5. Ensuring the availability of sufficiently trained carers

Lithuania could follow similar strategies to other countries where recruitment initiatives have focused on providing incentives to (re)enter the sector. In addition, it could also initiate other policies such as bringing back workers who emigrated and bringing in foreign-workers.

Lithuania could recruit unemployed and inactive people to enter the LTC sector. In Lithuania, an estimated 32% of the working age population is facing labour-market difficulties and could be a potential pool. This category includes early retirees with health limitations, inactive individuals, long-term unemployed, skilled women who were out-of-the-labour force for family reasons, and underemployed people with low earnings (Pacifico et al., 2018[1]). For instance, in Norway, a country where municipalities play a strong role in LTC, the central government provides grants to be spent on targeted training for the unskilled, to attract unemployed and inactive people (Helsedirektoratet, 2021[2]). Japan financed training programmes for students and experienced workers returning to work after a long break. Such strategy proved to be very successful as it increased LTC workforce by 20% between 2011 and 2015 (OECD, 2020[3]).

Lithuania could also foresee a rotational training programme where unskilled people are trained to enter the LTC sector and LTC workers with low skills are offered opportunities to train full time or part time and skilled LTC workers have the opportunity to receive specialised training on specific diseases and/or managerial and mentoring topics. In 2019 Sweden put in place a similar rotational training programme, targeting three groups: long-term unemployed people, LTC workers with low skills, LTC workers with formal education. LTC workers with low skills are enrolled in a training programme lasting three semesters to gain formal skills. During their absence from work, LTC workers are replaced by long-term unemployed people, who are trained and sign after with a temporary contract with the municipality. The training for the unemployed includes training on Swedish language, information technology skills and workshops on soft skills. As of 2022, the programme includes only part-time training for LTC workers to allow them to work alongside the training and to need less long-term unemployed people. The training for unemployed people focuses first on motivating them and providing them with the ability to study and the language skills that they might need. The programme’s strengths rely on the good collaboration with the employers taking part in the programme and the small size of classes (around 10-15 students per class) which allows for good quality. Lithuania could foresee a similar rotational programme, attracting not only unemployed people but also workers from other less labour-intensive sectors where the demand for workforce has decreased in recent years.

Lithuania could also make efforts to improve job opportunities and skill recognition to Lithuanian emigrants and more generally improve services assisting the return of Lithuanian emigrants (OECD, 2018[4]). Net migration has been mostly negative in the past decades in Lithuania. A number of countries facilitate the return of citizens working abroad. Lithuania could attract citizens back by providing favourable conditions such as a tax relief. Italy has implemented tax reliefs for citizens who return to Italy after working from abroad for at least 2 years. To obtain the tax relief, citizens need to transfer their residency in Italy for at least two years and are required to have their main economic activity in Italy. The tax relief consists of at least a 70% reduction for tax to pay and varies according to the personal situation of the citizen (e.g. better conditions are available for workers with kids and/or who buy a house in Italy) (Agenzia delle entrate, 2022[5]).

Lithuania could consider recruiting foreign workers into the LTC sector by including LTC workforce in the list of professions that are scarce in Lithuania. This would ease the requirements for foreign workers to work (Migration Information Centre, 2022[6]). Croatia included for the first time in 2019 personal carers and nurses working in social care (55 for nurses and 90 for carers in 2020) in its “Decision on establishing the yearly quota of permits for hiring foreigners in 2019”, and the quota was reached for carers but only for half of the nurse quota. Since 2019, Japan has allowed foreign workers to obtain a residency status, the “Specified Skilled Workers”, to work in the LTC sector (OECD, forthcoming[7]). Israel is a country that relies heavily on foreign workers, especially for home care. Foreign workers can receive a permission to stay in the country if they work in one of the sectors listed by law, including LTC. Older people and relatives who wish to hire a foreign caregiver contact directly a recruitment agency. They become employers and must provide employees with private health insurance and adequate housing. Foreign workers are allowed to stay in Israel for a maximum of 63 months, but the regulation can be eased for LTC workers who have been employed for at least 12 consecutive months, if they can prove that a change of carer might harm the older person in need of care (PIBA, 2013[8]).

Germany has put in place comprehensive programmes to attract and train foreign-born nurses. Germany has attracted nurses from southern European countries, Serbia, Bosnia, the Philippines, Tunisia and Viet Nam. The German Triple Win programme has led to the recruitment of 1 000 nurses between 2017 and 2020. A different programme is in place to recruit nurses from Viet Nam and it requires that, before moving to Germany, nurses complete their degree and take one year of German language classes in Viet Nam. Once they arrive in Germany, nurses must complete up to two years of training, including theoretical and practical courses and language classes. Afterwards, nurses must work in the sector for 3 years in order to obtain a permanent residence permit. The programme has been successful, with nurses remaining in the same firms after the training programme (OECD, 2020[3]).

Further strategies to recruit and retain LTC workers include offering placement opportunities to nurse students and personal care workers during their studies. In Lithuania, students currently pay the cost of nurses’ training programs out of pocket (EUR 2000). Lithuania could develop collaborations between care providers and training providers in order to develop programs of paid trainings with placement opportunities. For instance, Estonia has work-based learning programmes that allow students to study and work in the LTC sector. The students complete one-third of the studies at school and two-third in a LTC institution and receive a salary, which cannot be lower than the basic income (654 euros in 2022). At the end of the programme, students undertake an exam free of charge. In Canada, the Prior Learning Assessment and Recognition Process improves immigrants’ employability and facilitates their entry into post-secondary education institutions. It allows recognition of the international credentials of immigrants willing to work in health occupations.

Retaining LTC workers is not straightforward because of the multiplicity of factors that influence turnover. Low wages represent a challenge for staff retention, especially because there are few opportunities for pay progression. Lithuania could improve working conditions, starting with wages given the context of high inflation. In Lithuania, the inflation rate raised from 1.1% in 2020 to 4.6% in 2021 and 6.7% in 2022 (EC, 2022[9]). Since LTC workers’ wages in Lithuania are close to the minimum income, their standards of living are very likely impacted. However, wages are not the only factor driving low retention: workers also point to working times, stress, heavy workload, and poor support; and addressing these factors is similarly important. Beyond wages, promoting a healthier work environment and prevention of work-place accidents and illness can reduce absenteeism, turnover and poor workers health. The Netherlands has developed coaching programmes, while Japan has workplace counselling services to promote prevention of accidents and burnout. Giving workers more flexibility and control can also boost job satisfaction and reduce turnover. Self-managed teams, such as in the Netherlands, Australia and Japan, have given nurses more autonomy.

Lithuania can develop training programs with placement opportunities. Enhancing training can help improve job quality and influence retention. Better jobs will mean better quality of care and reductions in the high staff turnover and related costs. Examples of successful training programmes for LTC workers are in place in Norway and in Denmark. As part of the Competency lift 2025 action plan, Norway provides grants to municipalities. The programme entails 70 different grants for different types of training, for a total of around EUR 230 million. The training does not substitute the formal training, but provides additional skills and improves the motivation of LTC workers (Helsedirektoratet, 2021[2]). Each year, municipalities provide a report to the central government to detail their use of the grants. Denmark has also engaged to improve the competences of LTC workers and in particular personal care workers through training. All non-qualified employees in Denmark have the right to participate in a social care worker’s training programme, and employers must offer the training within the first three years of work. Employees receive leave and financial compensation to cover the cost of the training (FOA, 2009[10]).

A few countries encourage those with the lowest position to progress in their career, shifting across different roles within the LTC sector. Those countries also provide specific training to allow career perspectives. For instance, Denmark, Germany and Korea have modular training for personal carers to those who seek to access managerial roles or for nurse aides wanting to become nurses. In particular, Danish personal care workers can attend a two-year programme and undergo national examinations in order to progress and provide more advanced care, becoming health assistants. Similarly, in Norway nurses assistants can specialise and train for between six months and three years, as well as attending one year of vocational training, to become registered nurses (OECD, 2020[3]).

There are also other country examples to improve training opportunities. Germany started a new vocational training programme for nurses in 2020. The programme merges training for general, geriatric and paediatric nursing, exposing all nursing students to more general and comprehensive skills. People with an intermediate school certificate or a secondary school diploma – both German students and foreigners with good knowledge of the language – can apply for the training at the available employers. During the three-year training, students receive a monthly salary (starting at 1 200 euros gross per month, and increasing each year) and they are allowed to have a job in parallel to the training, for a set number of hours. After three years of training, nurses can expect to earn a variable amount of money, starting at around 2 300 euros gross per month, with additional bonuses for night shifts, weekends and public holidays (Pflege-Deutschland, 2022[11]; LifeinGermany, 2022[12]).

Another avenue to develop career pathways and improve people-centred care is to create the position of care managers. Denmark and Japan rely on care managers and Slovenia aims to introduce the role of care co-ordinator. In Denmark, the care manager is a social worker employed by the municipalities, whose role is to plan home services and co-ordinate home-based workers. This network of co-ordinators provides a single interface with older people and their relatives. In Japan, care managers draw up care plans for older people. They must be licensed professionals (e.g. social workers, nurse) with at least 5 years of experience and have followed a few days of training (which leads to a certification). Most care managers are full-time municipal employees (Tsutsui and Muramatsu, 2005[13]). They can also be employed by private care agencies. While older people are free to make their own care decisions, the system is sufficiently complicated to incentivise them to go through care managers. When older people work out their care plan with the care managers of agencies, it is common that the care managers encourage the use of the care of their agencies. Slovenia aims to introduce the role of care co-ordinator following the recent reform. Each provider of LTC will be required to have at least one co-ordinator. Co-ordinators will create a care plan with the eligible older people and will visit people to ensure that they receive quality LTC. The option adopted by Slovenia and Japan (yet not in Denmark) is to allow older people to choose care managers/co-ordinators employed by municipalities or care providers.

Given potential shortages of carers and the demographic and societal long-term changes, supporting informal carers is needed. It is a win-win option because it is beneficial for carers, care recipients and often for public finances. Care recipients often prefer to be looked after by family and friends.

A body of research shows that informal carers often wish to receive more training to enable them to provide better care (COFACE, 2017[14]). For instance, carers are not always knowledgeable about the diseases of the person they care for or have difficulties performing personal care (e.g. lifting someone from a bed to a chair without experiencing pain). According to Eurocarers, carers would mostly benefit from training on specific diseases, skills required to maintain or rehabilitate the health status of the care recipient, skills to deal with the management of symptoms, skills related to daily life activities, and the management of emergencies. Practical nursing skills – mainly managing and administering medication, pain management, and moving and handling techniques without suffering strain – are also often sought. These practical nursing skills are particularly important for carers who take over between nurse visits, which means mostly in the evening of working days and during the weekends.

Lithuania could consider enhancing training for informal carers. In the majority of OECD countries, free training (at least online) is available. Across OECD countries, most training relies heavily on the voluntary sector. Australia has developed a comprehensive public training programme in collaboration with non-governmental organisations (NGOs). In Mexico, the Institute of Social Security and Services for State Workers and the Institute for Social Security finance and organise online courses. In Greece, NGOs collaborated with academic institutions to create free training courses for carers – the “I care programme”. Similarly, in Canada, France, Ireland and the United Kingdom, countries collaborate with NGOs to provide regular training. In the United Kingdom, NGOs like Carers Trust and Carers UK are subcontracted to provide training across the country.

Lithuania could also consider policies which enable both men and women to more readily combine work and care responsibilities in order to reduce the risk of dropping out of the labour market altogether. Currently, about two-thirds of OECD and EU countries provide paid or unpaid leave to care for an older family member (Table 5.1). Over half of the countries offer paid leave for carers of older people (Rocard and Llena-Nozal, 2022[15]). Paid leave entitlements vary starkly across countries in terms of duration, eligibility criteria and generosity of compensation. A range of options is available across countries and Lithuania could decide on how generous the leave could be. The duration varies from two days in Spain to three months, renewable once, in France, to unlimited time in Denmark. In five countries (Estonia, Germany, Netherlands, Norway and Spain), paid care leave for non-terminally-ill care recipients is limited to less than one month. In all countries with paid leave, aside from the Nordic countries, Belgium and Ireland, the care recipient has to be a member of the family and/or be a co-resident. In five countries (Belgium, Denmark, France, Luxembourg and Sweden), paid leave targets specifically carers with a relative at the end of their life (Rocard and Llena-Nozal, 2022[15]). As in France and Belgium, Lithuania may consider compensating leave on a flat daily or a monthly rate rather than a share of the wage, to limit spending. The flat rate could be aligned with compensations for the cash benefit for nursing care (EUR 226 for the second level), and below the minimum wage to avoid a distortion on the labour market (EUR 730).


[5] Agenzia delle entrate (2022), Lavoratori impatriati - Che cos’è, https://www.agenziaentrate.gov.it/portale/web/guest/lavoratori-rimpatriati-che-cos-%25c3%25a8-cittadini (accessed on  2022).

[14] COFACE (2017), Study on the challenges and needs of family carers in Europe | COFACE, http://www.coface-eu.org/resources/publications/study-challenges-and-needs-of-family-carers-in-europe/ (accessed on 29 August 2020).

[9] EC (2022), Economic forecast for Lithuania, https://ec.europa.eu/info/business-economy-euro/economic-performance-and-forecasts/economic-performance-country/lithuania/economic-forecast-lithuania_en.

[10] FOA (2009), Working with the elderly, the sick and the disabled.

[2] Helsedirektoratet (2021), Job winner, https://www.helsedirektoratet.no/tema/kompetanseloft-2025/jobbvinner (accessed on  2022).

[12] LifeinGermany (2022), A new vocational training program for nurses in Germany, https://en.life-in-germany.de/a-new-vocational-training-program-for-nurses-in-germany/.

[6] Migration Information Centre (2022), Work in Lithuania, https://www.renkuosilietuva.lt/en/work-in-lithuania/ (accessed on  2022).

[3] OECD (2020), Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/92c0ef68-en.

[4] OECD (2018), OECD Reviews of Labour Market and Social Policies: Lithuania, OECD Reviews of Labour Market and Social Policies, OECD Publishing, Paris, https://doi.org/10.1787/9789264189935-en.

[7] OECD (forthcoming), Beyond Applause, OECD Publishing, Paris.

[1] Pacifico, D. et al. (2018), “Faces of Joblessness in Lithuania: A People-centred perspective on employment barriers and policies”, OECD Social, Employment and Migration Working Papers, No. 205, OECD Publishing, Paris, https://doi.org/10.1787/3657b81e-en.

[11] Pflege-Deutschland (2022), Nursing Education, https://www.pflege-deutschland.de/ausbildung (accessed on  2022).

[8] PIBA (2013), Foreign workers’ rights handbook, https://mfa.gov.il/MFA/ConsularServices/Documents/ForeignWorkers2013.pdf (accessed on  2022).

[15] Rocard, E. and A. Llena-Nozal (2022), “Supporting informal carers of older people: Policies to leave no carer behind”, OECD Health Working Papers, No. 140, OECD Publishing, Paris, https://doi.org/10.1787/0f0c0d52-en.

[13] Tsutsui, T. and N. Muramatsu (2005), “Care-Needs Certification in the Long-Term Care Insurance System of Japan”, Journal of the American Geriatrics Society, Vol. 53/3, pp. 522-527, https://doi.org/10.1111/j.1532-5415.2005.53175.x.

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