application for a permit, the voivode considers the results of the inspection, especially in terms of meeting the standards specified in article 68 of the Act of 12 March 2004 on social assistance. When issuing 249 a permit, the voivode enters the facility in the register of facilities. The private provider should meet the standards specified in article 68 of the Act of 12 March 2004 on social assistance, for scope of access to services, catering, and infrastructure, including the size of the premises and the equipment installed, applicable to DPS facilities. Facilities providing round-the-clock inpatient care must adhere to criteria outlined by the MRPiPS. Implementing uniform quality standards for private and public LTC institutions ensures that all providers adhere to the same high standards of care. This can level the playing field between providers and ensure that clients receive a uniform level of quality care, irrespective of whether they choose a public or private provider. By ensuring that private institutions are subject to the same regulatory framework as public ones, the LTC market remains competitive, while uniform quality standards and rigorous oversight contribute to enhanced client safety and well-being. It also minimizes the risk of substandard care, abuse, or neglect within private LTC institutions. Clients can also have confidence that their chosen LTC provider, whether public or private, adheres to the same stringent safety and quality measures. The improvement of oversight and inspection procedures creates transparency in how LTC facilities are monitored and promotes adherence to quality standards. When these standards are consistently applied, it becomes easier to hold private institutions accountable for any deviations or deficiencies in the care they offer. Standardized oversight and inspections provide a mechanism for continuous improvement in private LTC facilities. Regular assessments and feedback from oversight authorities can help private providers identify areas where they need to enhance their services, leading to better care for clients. Establishing robust oversight mechanisms in line with quality standards helps maintain or rebuild public trust in private LTC providers. Oversight and inspections discourage unethical practices and noncompliance, reducing the risk of exploitation and harm to clients. 250 PRIVATE MARKET SOLUTION 3: Improve and operationalize oversight and control mechanisms applicable to private institutions in line with the requirements set out in quality standards for private and public providers. key area(s) addressed: coordination/integration Partnerships between government, private actors, and NGOs already exist in the LTC system, and there are more opportunities to strengthen the relationship between these sectors. Regarding the provision of care services by municipalities, outsourcing to private providers is already common practice. However, the effectiveness of the public LTC system could be enhanced by leveraging more of the private sector's capacity. For one, the role of private spending and cost-sharing is pivotal in LTC financing. Private spending can provide additional resources for government-funded services, supporting the private sector's increased market share. Public institutions should endorse both roles and implement policies that enhance purchasing power for those with fewer resources. The establishment of a publicly accessible database of private and NGO providers across the country will facilitate enhanced communication, mapping, and development of these partnerships, fostering greater collaboration, and enabling public institutions to make informed decisions about engaging private and NGO services based on their capacity and expertise. Addressing these challenges is essential to ensure the sustainability of governmental programs in the evolving landscape of LTC. PRIVATE MARKET SOLUTION 4: Continue to promote public-private- and nongovernmental partnerships and information sharing. key areas: coordination/integration 251 Summary of Private Market Solutions PRIVATE MARKET SOLUTIONS WHAT IS BEING KEY AREA LTC GOAL ADDRESSED 1. Routinely update a database of all (including A. Public institutions Coordination/ Strong public and private) care services, including providing LTC fail to Integration private-public available capacity to facilitate searches of tap the potential of the partnerships places and to make good use of supply. private market; and regulations and oversight 2. Give LTC coordinators access to the LTC facility of private care providers database to enable them to advise their clients need improvement. about new openings and service availability. 3. Improve and operationalize oversight and control mechanisms applicable to private institutions in line with the requirements set out in quality standards for private and public providers. 4. Continue to promote public-private- and nongovernmental partnerships and information sharing. 252 ALIGNMENT WITH LTC VISION DOCUMENT This strategic overview complements the vision for long-term care in Poland which outlines a goal for the LTC system that is comprehensive and patient-centered, with respect for dignity, autonomy, and well-being of the patient at successive stages of life and aging. Thus, a system must be built that will be focused on the person in need of care and their individual needs, while protecting their dignity, autonomy, and well-being at advanced stages of aging. It should be a system where, as needed, people will be provided with attentive care, decide for themselves, and realize their potential by actively participating in society. The cornerstone of the LTC vision is equity and accessibility of services, and the guiding themes are human centeredness, dignity, self-reliance, and integration; these principles inform the solutions proposed in this report. Without equity and accessibility of long-term care, there is simply no way to comply with the principles of social justice, which state that everyone should have an equal opportunity to receive the care and support they need to live with dignity, regardless of criteria such as income, background, or where they live in the country. Equitable access to LTC services improves health outcomes and reduces health disparities. It allows timely response, implementation of prevention and treatment, resulting in better overall health and well- being. With access to LTC, the beneficiary can maintain autonomy, decision-making, and quality of life for longer. Beneficiaries can lead a fulfilling life, including socially, and receive care in a manner consistent with their preferences. Equity and accessibility in LTC translate into positive economic outcomes. Ensuring that those in need have timely access to appropriate care reduces the burden on health- care facilities, prevents unnecessary hospitalizations, and promotes cost 253 efficiency. The four guiding themes of the vision—human centeredness, dignity, self-reliance, integration—are reflected in the proposed solutions. Beneficiaries and their loved ones should be placed at the center of the LTC system, with the system organized around their preferences, needs, and aspirations. One important aspect to consider is social interaction and activity as important to maintaining well-being. The vision will be implemented through collaboration and coordination among various stakeholders, including health-care professionals, caregivers, social service providers, and NGOs. The goal is to seamlessly integrate services in health care, social assistance, and other forms of support for persons with disabilities to promote a holistic approach and be able to meet the entire spectrum of diverse needs of varying individuals. Innovative solutions should be sought, using technology to streamline care, improve communication, and give residents greater independence. Smart solutions and digital platforms will help redesign processes, increase efficiency, and deploy remote care methods where appropriate. The key to implementing the solutions in this report as part of the overall vision for providing quality long-term care in Poland is well- trained professionals. This means investing in systematic workforce development, education, training, and support for healthcare and social care professionals, and providing the conditions for compassionate and qualified caregivers to thrive. It will also be important to systematize support for families and loved ones, who at this time provide the overwhelming share of LTC. To achieve the vision of long-term care in Poland, it is necessary to launch change processes regarding the legal framework, financing, organization of services, human resources development, and innovation. Fostering lasting change can only happen through changing social attitudes, investing in human resources, and using data that are collected, analyzed, and disseminated on an ongoing basis to 254 strengthen reform. These change processes are necessary to implement the solutions in this report and to achieve effective coordination of the system, deinstitutionalization of care, and better supply of labor to support this challenge of achieving Poland’s vision for long-term care. 255 CONCLUSION Rapid population aging continues to put substantial pressure on health and social systems across Europe, and Poland is no exception, with the country experiencing an above average pace of population change. The growing share of the elderly has brought new challenges, such as rising disease burden at the population level, greater demands on the working-age population and public systems, and concerns about well- being, as many older people live in age-inappropriate conditions, experience poverty and social exclusion, or face premature institutionalization. One of the most pressing policy issues of this demographic trend, and the subject of this report, is how to care for people with disabilities and the rising number of elderly people in the population in the context of this intensifying urgency; and how to offer care that assures dignity and self-reliance, while also being efficient, sustainable, equitable, accessible, and of high quality. In this light, the World Bank, commissioned by the MFiPR, developed this Strategic Overview to assess the current key challenges facing the broader context of LTC in Poland. This report has been structured across the challenge areas of governance, financing, human resources, quality, infrastructure, and the private sector. The identification of these challenges has been the product of consultations and engagement with the main stakeholders of LTC, patients, caregivers, the population, interest groups and providers, and national policymakers. This report has also laid out comprehensive solutions that can be achieved in the short- to medium-term horizons. The connecting vision of these goals is to work toward improving the coordination and integration of the system; progress toward the deinstitutionalization of care to support people to age in place—at their home or within their community, as they prefer; and to strengthen and adapt labor markets as a cross- cutting area that should see the improved job satisfaction of formal 256 carers, help families and loved ones to overcome the adversity associated with care responsibilities, and improve quality of care outcomes. The report objective is to strategically review Poland’s care context to support the development of needed solutions and the LTC reform agenda. However, in addition to the enumerated challenges, there are many advantages that come with the Polish context. There is already a wide-ranging care structure—described in the Long-term Care System in Poland section. There are provisions for care in both the social and health-care sectors, with benefits ranging from the delivery of care, inpatient and residential care, care for mental health conditions, and cash benefits for dependents and their caregivers. In addition to the care system, numerous pilots and programs have been implemented with the goals of service provision, many in collaboration with the EU as a key strategic development partner; the actors involved in care are many, including collaborations between private and public partnerships. Policymakers have been engaged in reforms and programs such as Care 75+ and there are multiple laws that concern LTC. The solutions in this report therefore include those that improve the existing system with little substantial reform, such as helping people make sense of the various services on offer, for example, through LTC coordinators at local levels. While larger reforms, which are a feature of most European LTC strategies, include those that seek to develop community-based care, including home care, and increase financial investments in LTC. This report is situated in a broader program of policy reform and is informed by an LTC Vision document that outlines sweeping aspirations for Poland to achieve in relation to its obligations to its aging population and their families. This report constitutes the next step in developing a catalogue of solutions for addressing key challenges and supporting a better way forward toward achieving the LTC vision. The next step will be to establish a schedule for implementing priority solutions for the 257 reform of the long-term care system and their gradual operationalization, including conducting feasibility analysis of individual activities, human resources and investment needs, determining entities responsible for their enforcing and implementation stages. 258 APPENDIX 1: METHODOLOGY FOR REPORT ANALYTICS A. QUANTITATIVE DATA  DATA CLEANING AND ANALYSIS METHODOLOGY.  Data for analysis and evaluation of long-term care in Poland was sourced from reports of the MRPiPS; content defined as part of the tasks arising from the Act on Social Care: the NFZ and MZ; data made available on BASiW on LTC; medical staff websites, and budget reports from the MF. CASH BENEFITS The main sources of data with respect to LTC cash benefits are ZUS and MRPiPS. The data from the ZUS related to received benefits: nursing supplement and supplementary benefits. ZUS provided the World Bank with breakdowns of these benefits by gender and age for 2017–2021 for the nursing supplement, and for 2020 and 2021 for supplementary benefits. The data included information on the number of people, by gender and age, and the cost of benefits. The number of people and the cost of benefits were provided only for December. The main limitation and gap in the data was the lack of a breakdown by region. In addition, based on December data, it was not possible to accurately estimate the number of beneficiaries and the cost of benefits throughout the year. The MRPiPS, at the request of the World Bank, prepared summaries of benefits for the dependent person, nursing allowance and benefits for 259 the caregiver, nursing benefit, special care allowance, and caregiver allowance. The data included information on the number of benefits, the number of beneficiaries, and the cost in 2017–2021, by region. One limitation of this data is lack of information on gender and age of beneficiaries. In addition, departmental reports of the MRPiPS-03 were used to collect information on the permanent allowance, number of beneficiaries, and the amounts in 2017–2021, by region. SOCIAL SECTOR Data for the analysis and evaluation of LTC in the social sector came from two sources: MRPiPS and MF. INPATIENT CARE AND DAY CARE  Information on the number of clients, number of facilities and the number of beds in inpatient care came from residential homes (DPS), family care homes (RDP), and day care support centers (OW). Shelters providing care services are annually covered in the MRPiPS-06 departmental report and were shared with the World Bank for 2017– 2021. The MRPiPS-06 departmental report includes information on municipal and county facilities separately. These data were combined before proceeding with further analysis. In this way, information was collated on the number of residents and the number of facilities by region. One limitation of this data is lack of information on gender and age of beneficiaries. The MRiPS-05 departmental report contains information on gender and age - however, it only concerns number of residents of DPS reported in the last day of the year (December 31). Data on personnel of DPS facilities were collected based on the MRPiPS-05 departmental report. The analysis included the total number of employees providing care, education, and support services: 260 physicians, nurses, social workers, physical therapists, therapists, and caregivers. Information in the MRPiPS report relates to the number of employees and the number of full-time positions and is available by region. However, as with other data from the MRPiPS, there is no information on gender and age of personnel. The main purpose of collecting human resources data from DPS was to compare them with that of inpatient care in the health sector. Human resources for RDP and support centers are not included in the report due to lack of a corresponding employment category in the MRPiPS-06 departmental report, which is based on the Act on Social Assistance and the Regulation of the Council of Ministers on the remuneration of local government employees. Costs for DPS were calculated based on reports on the execution of the state budget as well as the budgets of regions, counties, and municipalities, released by the MF. After consultations with the MRPiPS, costs of DPS facilities were assumed as sum of expenditures from the state budget, regional budgets, county budgets and 5 percent of budgets of municipalities from budget line 85202. One limitation of this method is that it is not possible to present costs by region, since the state budget execution report is presented only for the entire country. Cost data for RDP is not routinely collected. The World Bank report presents the cost for 2022, shared on a one-time basis by MRPiPS. Costs for OW were calculated from reports on the execution of the state budget as well as the budgets of regions, counties, and municipalities, as released by the MF. The costs for OW were assumed as the total of expenditures from the state budget and budgets of regional and local governments from budget line 85203. 261 HOME CARE Data on clients and staff in home care come from the MRPiPS-03 departmental report. The report contains information on the number of clients and the cost of benefits by region. There is, however, no information on the gender and age of clients. Information on personnel in home care was collected from the MRPiPS-06 departmental report. The analysis included employees delivering care services. Data in the report are available by region, but there is no information on gender and age of personnel. An additional limitation in social sector data is that they are collected regardless of the type of care. For example, a client may be receiving home care services and at the same time be a client at OW. Based on the data from the MRPiPS, these people cannot be identified. Such a person is then counted twice in the total number of clients in the social sector, which leads to an overestimation of the total number of individuals in the entire social sector. HEALTH SECTOR Data for analysis and evaluation of long-term care in the health sector were provided by the NFZ, the MZ and the MF. PATIENTS - INFRASTRUCTURE Data on patients in LTC in the health sector came from the Ministry of Health - BASiW on long-term care. The data are publicly available and include information on gender, age groups and place of residence of the patients by county and region. The data are based on NFZ datasets and computed by the patient's personal identification number. 262 Therefore, the total number of patients in LTC does not include duplicate patients. In addition, information is available on the number of facilities providing LTC services and the number of beds available therein. WORKFORCE The NFZ provided the World Bank with data on LTC medical staff grouped as geriatricians, nurses, and medical caregivers. The data contains information only on the primary place of work, which makes it possible to calculate the overall number of personnel (by occupation) in the entire LTC area within the health sector. However, it was not possible to determine how many people are employed in inpatient and day care based on the data, which was disaggregated by gender, age, and region.  The second source of data on human resources was BASiW - medical personnel. This data contain information on the total number of medical staff, with no breakdown into geriatric specialists, nurses, and medical caregivers. This data are, however, available separately for home care - services in nursing LTC care and services for mechanically ventilated patients, and inpatient care in ZOL and ZPO. One limitation of this data source is a lack of information on gender, age, and occupation of the personnel. COSTS Costs in inpatient care (ZOL/ZPO) were calculated based on reports on the execution of the state budget as well as the budgets of regions, counties, and municipalities, and NFZ data. Cost of inpatient care was assumed as the sum of expenditures from the state budget, expenditures of local governments (budget line 85117), and NFZ benefits provided to patients in inpatient care. One limitation of this method is that it does not distinguish between expenditures on ZOL and ZPO, as 263 they are presented in the same budget line. It is also not possible to calculate expenditures by region, as the state budget execution report is presented only for the entire country. Costs in day care were calculated based on data provided by the NFZ and are disaggregated by patient gender, age, and region.  PRIVATE SECTOR – INPATIENT CARE  The source of data for the private sector was an MRPiPS report containing information on the number of facilities, the number of beds, and the number of clients in private inpatient facilities. There is no information on the gender and age of clients.  DEMOGRAPHICS  The primary sources of data are Statistics Poland - Local Data Bank (GUS) and General Census of Population and Housing. The World Bank report uses information on population by gender, age, and region of residence. The 2023 population forecast of Poland was also used, which includes information on the projected population of Poland’s residents by gender, age, and county of residence until 2060.  GUS also provided regional data for 2021, specifying average life expectancy for men and women aged 0 and 65, healthy life expectancy, old-age dependency ratio, GDP per capita, unemployment rate, average monthly disposable income per person, population per square kilometer, percentage of people aged 65 and above.  Additional data were obtained from BASiW - long-term care, the nursing ratio and parental support ratio until 2021.  264 DATA PROCESSING – CALCULATIONS  From the accumulated data, ratios per 100,000 population were calculated for clients, patients, and personnel in each sector and in each level of care. The number of patients/clients per member/personnel (social or medical) was calculated. Costs per 100,000 population and per patient/client were also calculated.  Based on GUS population projection and the Census, a projection of demographic indicators—percentage of senior citizens, nursing ratio, parental support ratio, old-age dependency ratio—until 2060 were calculated for the whole country and by region and county.  The collected data was presented in a PowerBI tool, which enabled easy-to-read view of the data. Special attention was paid to the possibility of comparing the health sector with the social sector by number of patients/clients (coefficients), personnel, and costs.  B. EU ANALYSIS OF LTC PROJECTS  To obtain a set of projects financed from EU funds on LTC, elderly people, and people with disabilities, a set of projects called, ‘List of projects implemented from European Funds in Poland in 2014–2020’ was used.141 The list available on the website contains approximately 100,000 projects. These projects were downloaded and then filtered using the keyword ‘care’ and related words: elderly people, old age, old age, senior, long-term care, home, nursing, care, caregiver, care services, care, 24-hour care facility, seniors' home, nursing home, day care home, day care center, day medical care home, DDOM, social homes, DPS, care and treatment facility, ZOL, nursing and care facility, ZPO, dependent, 141 Ministerstwo Funduszy i Polityki Regionalnej. Fundusze Europejskie 2014-2020. https://www.gov.pl/web/ fundusze-regiony/dowiedz-sie-wiecej-o-funduszach 265 disability, unable to live independently, mechanical ventilation, respite care, assistant services, sheltered housing, sheltered housing, dementia, telecare.  The list of projects obtained by filtering in the manner described above was then manually verified by a detailed analysis of individual descriptions to eliminate projects that did not correspond to the purpose of the search but could qualify for the database due to similar keywords. Projects relating to the broadly understood development of LTC and aimed at developing the professional qualifications of LTC employees were included. Projects relating only to active integration, for example, Community Self-Help Homes, Senior Clubs) were excluded. Projects related to supporting care facilities during the COVID-19 pandemic were also not considered.  The resulting list of projects was subjected to basic statistical analysis, obtaining information on the value of projects and the amount of EU subsidies, distinguishing between individual funds and those specific to a project.  C. WORLD BANK SURVEYS QUANTITATIVE SURVEY This was conducted by the PBS market research company between April and July 2023, in randomly selected locations in Poland. The survey was conducted on a nationwide sample, n=1,000 interviews, representative in terms of basic demographic variables: gender, age, and the respondent's place of residence—region, type/size of locality. In addition, a so-called booster was carried out, an additional subsample with people ages 45–60, n=200 interviews. The booster also included quotas for gender and respondent's place of residence.  266 The survey was implemented using the computer-assisted personal interviewing (CAPI) technique—face-to-face (F2F) interviews conducted at the respondent’s place of residence, using the random route sampling method. Results from the primary sample and the booster were analytically weighted so that aggregate results (n=1200) could be reported for the nationwide population.  Thus, the data obtained at the quantitative survey stage allow inference for the nationwide population, reporting on the scale of occurrence of phenomena in the population, and in selected breakdowns. If the report presents breakdowns by specific demographic variables, and does not indicate otherwise, it means that there are statistically significant differences in each breakdown.  QUALITATIVE SURVEY Every scientific study carries the risk of an erroneous result. This statement is part of the canon of basic methodological principles.  The sample size can be both a source of errors and a safeguard against erroneous research results. Thus, sometimes a small sample size may limit the capture of the nature of a phenomenon. However, even a very large sample is no substitute for carefully planned selection, which increases the quality of the data obtained, even when the sample size is decidedly small. Sample size in qualitative research, although considered of secondary importance, is nevertheless subject to questions of both practical and theoretical nature. In general, the issue of sample size itself is also treated marginally, which should come as no surprise when the primary aspiration in qualitative research is to build theory as directly as possible from the available data. 267 ASSUMPTIONS OF THE QUALITATIVE STUDY During the qualitative research stage, 48 online Individual In-Depth Interviews (IDIs) were conducted, divided into 4 target groups of 12 IDIs each, as follows: Group A: Formal, institutional (inpatient) LTC staff, including DPS, z  RDP, ZOL, and ZPO. Group B: LTC providers, but in collaboration with NGOs and privately z  funded facilities. Group C: Formal long-term home care workers, including personnel z  providing care at home, for example, nurses, social workers, medical caregivers, assistants for persons with disabilities, physical therapists, psychologists working with LTC patients/clients.  Group D: Informal long-term caregivers: family caregivers, private z  caregivers who are paid by the families of the clients, and migrants. Formal care: understood as Groups A, B and C. Informal care: understood as Group D.  Qualitative research, unlike quantitative research, is not implemented using a representative sample. It can be carried out on a relatively small sample of respondents, since the analysis of qualitative data is purely analytical and is not presented in the form of graphs and figures. In this study, 12 interviews were conducted with each of the target groups described above. This number provides a substantive basis for inference per target group, while optimizing project costs and implementation time. 268 WORLD BANK WORKSHOPS/ D.  CONSULTATIONS Additionally, the analyzes conducted for the needs of the report, as well as the content and recommendations contained therein, were regularly consulted in the form of workshops or informed interviews with both representatives of ministries as well as top experts in broadly understood LTC, including representatives of the academia, representatives of entities competent to consult draft documents in the area of social assistance and health care, national and regional consultants in the field of geriatrics and long-term care. 269 Appendixes constituting a separate part of the report Evaluation of LTC in Poland based on WHO Appendix 2:  evaluation framework Appendix 3: List of legislative acts concerning LTC in Poland Appendix 4: Public opinion survey report Appendix 5: International examples – relevant for Poland 270