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Estonian National Action plan on the implementation of the Council Recommendation on access to affordable high-quality long-term care 1. Context and baseline 1.1. Diagnosis of the gaps and remaining challenges Long-term care (LTC) in Estonia is provided by both healthcare and welfare systems. Healthcare offers inpatient and home nursing care, while welfare services include residential, semi-residential, and home-based services. LTC is financed by public health insurance (nursing care), the state (special care services, rehabilitation, technical aids), local governments (social care), and private spending. In 2021, Estonia's spending on LTC was 0.7% of GDP, compared to the OECD average of 1.8%. There was a decrease in the share of people at risk of poverty or social exclusion, especially among older people and people with disabilities in 2023 (Figure 1 in Annex). Hence, older people's incomes still affect their ability to afford long-term care (LTC). Estonia is facing an aging and decreasing population (Figure 2 in Annex). While average life expectancy has risen to 79 years in 2023, healthy life expectancy remains at 58 years (Figure 3 in Annex). Many Estonians over 65 require assistance with daily activities; in 2023, 59% reported limitations, and 25% reported severe limitations (Figure 4 in Annex). By 2050, Estonia's population is projected to decline to 1.32 million, with the share of people aged 65+ increasing from 20.5% in 2024 to 27.4%. The ratio of working-age individuals per person aged 65+ will decrease from 3 to 2.2. At the same time the demand for LTC is expected to rise due to an aging population. As people age, the likelihood of experiencing activity limitations increases. According to the 2020 survey1, 6% of the Estonian population, or 10% of those with activity limitations, need additional services due to health problems, chronic illness, or activity limitations. This equates to 56,000 to 75,900 people, with an estimated 28,000 to 38,000 potentially feeling that their needs are unmet due to the lack of necessary assistance and LTC services. Estonia's overarching policy aims to enhance accessibility to home-support services and reduce care burden. Remaining challenges Limited integration between social welfare and healthcare systems is posing significant barriers. Coordination across different levels of government remains insufficient, compounded by widely varying funding models that hinder service integration and inadequate data sharing between sectors. Finding solutions to improve coordination between social welfare and healthcare services, as well as developing and implementing funding models that support coordinated service delivery is crucial. Moreover, more support is needed to ensure the well-being of both informal caregivers and care recipients. Informal caregivers play an essential role in minimizing LTC costs. In 2023, 35,400 women and 19,500 men aged 16 and above provided care for their relatives, with 26,700 dedicating 20 or more hours per week to caregiving. This high caregiving burden significantly impacts employment, with 2,500 women and 700 men not working due to caregiving responsibilities. To alleviate the burden on informal caregivers and promote their employment, the LTC policy focuses on enhancing the accessibility and quality of formal care services rather than relying on financial assistance. 1 The Activity Limitations and Care Needs of the Population, 2020 1 Additionally, the aging population and rising demand for higher-quality LTC emphasize the need to expand the care workforce. With fewer families available for caregiving, the demand for social sector workers is expected to rise by 20% by 2030, necessitating nearly 3,000 new employees annually across care homes, hospitals, and home-based care. Meanwhile, approximately 1,000 care workers leave their roles each year for better-paying jobs in commerce and services.2 In 2020, 46% of care workers were over 55 years old, and 94% were women. Social sector care workers earn about 37% less than the national average wage of €1832, with an average monthly salary of €1155.3 Enhancing pay, working conditions, and training is critical to attract and retain personnel in the sector during labour shortages. As these shortages worsen, a key future challenge will be addressing debates around importing labour from third countries. 1.2. Stakeholders’ involvement This action plan is informed by insights from working groups convened between 2019 and 2022, involving a diverse array of stakeholders. Through proposals, dialogues, thematic discussions, and regular meetings, we synthesized inputs to shape our strategy. Led by the Ministry of Social Affairs, this collaboration included advocacy groups, government bodies, local authorities, and representatives of target groups, ensuring a comprehensive approach. The action plan aligns with previously agreed-upon directions, some of which, like the care reform, have already been implemented. This action plan does not cover national special care services, which are primarily provided to working-age individuals with mental disorders. The interventions described in the action plan are based on the objectives set forth in the Welfare Development Plan 2023-2030 and the National Health Plan 2020-2030. The Steering Committees of the Development Plans consists of representatives of ministries, local governments, social partners and strategic partners of the Ministry. The implementation of development plans is additionally advised by experts. Separate Government Population Policy Commission, established in 2021, addresses population related questions. 2. Policy objectives and measures (to be) taken 2.1. Overall policy response Since 2016, Estonia has made significant steps in developing its LTC policies. A high-level Task Force on reducing care burden convened by the Government Office in 2016-2017 laid the groundwork for policy recommendations aimed at reducing care burden and improving LTC organization. Initial proposals were approved in 2018, followed by the launch of preparations for LTC financing schemes in early 2019. Seven working groups formed by the Ministry of Social Affairs that year focused on updating social welfare and LTC policies. One of these working groups proposed solutions in LTC organization, financing, and individual contribution principles, resulting in over ten potential combinations for Estonia's long-term system. Three most feasible models were selected and presented to the Cabinet of Ministers in 2019, with the local government-state partnership model approved. In 2021, the Ministry of Social Affairs sought a mandate to continue restructuring the LTC system, including drafting legislation on local government-state partnerships and seeking support for informal caregiver initiatives. Emphasis was also placed on securing additional state budget funding, particularly for home- and general care services. 2 Occupational Skills Needs Assessment (OSKA) report on workforce and skills demand for 2021-2030 3 Statistics Estonia, 2023 2 The first significant legislative changes were implemented between 2022 and 2023. One change was also defining the concept of LTC at the legislative level. According to the definition, LTC involves assisting individuals who require extended support in daily activities due to physical or mental impairment or reduced work capacity. It includes healthcare services, caregiving services, and support for daily functioning. In 2023, Estonia received a Country Specific Recommendations (CSR) concerning affordability, quality, and sustainability of financing of long-term care4. The current action plan contributes to the effective implementation of the CSR. Measure Name of measure LTC Recommendation no article/ letter 1 Recent amendments in long-term care related legislation 4/a, b 2 Care reform 4/a, c; 5 d; 6 e 2 Informal carers 9/b, c; 10/b, h, g 4 Social sector workforce 7/a, b; 8/ a, b, e; 10/ b, h 5 Health care workforce 7/a, b; 8/b, e; 10 b/h 6 Quality of social services 6/a, d, e; 10/b, h 7 Coordination of social and healthcare 4/a, b; 5/e; 10/b, h 8 Independent living, dignity, and non-discrimination 5/a, a, c, d, e; 6/e, f; 8/f; 10/b, h 9 Long-term care management and monitoring 10/a, b, c, d, e, f 2.2. Detailed description of the measures Measure 1 Recent amendments in long-term care related legislation Aim To enhance legal clarity and support for persons who need assistance Type (e.g., legislative Legislative Changes reform, investment, etc.) Target group Measure across target groups (definition and size) People in need of assistance and support, their families, carers, and local governments Results and impact Expected outcomes: (expected or  prioritizing independent living at home or in the community over achieved) institutional care;  clarifying the process of assessing, identifying, and organizing the provision of assistance and support;  highlighting informal caregivers as a target group alongside care recipients who may need assistance;  ensuring proactive assistance for people with disabilities and preventing the escalation of their care needs; 4 2023 European Semester: Country Specific Recommendation / Commission Recommendation - Estonia https://commission.europa.eu/document/download/c5b996c6-e313-4ed1-a0bf- 48decc7cabfb_en?filename=COM_2023_606_1_EN.pdf 3   reducing the burden on family members in financing care services. Amendments in Social Welfare Act:  A new subsection 2¹ was added to § 3, stipulated the assistance and support must primarily be offered in a way that allows people to live at home or a home-like environment and living arrangements. This addition was necessary to ensure that the local governments responsible for organizing assistance and support would prioritize services that support living at home. Although LTC services include institutional care services, the option of moving into an institution should remain the last resort when it is no longer possible to ensure a person's dignified and safe living at home.  In paragraph 9, subsection 11, long-term care is defined in legislation for the first time.  The regulations for local governments regarding the assessment of care needs and the provision of assistance have been clarified. The revised wording under § 15 subsection 1 specifies the local government's responsibility to assess the person's need for assistance and determine its extent, followed by organizing the provision of appropriate support. A person must not be left without necessary support due to the lack of a specific service in the local government's area.  The local government must also assess the support needs of the person providing care during the assessment of the care recipient's needs (§ 15 subsection 4). The support needs assessment should consider the informal caregiver's actual care burden, ability to cope, and factors affecting participation in society. Emphasizing the need to assess informal caregiver support helps standardize local government practices and ensures that caregivers have equal opportunities to receive support, such as supportive services, training, counselling, or financial assistance.  A new section (15², entered into force 01.02.2023) was added, allowing local governments to access data on adults with disabilities residing within their territory through the Social Services and Benefits Data Registry (STAR). With this change, local governments gained the right to contact adults with profound disabilities and proactively identify potentially individuals who might need support. Within 30 days local governments are obligated to proactively assess the needs of adults with profound disabilities and offer assistance. This supports the independent living and ensures assistance reaches those who need it but may not seek it.  The amendment to Section 96 of the Family Law Act relieved second-degree relatives of their obligation to provide (financial) support and cover related expenses for their adult relatives. Following the amendment, the responsibility for support falls on first-degree relatives, both ascending and descending. Second- degree ascending relatives are only obligated to provide support for their minor descending relatives (e.g., grandparents for minor grandchildren). 4 Timeline Amendments entered into force May 2022 and February 2023. Financial resources The implementation of the legal amendments was supported with around (both national and EU 0,5 MEUR both national and EU funding. funding) Implementing Primary implementers are local governments and Social Insurance Board. body(ies) and Since 2019 a new advisory unit has been established at the Social Insurance cooperation with Board to enhance state support for local governments in social welfare stakeholders tasks, standardize and improve assistance measures, and develop a strong primary-level social welfare system. The unit coordinates regional network meetings between local governments and social service providers, compiles and shares best practices, creates guidelines, and organizes seminars and trainings. Evaluation Indicators: Initial level Target level 2023 2028 Percentage of people aged 16 or over who provide care for their family members, % 5 decreases Source: Statistics Estonia, Estonian Labour Force Survey Percentage of adults who receive services that support independent living at home, % 2,6 increases Source: Social Welfare Statistics of the Ministry of Social Affairs, Statistics Estonia Ratio of an adult recipients of services that support independent living at home to recipients of 24-hour institutional care 1,0 1,3 Source: Social Welfare Statistics of the Ministry of Social Affairs, Social Insurance Board Cross-linkages with 2, 3, 6, 7, 8 other measures Measure 2 Care Reform Aim To reduce out-of-pocket payments for general care service, improve the quality and the working conditions for care staff, and enhance the availability and quality of home-based care services. Type (e.g. legislative Legislative reform and investments reform, investment, etc.) Target group People aged 18+ who need care, their families, and carers (definition and size) 5 Results and impact Initial results for 2023: (expected or achieved)  the general care service is financially accessible for individuals receiving the average old age pension;  the number of care staff (care workers and assistant care workers) has grown significantly, reaching a 25% increase, which is higher than the typical annual growth of 4% to 13% seen in the past 10 years;  the number of informal caregivers for family members aged 65 and older decreased from 31,900 to 30,500 individuals compared to 2022.  Informal caregivers providing intensive care (20+ hours per week) decreased from 15,300 to 14,000. This decline, predominantly used by elderly individuals (91%), may reflect improved financial accessibility to general caregiving services. Timeline Implemented from 1st of July 2023 Financial resources Additional financial support for local municipalities was 40 MEUR in 2023. (both national and EU In 2024, further state funding for local municipalities' revenue base and funding) equalization fund amounts to 61 million euros. The funding will increase yearly in accordance with the income tax revenues and is expected to reach to 76,6 MEUR by 2028. This funding gives local governments flexibility to use the funds for the best ways to organize LTC in their areas. The allocation of funds is based on the proportion of elderly (aged 65+) in a municipality, as the likelihood of needing care increases among the older population. Implementing Implementers: local governments and elderly care homes, Social body(ies) and Insurance Board (supervision and guiding) cooperation with Ministry of Social Affairs and Social Insurance Board maintains continuous stakeholders collaboration with local governments and service providers monitoring the progress of the reform. This includes also ongoing cooperation with the Ministry of Regional Development and Agriculture to monitor changes in local government expenditures. Each year, municipalities engage in negotiations concerning the state's budget strategy for the next four years and the upcoming year's state budget. The objective is to reach consensus on the size and allocation of the revenue base, equalization fund, and state budget allocations for local governments as outlined in the draft state budget law. These negotiations also address sector-specific policy directions that directly impact local governance. The Ministry of Social Affairs coordinates these discussions through the Labour, Social, and Health Working Group. Evaluation Indicators: Initial level Target level 2023 2028 Percentage of total service costs covered by individuals receiving 24-hour general care services, % 78 (2022) 60 Source: Social Welfare Statistics of the Ministry of Social Affairs 6  Percentage of people aged 16 or older with a high caring burden who provide care to their family member aged 65+, % 14 000 decreases Source: Statistics Estonia, Estonian Labour Force Survey Ratio of 24-hour general care services service users to of home care users 1,7 decreases Source: Social Welfare Statistics of the Ministry of Social Affairs The impact assessment of the reform will be conducted in IV quarter of 2026. Beyond registry-based data collection, several studies targeting specific groups are planned for 2025, for example satisfaction of service users with the quality of general care service and reform impacts on family members employment. The second survey on the population's care needs and activity restrictions will be carried out in 2025 and the next population care burden survey is planned for 2027. Cross-linkages with Measures 1, 3, 4, 6, 8, 9 other measures Measure 3 Informal carers Aim To reduce the burden of care by creating a support system for informal carers, providing training and supportive services to help them cope better with their caregiving responsibilities, and ensuring better social guarantees and opportunities to balance work and caregiving. Type (e.g. legislative Legislative changes and investment reform, investment, etc.) Target group Persons with care burden. According to the 2023 Estonian Labour Survey, (definition and size) 55,000 people aged 16+ (19,500 men and 35,400 women) reported care burden, amounting to 5% of the population. Additionally, 11,792 people received caregiver's allowance from municipalities. Results and impact Expected outcome: (expected or achieved)  Long-term care heavily relies on informal caregivers, underscoring the need for increased support to mitigate the adverse effects of caregiving on their health, social lives, and finances, while enabling balancing their work and family life. Therefore, the definition and minimum support package (services, trainings, social guarantees etc.) for informal caregivers must be agreed and regulated by law to ensure their equal treatment. Key initiatives:  In 2020, a working group convened by the Ministry of Social Affairs reached an agreement on the definition of informal caregivers and principles for their support. Proposals regarding the support of informal caregivers were submitted to the Cabinet 7  of Ministers in 2021 and were approved but funding decisions were not made.  In 2021 the Ministry of Social Affairs initiated amendment of the Employment Contracts Act and related laws so that employees and officials with caring responsibilities have the right to apply for flexible working conditions (for example, part-time or flexible working hours, teleworking, etc.). The amendment provides additional protection for employees and officials with caring responsibilities in the event of termination of employment or dismissal, and the reversal of the burden of proof in disputes concerning termination of employment or dismissal.  A new leave form (carer leave) entered into force under the Employment Contracts Act from 1st July 2018. Employees can use additional leave (5 days per calendar year) to care for an adult family member with a profound disability. The leave allowance is compensated based on minimum wage.  In 2022, a legislative intent was sent for public consultation aiming to expand care leave and introduce a social tax incentive for balancing work, caregiving, and family life. According to legislative intent, the right to use care leave is tied to the care needs of the dependent, not to their disability as identified by the Social Insurance Board. Additionally, the proposed paid leave benefit rate would increase from the minimum wage to the average income subject to social tax contributions, ensuring that caregivers using leave do not lose their income. The implementation of these regulations required approximately 20 MEUR from the state budget. Due to the state's financial situation, funding has not been available to implement these changes.  In collaboration with the Estonian Chamber of Disabled People, a web solution for informal caregivers is being launched in the summer of 2024. Informal caregivers will have access to information, counselling, and training. The initiative also aims to establish a network that advocates for the interests of informal caregivers, which is currently missing in Estonia. The budget for 2023-2025 is 0,36 MEUR (ESF+ and state co-financing).  During 2024-2025, an analysis will be conducted on international and local practices related to supporting informal caregivers, including funding, as well as the needs and barriers to employment. In 2025, an overview, analysis, and recommendations will be conducted for the development of support systems at the local level aimed at persons with dementia and their families. This will encompass evidence-based intervention options for supporting individuals with dementia living at home. These findings will give input for the implementation of supportive measures for people with dementia and their families in 2026, funded by the European Social Fund (ESF). The budget for 2024-2025 is around 0,3 MEUR (ESF+ and state co-financing).  Dementia Competence activities continue, aimed at supporting individuals with dementia and their families. One of the tasks of 8  the Competence Centre is to establish and maintain a network of support groups for informal carers of people with dementia across Estonia. The goal is to ensure the operation of support groups and provide necessary assistance to informal carers. In 2023 30 support groups were operating across the country. The budget for 2024-2028 is 1,36 MEUR (state budget).  Local municipalities have possibility to apply for funding to develop supportive services for informal caregivers throughout the current ESF+ period. From 2016 to 2023, over 100 projects have been implemented, focusing on improving home care availability, reducing care burden, and enhancing support for informal caregivers. Approximately 15 MEUR were allocated with support from EU structural funds and state financing. Similar support will be available to municipalities in the coming years.  To ensure gender equality, goals and actions have been established in the Welfare Development Plan 2023-2030. The goal is to achieve gender equality by enhancing economic equality, increasing women’s participation in decision-making processes, transforming societal attitudes, and strengthening institutional capacities to promote gender equality. The working programmes of the strategy are being updated every year to ensure and monitor the effective implementation of the strategy. Timeline 2023-2028 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementing bodies: Research institutions, universities, Social Insurance body(ies) and Board, Estonian Chamber of Disabled People, local municipalities, NGO cooperation with Life with Dementia, Dementia Competence Centre and others. The stakeholders Ministry of Social Affairs collaborates with stakeholders through contracts and strategic partnerships, regular discussions etc. Seminars and trainings are organized for municipalities' funding rounds. Evaluation Indicators: Initial level Target 2023 level 2028 Percentage of people aged 16 or over who provide care for their family members, % 5 decreases Source: Statistics Estonia, Estonian Labour Force Survey Percentage of people aged 16 and over with a high caring burden (20 hours or more per week), % 2,4 decreases Source: Statistics Estonia, Estonian Labour Force Survey Ratio of adults receiving formal social services compared to those receiving informal care (supported by caregiver allowance) 3,7 increases Source: Social Welfare Statistics of the Ministry of Social Affairs, Social Insurance Board Cross-linkages with Measures 1, 2, 7, 8 other measures 9 Measure 4 Social sector workforce Aim To improve care workers' working conditions, update training and professional standards for social sector workers, develop basic education and in-training systems to improve the quality of the social workforce, enhance the knowledge and skills of social sector leaders, advocate for the interests of social sector workers, and promote the image of professions in society. Type (e.g., legislative Legislative changes and investment reform, investment, etc.) Target group Long-term care workforce (care workers, assistant care workers, support (definition and size) persons, activity supervisors), social field advisory workers (social worker, child protection worker), social field managers (managers of municipal social departments, heads of welfare institutions), social field lecturers, vocational teachers, and in-training teachers. Results and impact Expected outcomes: (expected or achieved)  all care homes comply with the care worker-to-client ratio requirements by 1st of July in 2026;  modernized curricula and new educational programs for professionals has been implemented ensuring a larger number and more skilled workforce.  ongoing training opportunities for professionals in accordance with the updated curricula are available.  a support and counselling system specifically designed for workers in the social sector, aimed at enhancing their well-being and effectiveness has been established. Key interventions:  A study on labour force demand in the LTC sector was carried out in 2022 by Foundation Praxis and Haap Consulting Ltd. The study proposes changes in curricula, internship programs, and activities aimed at improving the image and attitudes towards care work. The study also revealed conservative attitudes towards the migrant workforce in the sector.  In 2023, the Minister of Social Protection issued a decree setting client-to-staff ratios for 24-hour general care services, which will take effect on July 1, 2026. The care home always guarantees the presence of one care worker per 36 service recipients, along with at least one care worker or assistant care worker per 12 service recipients during the day, for 12 consecutive hours.  The program for the development of adult education and provision of non-formal learning opportunities focuses on enhancing adult education and offering non-formal learning opportunities for professions such as care workers, activity coordinators, social workers, support personnel, and childminders. The program targets adults without professional- level or secondary education, as well as those with outdated skills, aiming to address these priorities through training in various fields, including digital competencies. The training is part of the 10  national continuing education order for social sector workers and financed by ESF+ funds totalling 2.6 MEUR, including state co- financing.  A program strengthening social and child protection services under the Estonia-Switzerland cooperation program includes the development and modernization of curricula in higher education and vocational education for social work professionals, promoting new opportunities and positive changes in social and child protection studies and work environments. It also involves supporting migrants and refugees in accessing the labour market in the social care sector, developing a continuing education and training system for child protection and care workers, and providing training for specialists. Additionally, the program implements a workplace-based counselling and support system for workers in the social sector. The program is funded by the Estonia-Switzerland Cooperation Program with a total of 6.56 MEUR including national co-financing 15%.  The state has strategic partnership with Estonian Social Work Association to collaboratively develop the workforce and enhance professional standards. This includes funded support for shaping and implementing social and health policies. Activities focus on knowledge exchange, harmonizing social work practices, addressing skills shortages through monitoring, and updating qualifications, promoting certification awareness, supporting adherence to human rights and ethical principles, promoting self- care and professional development, mentoring programs for leaders, and enhancing the social sector's public image. Recognition and awards are also given for outstanding achievements across various professional fields within the social sector. For 2022-2024 state funding amounts up to 0.47 MEUR. Conditions and financing for period 2025-2028 is under negotiation.  A program to support societal change in Ida-Viru County in collaboration with the Ida-Viru County Municipalities Association started in 2023. The goal is to enhance the competence of social and healthcare workers and attracting new specialists to the region. Funding is allocated to three activities: improving the availability of integrated social and healthcare services, incentivizing professionals to work in the region through a motivation package and providing innovation grants to enhance social and healthcare services. The program is implemented with funding from JTF 7.2 MEUR, including state co-financing. Timeline 2022-2029 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementers: body(ies) and Vocational educational institutions, universities of social work in cooperation with partnership with university Bern University from Switzerland, Estonian stakeholders Health Development Institute, Estonian Social Work Association, Social Insurance Board, Ministry of Education and Ministry of Social Affairs. The 11  Ministry of Social Affairs collaborates with implementers through contracts, partnerships, and regular discussions. Evaluation Indicators: Initial Target level level 2023 2028 Percentage of care homes meeting care worker to client minimum ratios, % 66 100 Source: Social Welfare Statistics of the Ministry of Social Affairs Number of participants in non-formal adult education in the social field (participation occasions) 2077 0 (2022) (2029) Source: Ministry of Education and Research Cross-linkages with 1, 2, 6, 7, 8 other measures Measure 5 Healthcare sector workforce Aim Ensuring the presence of motivated healthcare workers and other specialists in all regions of Estonia and supporting their empowerment. Type (e.g., legislative Legislative changes and investment reform, investment, etc.) Target group Healthcare professionals (definition and size) Results and impact Expected outcomes: (expected or achieved)  The healthcare sector has motivated and competent specialists whose training meets the needs of the population and the healthcare system. Key interventions:  The Strategic Framework for addressing health workforce shortages was approved in 2023 by the regulation of the Minister of Health and Labour. In 2024 it is going to be mapped against WHO European framework for action on the health and care workforce 2023-2030 and a draft for updated Estonian Strategic Framework will be created.  Amendments to the Health Services Organisation Act and the Regulation of the Minister of Health and Labour Beginner’s allowance for medical specialists were approved in November 2023. In 2024, nurses, who start working outside larger cities receive allowance of 30,000 euros. The allowance for pharmacists is 15,000 euros, if the pharmacist starts working for at least 3 years, and 25,000 euros, if the pharmacist starts working in the region for at least 5 years. The allowance for specialist doctor is now 30 000 and for family doctor 45 000. By 2028 the analyse will be conducted of the impact of beginner’s allowances and to work on improving, advancing, and expanding allowances to ensure the provision of quality and sustainable healthcare services regardless of a person's place of residence. The measure is funded from the state budget as an estimated expense. For the years 2024-2028, 12  an allocation around 12 MEUR has been planned in the state budget.  According to the Consensus Agreement signed in 2022 the admission of persons to nursing training has been increased in 2022/2023 (600) by 16% compared to 2020 (517) and by 35% (700) in 2023/2024 compared to 2020 (517). A Training Committee has been called together for more transparent and better-informed intake decisions for training health care specialists.  The "Back to Healthcare" projects for healthcare workers started in 2015 will continue. Projects are funded from the state budget, with approximately 2 MEUR allocated for this purpose for the years 2024-2028.  With the backing of the European Union Structural Reform Implementation Program (TSI), a framework will be formulated to enhance digital skills. Educational and practical opportunities will be adjusted to correspond with the advancement of the healthcare system, facilitating the implementation of a human- centred integrated service model, and efforts will be made to develop and widely implement innovative digital solutions that support the daily work of professionals. The project period is October 2022 to 2024, and the procurement was initiated by the European Commission DG REFORM.  There is ongoing development of health care workers and specialist prognose system and governance framework (Joint- Action HEROES, OSKA report on primary care). Action plan is developed in 2024 together with the University of Tartu.  Participation continues in the pan-European collaborative project HEROES funded through the EU4Health program. Within the project, teams defining the skills required for healthcare workforce planning are established, alongside the description of a national framework for healthcare workforce planning. The aim is to develop forecasting models to align roles and responsibilities among stakeholders involved in organizing healthcare education, including the Ministry of Social Affairs and its implementing agencies, the Ministry of Education, educational institutions, and professional associations. The project is funded by EU structural funds, with a total budget of 0.3 MEUR allocated to the Ministry of Social Affairs, of which 20% is covered as co-financing.  Together with stakeholders (Health Board, University of Tartu, healthcare colleges, Ministry of Education and Research, professional associations), a strategic plan is being developed by 2025 to update and clarify legislation related to the qualifications, competence, registration of healthcare professionals, and activities related to the employment of other foreign qualified healthcare workers in Estonia.  By 2026, Estonia will revise its healthcare worker shortage strategy in collaboration with WHO, incorporating its HRH framework into policy processes through regular meetings. Timeline 2023-2028 13 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Information about implementing bodies and cooperation with body(ies) and stakeholders is provided in the previous box „Results and impact cooperation with (expected or achieved)“. The Ministry of Social Affairs collaborates with stakeholders implementers through contracts, partnerships, and regular discussions. Evaluation Indicators: Initial level Target level 2022 2027 Number of nurses per 100,000 inhabitants 650,3 782,9 Source: National Institute for Health Development Number of doctors per 100,000 inhabitants 342,9 372,4 Source: National Institute for Health Development Cross-linkages with Measures 4, 7, 8 other measures Measure 6 Quality of social services Aim Enhance and empower the quality of social services. Type (e.g., legislative Legislative changes reform, investment, etc.) Target group Measure across target groups (definition and size) Results and impact Expected outcomes: (expected or achieved)  Improved client satisfaction, enhanced effectiveness of interventions, and strengthened societal well-being through accessible and responsive social services. Overall quality framework: The quality requirements of healthcare services are established in a regulatory decree issued by the Minister of Social Protection under the Health Services Organization Act. The tasks related to the quality of healthcare services are divided among Ministry of Social Affairs, Health Board, Health Insurance Fund, healthcare service providers, professional associations of healthcare workers, and educational institutions who train healthcare professionals. The minimum requirements for social services and general quality principles that service providers must follow, are established in Social Welfare Act. Since 2020, institutions providing out-of-home general care services must have an operating license. The quality of social services is monitored by Estonian Social Insurance Board who also is responsible for issuing social service activity licenses and for administrative and state supervision. Health Board oversees the compliance with health protection requirements in care institutions. 14 The Chancellor of Justice ensures that people in care homes are treated with dignity and that their fundamental rights are protected. The Chancellor of Justice examines whether people are treated with respect for their dignity, what the living conditions of the care home are and whether people's lives and health are not endangered in the care home and whether they receive necessary treatment. To enhance the capacity of local governments to organize welfare assistance, the Social Insurance Board established in 2019 a consultation unit for local governments. Quality guidelines for social services have been developed, based on the European Voluntary Quality Framework for Social Services. Key interventions:  Streamlining the tasks and roles of the Social Insurance Board and reorganizing supervisory activities within the Ministry of Social Affairs' jurisdiction are among the priorities for 2024. The changes are planned to take effect in 2025.  As part of the Care Reform more detailed minimum requirements were established for general care service (entered into force 01.07.2023) and for home care service which has transition period until 2025.  By 2025, the health protection requirements for social services and care institutions will be updated through a regulation issued by the Minister of Health under the Public Health Act.  In 2024, the guidelines for organizing home care, 24-hour general care service, housing service, support person service, personal assistant service, and care service for adults are being updated. Additionally, the quality guidelines for 24-hour general care service and home care will be updated. The updating of guidelines for other social services and guidelines for municipalities on how to assess the ability of individuals in need and their families to pay for social services will be carried out in 2025.  A digital needs assessment tool will be available for municipalities from 2025, followed by a informal carers assessment tool in 2027 in the Data Registry for Social Services and Benefits (STAR). This aims to optimize case management and to support social work specialists by gathering initial assessment information uniformly across municipalities. It streamlines data collection, reducing duplication and enabling statistical analysis for policymaking.  In 2024, an evidence-based risk forecasting model for general care homes, which will enable the identification of problematic care homes. A local government social work risk forecast (assessment of need and direction of service provision) will be developed in 2025.  Between 2026-2028, a digital self-assessment tool for social service providers will be developed. Tool allows providers to evaluate their service quality, identify shortcomings, and analyse services in a standardized format. The Social Insurance Board will gain a comprehensive view of nationwide service quality and valuable input for planning supervision activities and support 15  measures for service providers, such as training and development initiatives.  By 2028, the goal is to review and establish new qualification requirements for key social sector positions, e.g., the director of a care facility and others. Timeline 2023-2028 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementers: body(ies) and Social Insurance Board, service providers, local municipalities. In the cooperation with development of quality, stakeholders such as advocacy organizations, stakeholders local governments, service providers, implementing agencies and others are involved. Social Insurance Board organizes regular meetings with the representatives of care homes, service providers and regional network meetings with local governments. Evaluation Indicators: Initial level Target level 2023 2028 Satisfaction with services survey(ies) Source: Service Satisfaction Survey N/A has been carried out Quality guidelines for social services provided by municipalities are updated N/A updated Source: Social Insurance Board Existence of quality standards in home care and residential care established established Source: Ministry of Social Affairs Cross-linkages with Measures 1, 2, 4, 7, 8, 9 other measures Measure 7 Coordination of social- and healthcare Aim To develop and implement better coordination between social- and healthcare, ensuring quality assistance throughout life span. This involves providing timely support tailored to people, reducing administrative burden for individuals and families, and empowering professionals to collaborate effectively in providing assistance and support. Type (e.g., legislative Legislative changes and investment reform, investment, etc.) Target group Measure across target groups (definition and size) 16 Results and impact Expected outcome: (expected or achieved)  Improved coordination includes the delivery of cohesive and personalized assistance, services, and support nationwide for individuals with complex needs. This will lead to enhanced quality of life, prolonged independence, reduced administrative burden, and strengthened professional collaboration. Key interventions:  The 4th phase of the care coordination initiative started in 2023 and aims to expand the regional social and health care network to a county-wide. Four regional projects will run until 2025, after which nationwide coordination model and financing principles will be elaborated by the end of 2026. The project is funded by the ESF+1.7 MEUR, including state co-financing.  Estonia’s Government Action Plan 2023-2027 foresees the need for better coordination of social- and health care, development of palliative care services, and simplifying the legal processes for drawing up patient wills and defining end-of-life decisions by the end of 2024. Proposals for establishing a unified coordination and financing model of social and healthcare services will be submitted to the Cabinet of Ministers in 2025. The following activities are planned after the government's decision.  In 2024, a legislative intent will be prepared proposing solutions for the integration of assistive devices and medical equipment systems to simplify access to services for people in need of assistive devices. Implementation of the new system is estimated in 2029. The need for state budget funds, depending on the chosen solution, may range from 18 to 27 MEUR in 2024 prices.  By 2027, the plan is to transition rehabilitation services to a new system that simplifies access and makes service organization more transparent. The goal is for the system to be more user- centred and better aligned with people's needs.  In recent years, steps have been taken to implement the International Classification of Functioning, Disability and Health (ICF) across various sectors. In 2021 the Estonian ICF translation and guidelines were updated. In early 2023, the ICF became a national classification to ensure comprehensive data exchange between systems. The Health Development Institute now maintains the ICF, ensuring its updates, terminological coherence, and providing ongoing training and mentorship programs. Timeline 2023-2029 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) 17 Implementing In 2024, broad-based working groups were established under the Ministry body(ies) and of Social Affairs to develop solutions related to the integration of social cooperation with and health care and the development of palliative care services. These stakeholders working groups include representatives from the social and health sectors, professional organizations, research institutions, local governments, Health Insurance Fund, Social Insurance Board, Ministry of Regional Affairs and Agriculture, Nurses Union, Family Doctors Association, Estonian Association of Gerontology and Geriatrics, Hospitals Association, National Institute for Health Development, and many others. Evaluation The indicators and measurement system for goals and outcomes will be developed 2025 Cross-linkages with Measures 1, 2, 3, 4, 5, 6, 8, 9 other measures Measure 8 Enhancing independent living, dignity and non-discrimination Aim To ensure independent living, autonomy and social inclusion of older people and people with disabilities, providing them with equal opportunities and ensuring their well-being and social security. Type (e.g. legislative Legislative changes and investments reform, investment, etc.) Target group Measure across target groups (definition and size) Results and impact Expected outcomes: (expected or achieved)  prioritizing independent living at home or in the community over institutional care;  ensuring proactive assistance for people with disabilities and preventing the escalation of their care needs;  older people and people with disabilities are socially included in the society, have equal opportunities. Key interventions:  To support care reform implementation and enhance home- based care at the local level while reinforcing support for informal caregivers, two funding rounds were initiated in the first and second quarters of 2024. These calls for proposals were backed by 33.3 MEUR from EU Structural Funds, supplemented by state co-funding. This includes 9.9 MEUR (ESF+) for home-based services, with project eligibility until the end of 2027, and 23.4 MEUR (ERDF) for establishing community-based housing for individuals with lesser support needs, with eligibility until the end of 2028. These initiatives also aim to promote the use of digital assistive technologies in service development.  To address regional disparities in access and quality of social services while fostering innovation, person-centered solutions, and collaboration, the Southeast Estonia Support Program is being implemented from 2023 to 2027, with a total funding of 3 18  MEUR (ESF+), including state co-financing. A similar program implemented in Ida-Viru County from 2019 to 2021 demonstrated effectiveness. Another measure was launched in I Q of 2024 to support communities in ensuring the availability and quality of LTC services, as well as alleviating care burden. Additionally, activities aimed at enhancing social inclusion are funded. The total budget for the grant application round is 7.1 MEUR (ESF+), including state co-financing.  In 2020, the government approved a green paper with the objective of enhancing technology adoption to improve individuals' daily living and well-being at home. Despite initiatives in innovation, effective implementation of new technologies and approaches, as well as service innovation, necessitates stronger leadership in social sector. The Ministry of Social Affairs will submit proposals for innovation and technology use in the social sector to the Cabinet of Ministers by the end of 2024. Follow-up activities are starting from 2025, supported by ERDF, to facilitate the adoption of innovative solutions in living and service environments.  In 2023, the new Victim Support Act came into force, expanding the range of victim support services and the scope of individuals who receive support. For the first time, principles for the treatment of victims and educational requirements for specialists working with victims were introduced. With the new law, psychological help, and support for victims of domestic and sexual violence recovering from trauma will become more accessible, without the prerequisite of initiating criminal proceedings. Additionally, the legislation clarifies the roles of institutions and organizes data exchange to enhance system integrity.  In 2024, a draft law is being prepared to merge the Gender Equality Act and the Equal Treatment Act and revise the regulation. The new law will widen the scope of protection and the grounds of protection to a similar level as is for gender with the current legislation. For example, disabled people will receive protection against discrimination in all areas of social life, as the ground of disability is currently only protected against discrimination in employment.  In 2025, an applied study will be conducted to shape attitudes that value older adults and reduce age-related prejudices in society, particularly among employers. The study aims to identify the main reasons for exclusion from the labour market and societal life, proposing interventions to achieve desired outcomes. The goal is to design and implement effective measures that help change the negative perception of older adults within society, among employers, and among older adults themselves. Additionally, the activities of senior councils are supported, and the promotion of age-friendliness in local governments is encouraged.  In 2019, the Estonian Government established a high-level Accessibility Task Force under the leadership of the State Office. The Task Force aimed to assess and address accessibility 19  challenges across various aspects of society, including public buildings, public spaces, services, housing, and transportation. Its goal was to develop policy guidelines and solutions to achieve an accessible society and public spaces within the next decade. The Task Force involved ministries, state agencies, local governments, employers, and NGOs. In fall 2021, the Task Force submitted its final report to the Government, which approved the recommendations. The Ministry of Economic Affairs and Communications coordinates the implementation efforts.  Amendments to the law are being prepared to increase disability benefits from June 1, 2025: the allowance for working-age individuals with profound disabilities will double from 43.47 euros to 100 euros per month, the allowance for working-age individuals with severe disabilities will increase from 38.78 euros to 50 euros per month, and the disability allowance for children with profound disabilities will be raised to 270 euros per month and for severe disabilities to 180 euros per month. Additionally, the eligibility for assistive devices will no longer be tied to disability status, and out-of-pocket payments will be reduced. This will result in an annual cost to the state budget of around 7,5 MEUR.  In 2023, over 13,356 individuals used inpatient nursing care, with the Health Insurance Fund covering 48 million euros while persons contributed 8 million euros, with an average out-of- pocket payment of 657 euros. The political analysis of Estonia's healthcare financing was completed in 2023, with discussions scheduled in the Cabinet of Ministers in IV quarter of 2024. By the end of 2024, the Health Insurance Fund will develop an analysis and implementation plan for measures to reduce out-of-pocket payments in healthcare, where among other things will explore options to reduce persons' out-of-pocket payments for inpatient nursing care. Timeline 2023-2028 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementers are local municipalities, Ministry of Economic Affairs and body(ies) and Communications, implementing agencies of ministries, Social Insurance cooperation with Board, Health Insurance Board. stakeholders The preparation of measures involves a broad range of stakeholders, including representatives of the target group, advocacy organizations, and other relevant stakeholders. Collaboration with implementers is facilitated through regular meetings, seminars, contracts, and partnerships. 20 Evaluation Indicators: Initial level Target level 2023 2028 Percentage of people 16 and over who provide care to their family members, % 5 decreases Source: Statistics Estonia, Estonian Labour Force Survey Percentage of people aged 16 and over with a high caring burden (20 hours or more per week), % 2,4 1,8 Source: Statistics Estonia, Estonian Labour Force Survey Ratio of recipients of services that support independent living at home to recipients of 24-hour institutional care services 1,1 1,3 Source: Ministry of Social Affairs welfare statistics, Social Insurance Board Cross-linkages with Measures 1, 2, 3, 4, 6, 7, 9 other measures Measure 9 Long-term care management and monitoring Aim Policy development is based on evidence-based and high-quality data. Type (e.g. legislative Investment (IT development) reform, investment, etc.) Target group Measure across target groups (definition and size) Results and impact Expected outcomes: (expected or achieved)  There are high-quality data available for policy development and monitoring, resulting in reduced workload for data providers and processors due to the availability of user-friendly tools. Overall framework: The development of LTC policy falls under the responsibility of the Ministry of Social Affairs, healthcare and social welfare are overseen by two ministers. The Social Welfare Department includes a role focused on developing LTC policy in social sector. The strategic goals of LTC (social sector) are set in Welfare Development Plan 2023-2030 and National Health Plan 2020-2030, and their subprograms implemented over the 4 years. Additionally, development objectives for the LTC sector, including coordinated provision of social and healthcare services and sustainability of funding, are reflected in the Estonia 2035 strategy. The Ministry of Social Affairs collects data on social services and other welfare measures organized by local governments and the state, and regularly conducts sectoral studies. Statistics Estonia publishes data on general care service, special care services, and social protection expenditures. The website minuomavalitsus.fin.ee provides an overview of the situation and development opportunities for services in each municipality, serving as a basis for local development. 21  Key interventions:  In 2024-2025 the Ministry of Social Affairs is preparing a data strategy and action plan with the aim of mapping the aspects related to data collection and use. The data strategy helps determine which data is collected, how it is stored, and who has access to it. This allows for more efficient data management and reduces duplication. Well-structured data enables more informed decisions in policy making and service development. In summary, the creation of a data strategy and action plan is an important step towards more efficient and secure use of data in the social sector, enabling better service delivery and supporting evidenced-based policy making.  Transition to registry-based data collection. Municipalities use daily Social Services and Benefits Registry (STAR), which is digital workspace for social work professionals, streamlining case management and documentation. STAR is linked to various national data registries, including the Population Register, Unemployment Insurance Fund, Tax and Customs Board, Health Information System, Education Information System, and Social Protection Information System etc. By the end of 2027, all social service data, including applications and service details, must be entered into STAR as per legal requirements. The goal by 2028 is to start obtaining data through this registry and eliminate the current manual data submission process via the S and H web database used by local governments and service providers. Registry-based data collection reduces the administrative burden on local governments and service providers while enabling the collection of higher-quality data.  Ensuring readiness for crises involves supporting and preparing responsible authorities and municipalities in the social sector. This includes managing new tasks from legislation and the new Civil Crisis and National Defence Act, which is currently under preparation and scheduled to come into effect by the end of 2025. Key activities include staffing crisis teams, training, exercises, and preventive measures for service continuity. Clear legal frameworks will be established for local governments, agencies, and service providers to develop crisis plans and solutions for various threat scenarios. Timeline 2023-2028 Financial resources Both national and EU funding are used. Approximately 6 MEUR have been (both national and EU allocated for the development of information systems and the funding) implementation of smart IT solutions necessary for the implementation of LTC (social sector) measures (i.e. STAR) in 2024-2025. Implementing Implementers: Ministry of Social Affairs, Social Insurance Board, Health body(ies) and and Welfare Information Systems Centre (TEHIK), local municipalities, cooperation with service providers. stakeholders The preparation of measures involves a broad range of relevant stakeholders, including research institutions, IT companies, social partners, local governments, etc. Collaboration with implementers is 22  facilitated through regular meetings, seminars, contracts, and partnerships. Evaluation  The data strategy and action plan have been developed by 2026  Social Services and Benefits Registry (STAR) first phase development will be in use by 2028 Cross-linkages with Cross-linkages with all other measures described in action plan other measures 3. Remaining challenges and needs for EU support 3.1. Remaining challenges The welfare policy aims to help older people maintain independence at home for as long as possible. To achieve this, there is a need to enhance preventive efforts systematically. It is crucial to emphasize the use of community resources to prevent social exclusion and increase older people’s participation in voluntary activities. However, significant challenges persist, including inadequate recognition of prevention benefits, funding shortages, and legal issues concerning data. Addressing mental health support for the elderly and preventing abuse in both homes and institutions requires greater attention. Another challenge lies in addressing the issue of workforce shortages from third countries. Recruitment faces hurdles such as labour import quotas and the requirement to pay wages significantly higher than the average in the care sector. While short-term employment is permitted, its adoption in long-term care, particularly in the social sector, remains limited. The labour migration policy, traditionally geared towards high-skilled sectors, needs adjustment to alleviate shortages in low-skilled sectors like caregiving. Although Ukrainian workers have been employed under international protection schemes, a more systematic approach is necessary, contingent on political backing, to integrate third-country labour effectively. This effort requires a long-term, multifaceted implementation strategy, considering the readiness of the current elderly population to be cared for by foreign caregivers. A critical challenge ahead is the need to focus not just on structure and process indicators but also on outcome indicators when evaluating care quality, especially in the context of long-term care. There is a clear trend towards prioritizing aspects like quality of life and person-centred care in these assessments. Developing strong models and indicators for measuring these outcomes is crucial for ensuring that care services meet the holistic needs of individuals. This shift is essential because it ensures that care is not just about procedural efficiency or facility standards but genuinely enhances the well-being and dignity of those receiving care. Addressing this challenge comprehensively and proactively is imperative for advancing the standards and effectiveness of LTC in the future. 3.2. EU support We consider it important and necessary to receive support through soft measures, such as funding mechanisms, collaborative meetings, expert exchange programs, peer reviews, voluntary guidelines, and tools. For instance, in 2010, the EU introduced a voluntary quality framework for social services, which significantly contributed to fostering a unified understanding of social service quality in Estonia. Estonia does not support the introduction of binding regulations at the EU level. 23 Like other countries, Estonia also could benefit from effective voluntary guidelines and tools to address gaps in statistics, interventions, and outcomes, emphasizing best practices. We eagerly anticipate the development of a self-assessment tool at the EU level to assess progress in long-term care. We also highly appreciate the exchange on best practices between Member States, as well as analytical reports and studies that are carried out by the Commission or in cooperation with Member States and other international organisations (e.g., OECD). 4. Annex Figure 1. Persons at risk of poverty or social exclusion in Estonia (%), 2017-2023 60 50 47 42,5 40 41 38,5 30 23,3 24,2 20 10 0 2017 2018 2019 2020 2021 2022 2023 whole population (aged 16 and over) persons aged 65 and over persons with disabilities Source: Eurostat 24 Figure 2. Estonian population in 2015-2050 1380000 1 374 687 1370000 1360000 1350000 1340000 1330000 1320000 1 318 087 1310000 1300000 1290000 1280000 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037 2039 2041 2043 2045 2047 2049 Actual population figure Projection Source: Statistics Estonia Figure 3. Life expectancy and heathy life years, 2004-2024 Source: Statistics Estonia 25 Figure 4. Limitations in daily activities in adults aged 65 and over, 2015-2023 50,0 44,8 45,0 40,0 40,8 35,0 33,9 28,7 30,0 26,5 25,4 25,0 20,0 15,0 10,0 5,0 0,0 2015 2016 2017 2018 2019 2020 2021 2022 2023 Severe limitations Some limitations No limitations Source: Statistics Estonia 26 Estonian National Action plan on the implementation of the Council Recommendation on access to affordable high-quality long-term care 1. Context and baseline 1.1. Diagnosis of the gaps and remaining challenges Long-term care (LTC) in Estonia is provided by both healthcare and welfare systems. Healthcare offers inpatient and home nursing care, while welfare services include residential, semi-residential, and home-based services. LTC is financed by public health insurance (nursing care), the state (special care services, rehabilitation, technical aids), local governments (social care), and private spending. In 2021, Estonia's spending on LTC was 0.7% of GDP, compared to the OECD average of 1.8%. There was a decrease in the share of people at risk of poverty or social exclusion, especially among older people and people with disabilities in 2023 (Figure 1 in Annex). Hence, older people's incomes still affect their ability to afford long-term care (LTC). Estonia is facing an aging and decreasing population (Figure 2 in Annex). While average life expectancy has risen to 79 years in 2023, healthy life expectancy remains at 58 years (Figure 3 in Annex). Many Estonians over 65 require assistance with daily activities; in 2023, 59% reported limitations, and 25% reported severe limitations (Figure 4 in Annex). By 2050, Estonia's population is projected to decline to 1.32 million, with the share of people aged 65+ increasing from 20.5% in 2024 to 27.4%. The ratio of working-age individuals per person aged 65+ will decrease from 3 to 2.2. At the same time the demand for LTC is expected to rise due to an aging population. As people age, the likelihood of experiencing activity limitations increases. According to the 2020 survey1, 6% of the Estonian population, or 10% of those with activity limitations, need additional services due to health problems, chronic illness, or activity limitations. This equates to 56,000 to 75,900 people, with an estimated 28,000 to 38,000 potentially feeling that their needs are unmet due to the lack of necessary assistance and LTC services. Estonia's overarching policy aims to enhance accessibility to home-support services and reduce care burden. Remaining challenges Limited integration between social welfare and healthcare systems is posing significant barriers. Coordination across different levels of government remains insufficient, compounded by widely varying funding models that hinder service integration and inadequate data sharing between sectors. Finding solutions to improve coordination between social welfare and healthcare services, as well as developing and implementing funding models that support coordinated service delivery is crucial. Moreover, more support is needed to ensure the well-being of both informal caregivers and care recipients. Informal caregivers play an essential role in minimizing LTC costs. In 2023, 35,400 women and 19,500 men aged 16 and above provided care for their relatives, with 26,700 dedicating 20 or more hours per week to caregiving. This high caregiving burden significantly impacts employment, with 2,500 women and 700 men not working due to caregiving responsibilities. To alleviate the burden on informal caregivers and promote their employment, the LTC policy focuses on enhancing the accessibility and quality of formal care services rather than relying on financial assistance. 1 The Activity Limitations and Care Needs of the Population, 2020 1 Additionally, the aging population and rising demand for higher-quality LTC emphasize the need to expand the care workforce. With fewer families available for caregiving, the demand for social sector workers is expected to rise by 20% by 2030, necessitating nearly 3,000 new employees annually across care homes, hospitals, and home-based care. Meanwhile, approximately 1,000 care workers leave their roles each year for better-paying jobs in commerce and services.2 In 2020, 46% of care workers were over 55 years old, and 94% were women. Social sector care workers earn about 37% less than the national average wage of €1832, with an average monthly salary of €1155.3 Enhancing pay, working conditions, and training is critical to attract and retain personnel in the sector during labour shortages. As these shortages worsen, a key future challenge will be addressing debates around importing labour from third countries. 1.2. Stakeholders’ involvement This action plan is informed by insights from working groups convened between 2019 and 2022, involving a diverse array of stakeholders. Through proposals, dialogues, thematic discussions, and regular meetings, we synthesized inputs to shape our strategy. Led by the Ministry of Social Affairs, this collaboration included advocacy groups, government bodies, local authorities, and representatives of target groups, ensuring a comprehensive approach. The action plan aligns with previously agreed-upon directions, some of which, like the care reform, have already been implemented. This action plan does not cover national special care services, which are primarily provided to working-age individuals with mental disorders. The interventions described in the action plan are based on the objectives set forth in the Welfare Development Plan 2023-2030 and the National Health Plan 2020-2030. The Steering Committees of the Development Plans consists of representatives of ministries, local governments, social partners and strategic partners of the Ministry. The implementation of development plans is additionally advised by experts. Separate Government Population Policy Commission, established in 2021, addresses population related questions. 2. Policy objectives and measures (to be) taken 2.1. Overall policy response Since 2016, Estonia has made significant steps in developing its LTC policies. A high-level Task Force on reducing care burden convened by the Government Office in 2016-2017 laid the groundwork for policy recommendations aimed at reducing care burden and improving LTC organization. Initial proposals were approved in 2018, followed by the launch of preparations for LTC financing schemes in early 2019. Seven working groups formed by the Ministry of Social Affairs that year focused on updating social welfare and LTC policies. One of these working groups proposed solutions in LTC organization, financing, and individual contribution principles, resulting in over ten potential combinations for Estonia's long-term system. Three most feasible models were selected and presented to the Cabinet of Ministers in 2019, with the local government-state partnership model approved. In 2021, the Ministry of Social Affairs sought a mandate to continue restructuring the LTC system, including drafting legislation on local government-state partnerships and seeking support for informal caregiver initiatives. Emphasis was also placed on securing additional state budget funding, particularly for home- and general care services. 2 Occupational Skills Needs Assessment (OSKA) report on workforce and skills demand for 2021-2030 3 Statistics Estonia, 2023 2 The first significant legislative changes were implemented between 2022 and 2023. One change was also defining the concept of LTC at the legislative level. According to the definition, LTC involves assisting individuals who require extended support in daily activities due to physical or mental impairment or reduced work capacity. It includes healthcare services, caregiving services, and support for daily functioning. In 2023, Estonia received a Country Specific Recommendations (CSR) concerning affordability, quality, and sustainability of financing of long-term care4. The current action plan contributes to the effective implementation of the CSR. Measure Name of measure LTC Recommendation no article/ letter 1 Recent amendments in long-term care related legislation 4/a, b 2 Care reform 4/a, c; 5 d; 6 e 2 Informal carers 9/b, c; 10/b, h, g 4 Social sector workforce 7/a, b; 8/ a, b, e; 10/ b, h 5 Health care workforce 7/a, b; 8/b, e; 10 b/h 6 Quality of social services 6/a, d, e; 10/b, h 7 Coordination of social and healthcare 4/a, b; 5/e; 10/b, h 8 Independent living, dignity, and non-discrimination 5/a, a, c, d, e; 6/e, f; 8/f; 10/b, h 9 Long-term care management and monitoring 10/a, b, c, d, e, f 2.2. Detailed description of the measures Measure 1 Recent amendments in long-term care related legislation Aim To enhance legal clarity and support for persons who need assistance Type (e.g., legislative Legislative Changes reform, investment, etc.) Target group Measure across target groups (definition and size) People in need of assistance and support, their families, carers, and local governments Results and impact Expected outcomes: (expected or  prioritizing independent living at home or in the community over achieved) institutional care;  clarifying the process of assessing, identifying, and organizing the provision of assistance and support;  highlighting informal caregivers as a target group alongside care recipients who may need assistance;  ensuring proactive assistance for people with disabilities and preventing the escalation of their care needs; 4 2023 European Semester: Country Specific Recommendation / Commission Recommendation - Estonia https://commission.europa.eu/document/download/c5b996c6-e313-4ed1-a0bf- 48decc7cabfb_en?filename=COM_2023_606_1_EN.pdf 3   reducing the burden on family members in financing care services. Amendments in Social Welfare Act:  A new subsection 2¹ was added to § 3, stipulated the assistance and support must primarily be offered in a way that allows people to live at home or a home-like environment and living arrangements. This addition was necessary to ensure that the local governments responsible for organizing assistance and support would prioritize services that support living at home. Although LTC services include institutional care services, the option of moving into an institution should remain the last resort when it is no longer possible to ensure a person's dignified and safe living at home.  In paragraph 9, subsection 11, long-term care is defined in legislation for the first time.  The regulations for local governments regarding the assessment of care needs and the provision of assistance have been clarified. The revised wording under § 15 subsection 1 specifies the local government's responsibility to assess the person's need for assistance and determine its extent, followed by organizing the provision of appropriate support. A person must not be left without necessary support due to the lack of a specific service in the local government's area.  The local government must also assess the support needs of the person providing care during the assessment of the care recipient's needs (§ 15 subsection 4). The support needs assessment should consider the informal caregiver's actual care burden, ability to cope, and factors affecting participation in society. Emphasizing the need to assess informal caregiver support helps standardize local government practices and ensures that caregivers have equal opportunities to receive support, such as supportive services, training, counselling, or financial assistance.  A new section (15², entered into force 01.02.2023) was added, allowing local governments to access data on adults with disabilities residing within their territory through the Social Services and Benefits Data Registry (STAR). With this change, local governments gained the right to contact adults with profound disabilities and proactively identify potentially individuals who might need support. Within 30 days local governments are obligated to proactively assess the needs of adults with profound disabilities and offer assistance. This supports the independent living and ensures assistance reaches those who need it but may not seek it.  The amendment to Section 96 of the Family Law Act relieved second-degree relatives of their obligation to provide (financial) support and cover related expenses for their adult relatives. Following the amendment, the responsibility for support falls on first-degree relatives, both ascending and descending. Second- degree ascending relatives are only obligated to provide support for their minor descending relatives (e.g., grandparents for minor grandchildren). 4 Timeline Amendments entered into force May 2022 and February 2023. Financial resources The implementation of the legal amendments was supported with around (both national and EU 0,5 MEUR both national and EU funding. funding) Implementing Primary implementers are local governments and Social Insurance Board. body(ies) and Since 2019 a new advisory unit has been established at the Social Insurance cooperation with Board to enhance state support for local governments in social welfare stakeholders tasks, standardize and improve assistance measures, and develop a strong primary-level social welfare system. The unit coordinates regional network meetings between local governments and social service providers, compiles and shares best practices, creates guidelines, and organizes seminars and trainings. Evaluation Indicators: Initial level Target level 2023 2028 Percentage of people aged 16 or over who provide care for their family members, % 5 decreases Source: Statistics Estonia, Estonian Labour Force Survey Percentage of adults who receive services that support independent living at home, % 2,6 increases Source: Social Welfare Statistics of the Ministry of Social Affairs, Statistics Estonia Ratio of an adult recipients of services that support independent living at home to recipients of 24-hour institutional care 1,0 1,3 Source: Social Welfare Statistics of the Ministry of Social Affairs, Social Insurance Board Cross-linkages with 2, 3, 6, 7, 8 other measures Measure 2 Care Reform Aim To reduce out-of-pocket payments for general care service, improve the quality and the working conditions for care staff, and enhance the availability and quality of home-based care services. Type (e.g. legislative Legislative reform and investments reform, investment, etc.) Target group People aged 18+ who need care, their families, and carers (definition and size) 5 Results and impact Initial results for 2023: (expected or achieved)  the general care service is financially accessible for individuals receiving the average old age pension;  the number of care staff (care workers and assistant care workers) has grown significantly, reaching a 25% increase, which is higher than the typical annual growth of 4% to 13% seen in the past 10 years;  the number of informal caregivers for family members aged 65 and older decreased from 31,900 to 30,500 individuals compared to 2022.  Informal caregivers providing intensive care (20+ hours per week) decreased from 15,300 to 14,000. This decline, predominantly used by elderly individuals (91%), may reflect improved financial accessibility to general caregiving services. Timeline Implemented from 1st of July 2023 Financial resources Additional financial support for local municipalities was 40 MEUR in 2023. (both national and EU In 2024, further state funding for local municipalities' revenue base and funding) equalization fund amounts to 61 million euros. The funding will increase yearly in accordance with the income tax revenues and is expected to reach to 76,6 MEUR by 2028. This funding gives local governments flexibility to use the funds for the best ways to organize LTC in their areas. The allocation of funds is based on the proportion of elderly (aged 65+) in a municipality, as the likelihood of needing care increases among the older population. Implementing Implementers: local governments and elderly care homes, Social body(ies) and Insurance Board (supervision and guiding) cooperation with Ministry of Social Affairs and Social Insurance Board maintains continuous stakeholders collaboration with local governments and service providers monitoring the progress of the reform. This includes also ongoing cooperation with the Ministry of Regional Development and Agriculture to monitor changes in local government expenditures. Each year, municipalities engage in negotiations concerning the state's budget strategy for the next four years and the upcoming year's state budget. The objective is to reach consensus on the size and allocation of the revenue base, equalization fund, and state budget allocations for local governments as outlined in the draft state budget law. These negotiations also address sector-specific policy directions that directly impact local governance. The Ministry of Social Affairs coordinates these discussions through the Labour, Social, and Health Working Group. Evaluation Indicators: Initial level Target level 2023 2028 Percentage of total service costs covered by individuals receiving 24-hour general care services, % 78 (2022) 60 Source: Social Welfare Statistics of the Ministry of Social Affairs 6  Percentage of people aged 16 or older with a high caring burden who provide care to their family member aged 65+, % 14 000 decreases Source: Statistics Estonia, Estonian Labour Force Survey Ratio of 24-hour general care services service users to of home care users 1,7 decreases Source: Social Welfare Statistics of the Ministry of Social Affairs The impact assessment of the reform will be conducted in IV quarter of 2026. Beyond registry-based data collection, several studies targeting specific groups are planned for 2025, for example satisfaction of service users with the quality of general care service and reform impacts on family members employment. The second survey on the population's care needs and activity restrictions will be carried out in 2025 and the next population care burden survey is planned for 2027. Cross-linkages with Measures 1, 3, 4, 6, 8, 9 other measures Measure 3 Informal carers Aim To reduce the burden of care by creating a support system for informal carers, providing training and supportive services to help them cope better with their caregiving responsibilities, and ensuring better social guarantees and opportunities to balance work and caregiving. Type (e.g. legislative Legislative changes and investment reform, investment, etc.) Target group Persons with care burden. According to the 2023 Estonian Labour Survey, (definition and size) 55,000 people aged 16+ (19,500 men and 35,400 women) reported care burden, amounting to 5% of the population. Additionally, 11,792 people received caregiver's allowance from municipalities. Results and impact Expected outcome: (expected or achieved)  Long-term care heavily relies on informal caregivers, underscoring the need for increased support to mitigate the adverse effects of caregiving on their health, social lives, and finances, while enabling balancing their work and family life. Therefore, the definition and minimum support package (services, trainings, social guarantees etc.) for informal caregivers must be agreed and regulated by law to ensure their equal treatment. Key initiatives:  In 2020, a working group convened by the Ministry of Social Affairs reached an agreement on the definition of informal caregivers and principles for their support. Proposals regarding the support of informal caregivers were submitted to the Cabinet 7  of Ministers in 2021 and were approved but funding decisions were not made.  In 2021 the Ministry of Social Affairs initiated amendment of the Employment Contracts Act and related laws so that employees and officials with caring responsibilities have the right to apply for flexible working conditions (for example, part-time or flexible working hours, teleworking, etc.). The amendment provides additional protection for employees and officials with caring responsibilities in the event of termination of employment or dismissal, and the reversal of the burden of proof in disputes concerning termination of employment or dismissal.  A new leave form (carer leave) entered into force under the Employment Contracts Act from 1st July 2018. Employees can use additional leave (5 days per calendar year) to care for an adult family member with a profound disability. The leave allowance is compensated based on minimum wage.  In 2022, a legislative intent was sent for public consultation aiming to expand care leave and introduce a social tax incentive for balancing work, caregiving, and family life. According to legislative intent, the right to use care leave is tied to the care needs of the dependent, not to their disability as identified by the Social Insurance Board. Additionally, the proposed paid leave benefit rate would increase from the minimum wage to the average income subject to social tax contributions, ensuring that caregivers using leave do not lose their income. The implementation of these regulations required approximately 20 MEUR from the state budget. Due to the state's financial situation, funding has not been available to implement these changes.  In collaboration with the Estonian Chamber of Disabled People, a web solution for informal caregivers is being launched in the summer of 2024. Informal caregivers will have access to information, counselling, and training. The initiative also aims to establish a network that advocates for the interests of informal caregivers, which is currently missing in Estonia. The budget for 2023-2025 is 0,36 MEUR (ESF+ and state co-financing).  During 2024-2025, an analysis will be conducted on international and local practices related to supporting informal caregivers, including funding, as well as the needs and barriers to employment. In 2025, an overview, analysis, and recommendations will be conducted for the development of support systems at the local level aimed at persons with dementia and their families. This will encompass evidence-based intervention options for supporting individuals with dementia living at home. These findings will give input for the implementation of supportive measures for people with dementia and their families in 2026, funded by the European Social Fund (ESF). The budget for 2024-2025 is around 0,3 MEUR (ESF+ and state co-financing).  Dementia Competence activities continue, aimed at supporting individuals with dementia and their families. One of the tasks of 8  the Competence Centre is to establish and maintain a network of support groups for informal carers of people with dementia across Estonia. The goal is to ensure the operation of support groups and provide necessary assistance to informal carers. In 2023 30 support groups were operating across the country. The budget for 2024-2028 is 1,36 MEUR (state budget).  Local municipalities have possibility to apply for funding to develop supportive services for informal caregivers throughout the current ESF+ period. From 2016 to 2023, over 100 projects have been implemented, focusing on improving home care availability, reducing care burden, and enhancing support for informal caregivers. Approximately 15 MEUR were allocated with support from EU structural funds and state financing. Similar support will be available to municipalities in the coming years.  To ensure gender equality, goals and actions have been established in the Welfare Development Plan 2023-2030. The goal is to achieve gender equality by enhancing economic equality, increasing women’s participation in decision-making processes, transforming societal attitudes, and strengthening institutional capacities to promote gender equality. The working programmes of the strategy are being updated every year to ensure and monitor the effective implementation of the strategy. Timeline 2023-2028 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementing bodies: Research institutions, universities, Social Insurance body(ies) and Board, Estonian Chamber of Disabled People, local municipalities, NGO cooperation with Life with Dementia, Dementia Competence Centre and others. The stakeholders Ministry of Social Affairs collaborates with stakeholders through contracts and strategic partnerships, regular discussions etc. Seminars and trainings are organized for municipalities' funding rounds. Evaluation Indicators: Initial level Target 2023 level 2028 Percentage of people aged 16 or over who provide care for their family members, % 5 decreases Source: Statistics Estonia, Estonian Labour Force Survey Percentage of people aged 16 and over with a high caring burden (20 hours or more per week), % 2,4 decreases Source: Statistics Estonia, Estonian Labour Force Survey Ratio of adults receiving formal social services compared to those receiving informal care (supported by caregiver allowance) 3,7 increases Source: Social Welfare Statistics of the Ministry of Social Affairs, Social Insurance Board Cross-linkages with Measures 1, 2, 7, 8 other measures 9 Measure 4 Social sector workforce Aim To improve care workers' working conditions, update training and professional standards for social sector workers, develop basic education and in-training systems to improve the quality of the social workforce, enhance the knowledge and skills of social sector leaders, advocate for the interests of social sector workers, and promote the image of professions in society. Type (e.g., legislative Legislative changes and investment reform, investment, etc.) Target group Long-term care workforce (care workers, assistant care workers, support (definition and size) persons, activity supervisors), social field advisory workers (social worker, child protection worker), social field managers (managers of municipal social departments, heads of welfare institutions), social field lecturers, vocational teachers, and in-training teachers. Results and impact Expected outcomes: (expected or achieved)  all care homes comply with the care worker-to-client ratio requirements by 1st of July in 2026;  modernized curricula and new educational programs for professionals has been implemented ensuring a larger number and more skilled workforce.  ongoing training opportunities for professionals in accordance with the updated curricula are available.  a support and counselling system specifically designed for workers in the social sector, aimed at enhancing their well-being and effectiveness has been established. Key interventions:  A study on labour force demand in the LTC sector was carried out in 2022 by Foundation Praxis and Haap Consulting Ltd. The study proposes changes in curricula, internship programs, and activities aimed at improving the image and attitudes towards care work. The study also revealed conservative attitudes towards the migrant workforce in the sector.  In 2023, the Minister of Social Protection issued a decree setting client-to-staff ratios for 24-hour general care services, which will take effect on July 1, 2026. The care home always guarantees the presence of one care worker per 36 service recipients, along with at least one care worker or assistant care worker per 12 service recipients during the day, for 12 consecutive hours.  The program for the development of adult education and provision of non-formal learning opportunities focuses on enhancing adult education and offering non-formal learning opportunities for professions such as care workers, activity coordinators, social workers, support personnel, and childminders. The program targets adults without professional- level or secondary education, as well as those with outdated skills, aiming to address these priorities through training in various fields, including digital competencies. The training is part of the 10  national continuing education order for social sector workers and financed by ESF+ funds totalling 2.6 MEUR, including state co- financing.  A program strengthening social and child protection services under the Estonia-Switzerland cooperation program includes the development and modernization of curricula in higher education and vocational education for social work professionals, promoting new opportunities and positive changes in social and child protection studies and work environments. It also involves supporting migrants and refugees in accessing the labour market in the social care sector, developing a continuing education and training system for child protection and care workers, and providing training for specialists. Additionally, the program implements a workplace-based counselling and support system for workers in the social sector. The program is funded by the Estonia-Switzerland Cooperation Program with a total of 6.56 MEUR including national co-financing 15%.  The state has strategic partnership with Estonian Social Work Association to collaboratively develop the workforce and enhance professional standards. This includes funded support for shaping and implementing social and health policies. Activities focus on knowledge exchange, harmonizing social work practices, addressing skills shortages through monitoring, and updating qualifications, promoting certification awareness, supporting adherence to human rights and ethical principles, promoting self- care and professional development, mentoring programs for leaders, and enhancing the social sector's public image. Recognition and awards are also given for outstanding achievements across various professional fields within the social sector. For 2022-2024 state funding amounts up to 0.47 MEUR. Conditions and financing for period 2025-2028 is under negotiation.  A program to support societal change in Ida-Viru County in collaboration with the Ida-Viru County Municipalities Association started in 2023. The goal is to enhance the competence of social and healthcare workers and attracting new specialists to the region. Funding is allocated to three activities: improving the availability of integrated social and healthcare services, incentivizing professionals to work in the region through a motivation package and providing innovation grants to enhance social and healthcare services. The program is implemented with funding from JTF 7.2 MEUR, including state co-financing. Timeline 2022-2029 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementers: body(ies) and Vocational educational institutions, universities of social work in cooperation with partnership with university Bern University from Switzerland, Estonian stakeholders Health Development Institute, Estonian Social Work Association, Social Insurance Board, Ministry of Education and Ministry of Social Affairs. The 11  Ministry of Social Affairs collaborates with implementers through contracts, partnerships, and regular discussions. Evaluation Indicators: Initial Target level level 2023 2028 Percentage of care homes meeting care worker to client minimum ratios, % 66 100 Source: Social Welfare Statistics of the Ministry of Social Affairs Number of participants in non-formal adult education in the social field (participation occasions) 2077 0 (2022) (2029) Source: Ministry of Education and Research Cross-linkages with 1, 2, 6, 7, 8 other measures Measure 5 Healthcare sector workforce Aim Ensuring the presence of motivated healthcare workers and other specialists in all regions of Estonia and supporting their empowerment. Type (e.g., legislative Legislative changes and investment reform, investment, etc.) Target group Healthcare professionals (definition and size) Results and impact Expected outcomes: (expected or achieved)  The healthcare sector has motivated and competent specialists whose training meets the needs of the population and the healthcare system. Key interventions:  The Strategic Framework for addressing health workforce shortages was approved in 2023 by the regulation of the Minister of Health and Labour. In 2024 it is going to be mapped against WHO European framework for action on the health and care workforce 2023-2030 and a draft for updated Estonian Strategic Framework will be created.  Amendments to the Health Services Organisation Act and the Regulation of the Minister of Health and Labour Beginner’s allowance for medical specialists were approved in November 2023. In 2024, nurses, who start working outside larger cities receive allowance of 30,000 euros. The allowance for pharmacists is 15,000 euros, if the pharmacist starts working for at least 3 years, and 25,000 euros, if the pharmacist starts working in the region for at least 5 years. The allowance for specialist doctor is now 30 000 and for family doctor 45 000. By 2028 the analyse will be conducted of the impact of beginner’s allowances and to work on improving, advancing, and expanding allowances to ensure the provision of quality and sustainable healthcare services regardless of a person's place of residence. The measure is funded from the state budget as an estimated expense. For the years 2024-2028, 12  an allocation around 12 MEUR has been planned in the state budget.  According to the Consensus Agreement signed in 2022 the admission of persons to nursing training has been increased in 2022/2023 (600) by 16% compared to 2020 (517) and by 35% (700) in 2023/2024 compared to 2020 (517). A Training Committee has been called together for more transparent and better-informed intake decisions for training health care specialists.  The "Back to Healthcare" projects for healthcare workers started in 2015 will continue. Projects are funded from the state budget, with approximately 2 MEUR allocated for this purpose for the years 2024-2028.  With the backing of the European Union Structural Reform Implementation Program (TSI), a framework will be formulated to enhance digital skills. Educational and practical opportunities will be adjusted to correspond with the advancement of the healthcare system, facilitating the implementation of a human- centred integrated service model, and efforts will be made to develop and widely implement innovative digital solutions that support the daily work of professionals. The project period is October 2022 to 2024, and the procurement was initiated by the European Commission DG REFORM.  There is ongoing development of health care workers and specialist prognose system and governance framework (Joint- Action HEROES, OSKA report on primary care). Action plan is developed in 2024 together with the University of Tartu.  Participation continues in the pan-European collaborative project HEROES funded through the EU4Health program. Within the project, teams defining the skills required for healthcare workforce planning are established, alongside the description of a national framework for healthcare workforce planning. The aim is to develop forecasting models to align roles and responsibilities among stakeholders involved in organizing healthcare education, including the Ministry of Social Affairs and its implementing agencies, the Ministry of Education, educational institutions, and professional associations. The project is funded by EU structural funds, with a total budget of 0.3 MEUR allocated to the Ministry of Social Affairs, of which 20% is covered as co-financing.  Together with stakeholders (Health Board, University of Tartu, healthcare colleges, Ministry of Education and Research, professional associations), a strategic plan is being developed by 2025 to update and clarify legislation related to the qualifications, competence, registration of healthcare professionals, and activities related to the employment of other foreign qualified healthcare workers in Estonia.  By 2026, Estonia will revise its healthcare worker shortage strategy in collaboration with WHO, incorporating its HRH framework into policy processes through regular meetings. Timeline 2023-2028 13 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Information about implementing bodies and cooperation with body(ies) and stakeholders is provided in the previous box „Results and impact cooperation with (expected or achieved)“. The Ministry of Social Affairs collaborates with stakeholders implementers through contracts, partnerships, and regular discussions. Evaluation Indicators: Initial level Target level 2022 2027 Number of nurses per 100,000 inhabitants 650,3 782,9 Source: National Institute for Health Development Number of doctors per 100,000 inhabitants 342,9 372,4 Source: National Institute for Health Development Cross-linkages with Measures 4, 7, 8 other measures Measure 6 Quality of social services Aim Enhance and empower the quality of social services. Type (e.g., legislative Legislative changes reform, investment, etc.) Target group Measure across target groups (definition and size) Results and impact Expected outcomes: (expected or achieved)  Improved client satisfaction, enhanced effectiveness of interventions, and strengthened societal well-being through accessible and responsive social services. Overall quality framework: The quality requirements of healthcare services are established in a regulatory decree issued by the Minister of Social Protection under the Health Services Organization Act. The tasks related to the quality of healthcare services are divided among Ministry of Social Affairs, Health Board, Health Insurance Fund, healthcare service providers, professional associations of healthcare workers, and educational institutions who train healthcare professionals. The minimum requirements for social services and general quality principles that service providers must follow, are established in Social Welfare Act. Since 2020, institutions providing out-of-home general care services must have an operating license. The quality of social services is monitored by Estonian Social Insurance Board who also is responsible for issuing social service activity licenses and for administrative and state supervision. Health Board oversees the compliance with health protection requirements in care institutions. 14 The Chancellor of Justice ensures that people in care homes are treated with dignity and that their fundamental rights are protected. The Chancellor of Justice examines whether people are treated with respect for their dignity, what the living conditions of the care home are and whether people's lives and health are not endangered in the care home and whether they receive necessary treatment. To enhance the capacity of local governments to organize welfare assistance, the Social Insurance Board established in 2019 a consultation unit for local governments. Quality guidelines for social services have been developed, based on the European Voluntary Quality Framework for Social Services. Key interventions:  Streamlining the tasks and roles of the Social Insurance Board and reorganizing supervisory activities within the Ministry of Social Affairs' jurisdiction are among the priorities for 2024. The changes are planned to take effect in 2025.  As part of the Care Reform more detailed minimum requirements were established for general care service (entered into force 01.07.2023) and for home care service which has transition period until 2025.  By 2025, the health protection requirements for social services and care institutions will be updated through a regulation issued by the Minister of Health under the Public Health Act.  In 2024, the guidelines for organizing home care, 24-hour general care service, housing service, support person service, personal assistant service, and care service for adults are being updated. Additionally, the quality guidelines for 24-hour general care service and home care will be updated. The updating of guidelines for other social services and guidelines for municipalities on how to assess the ability of individuals in need and their families to pay for social services will be carried out in 2025.  A digital needs assessment tool will be available for municipalities from 2025, followed by a informal carers assessment tool in 2027 in the Data Registry for Social Services and Benefits (STAR). This aims to optimize case management and to support social work specialists by gathering initial assessment information uniformly across municipalities. It streamlines data collection, reducing duplication and enabling statistical analysis for policymaking.  In 2024, an evidence-based risk forecasting model for general care homes, which will enable the identification of problematic care homes. A local government social work risk forecast (assessment of need and direction of service provision) will be developed in 2025.  Between 2026-2028, a digital self-assessment tool for social service providers will be developed. Tool allows providers to evaluate their service quality, identify shortcomings, and analyse services in a standardized format. The Social Insurance Board will gain a comprehensive view of nationwide service quality and valuable input for planning supervision activities and support 15  measures for service providers, such as training and development initiatives.  By 2028, the goal is to review and establish new qualification requirements for key social sector positions, e.g., the director of a care facility and others. Timeline 2023-2028 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementers: body(ies) and Social Insurance Board, service providers, local municipalities. In the cooperation with development of quality, stakeholders such as advocacy organizations, stakeholders local governments, service providers, implementing agencies and others are involved. Social Insurance Board organizes regular meetings with the representatives of care homes, service providers and regional network meetings with local governments. Evaluation Indicators: Initial level Target level 2023 2028 Satisfaction with services survey(ies) Source: Service Satisfaction Survey N/A has been carried out Quality guidelines for social services provided by municipalities are updated N/A updated Source: Social Insurance Board Existence of quality standards in home care and residential care established established Source: Ministry of Social Affairs Cross-linkages with Measures 1, 2, 4, 7, 8, 9 other measures Measure 7 Coordination of social- and healthcare Aim To develop and implement better coordination between social- and healthcare, ensuring quality assistance throughout life span. This involves providing timely support tailored to people, reducing administrative burden for individuals and families, and empowering professionals to collaborate effectively in providing assistance and support. Type (e.g., legislative Legislative changes and investment reform, investment, etc.) Target group Measure across target groups (definition and size) 16 Results and impact Expected outcome: (expected or achieved)  Improved coordination includes the delivery of cohesive and personalized assistance, services, and support nationwide for individuals with complex needs. This will lead to enhanced quality of life, prolonged independence, reduced administrative burden, and strengthened professional collaboration. Key interventions:  The 4th phase of the care coordination initiative started in 2023 and aims to expand the regional social and health care network to a county-wide. Four regional projects will run until 2025, after which nationwide coordination model and financing principles will be elaborated by the end of 2026. The project is funded by the ESF+1.7 MEUR, including state co-financing.  Estonia’s Government Action Plan 2023-2027 foresees the need for better coordination of social- and health care, development of palliative care services, and simplifying the legal processes for drawing up patient wills and defining end-of-life decisions by the end of 2024. Proposals for establishing a unified coordination and financing model of social and healthcare services will be submitted to the Cabinet of Ministers in 2025. The following activities are planned after the government's decision.  In 2024, a legislative intent will be prepared proposing solutions for the integration of assistive devices and medical equipment systems to simplify access to services for people in need of assistive devices. Implementation of the new system is estimated in 2029. The need for state budget funds, depending on the chosen solution, may range from 18 to 27 MEUR in 2024 prices.  By 2027, the plan is to transition rehabilitation services to a new system that simplifies access and makes service organization more transparent. The goal is for the system to be more user- centred and better aligned with people's needs.  In recent years, steps have been taken to implement the International Classification of Functioning, Disability and Health (ICF) across various sectors. In 2021 the Estonian ICF translation and guidelines were updated. In early 2023, the ICF became a national classification to ensure comprehensive data exchange between systems. The Health Development Institute now maintains the ICF, ensuring its updates, terminological coherence, and providing ongoing training and mentorship programs. Timeline 2023-2029 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) 17 Implementing In 2024, broad-based working groups were established under the Ministry body(ies) and of Social Affairs to develop solutions related to the integration of social cooperation with and health care and the development of palliative care services. These stakeholders working groups include representatives from the social and health sectors, professional organizations, research institutions, local governments, Health Insurance Fund, Social Insurance Board, Ministry of Regional Affairs and Agriculture, Nurses Union, Family Doctors Association, Estonian Association of Gerontology and Geriatrics, Hospitals Association, National Institute for Health Development, and many others. Evaluation The indicators and measurement system for goals and outcomes will be developed 2025 Cross-linkages with Measures 1, 2, 3, 4, 5, 6, 8, 9 other measures Measure 8 Enhancing independent living, dignity and non-discrimination Aim To ensure independent living, autonomy and social inclusion of older people and people with disabilities, providing them with equal opportunities and ensuring their well-being and social security. Type (e.g. legislative Legislative changes and investments reform, investment, etc.) Target group Measure across target groups (definition and size) Results and impact Expected outcomes: (expected or achieved)  prioritizing independent living at home or in the community over institutional care;  ensuring proactive assistance for people with disabilities and preventing the escalation of their care needs;  older people and people with disabilities are socially included in the society, have equal opportunities. Key interventions:  To support care reform implementation and enhance home- based care at the local level while reinforcing support for informal caregivers, two funding rounds were initiated in the first and second quarters of 2024. These calls for proposals were backed by 33.3 MEUR from EU Structural Funds, supplemented by state co-funding. This includes 9.9 MEUR (ESF+) for home-based services, with project eligibility until the end of 2027, and 23.4 MEUR (ERDF) for establishing community-based housing for individuals with lesser support needs, with eligibility until the end of 2028. These initiatives also aim to promote the use of digital assistive technologies in service development.  To address regional disparities in access and quality of social services while fostering innovation, person-centered solutions, and collaboration, the Southeast Estonia Support Program is being implemented from 2023 to 2027, with a total funding of 3 18  MEUR (ESF+), including state co-financing. A similar program implemented in Ida-Viru County from 2019 to 2021 demonstrated effectiveness. Another measure was launched in I Q of 2024 to support communities in ensuring the availability and quality of LTC services, as well as alleviating care burden. Additionally, activities aimed at enhancing social inclusion are funded. The total budget for the grant application round is 7.1 MEUR (ESF+), including state co-financing.  In 2020, the government approved a green paper with the objective of enhancing technology adoption to improve individuals' daily living and well-being at home. Despite initiatives in innovation, effective implementation of new technologies and approaches, as well as service innovation, necessitates stronger leadership in social sector. The Ministry of Social Affairs will submit proposals for innovation and technology use in the social sector to the Cabinet of Ministers by the end of 2024. Follow-up activities are starting from 2025, supported by ERDF, to facilitate the adoption of innovative solutions in living and service environments.  In 2023, the new Victim Support Act came into force, expanding the range of victim support services and the scope of individuals who receive support. For the first time, principles for the treatment of victims and educational requirements for specialists working with victims were introduced. With the new law, psychological help, and support for victims of domestic and sexual violence recovering from trauma will become more accessible, without the prerequisite of initiating criminal proceedings. Additionally, the legislation clarifies the roles of institutions and organizes data exchange to enhance system integrity.  In 2024, a draft law is being prepared to merge the Gender Equality Act and the Equal Treatment Act and revise the regulation. The new law will widen the scope of protection and the grounds of protection to a similar level as is for gender with the current legislation. For example, disabled people will receive protection against discrimination in all areas of social life, as the ground of disability is currently only protected against discrimination in employment.  In 2025, an applied study will be conducted to shape attitudes that value older adults and reduce age-related prejudices in society, particularly among employers. The study aims to identify the main reasons for exclusion from the labour market and societal life, proposing interventions to achieve desired outcomes. The goal is to design and implement effective measures that help change the negative perception of older adults within society, among employers, and among older adults themselves. Additionally, the activities of senior councils are supported, and the promotion of age-friendliness in local governments is encouraged.  In 2019, the Estonian Government established a high-level Accessibility Task Force under the leadership of the State Office. The Task Force aimed to assess and address accessibility 19  challenges across various aspects of society, including public buildings, public spaces, services, housing, and transportation. Its goal was to develop policy guidelines and solutions to achieve an accessible society and public spaces within the next decade. The Task Force involved ministries, state agencies, local governments, employers, and NGOs. In fall 2021, the Task Force submitted its final report to the Government, which approved the recommendations. The Ministry of Economic Affairs and Communications coordinates the implementation efforts.  Amendments to the law are being prepared to increase disability benefits from June 1, 2025: the allowance for working-age individuals with profound disabilities will double from 43.47 euros to 100 euros per month, the allowance for working-age individuals with severe disabilities will increase from 38.78 euros to 50 euros per month, and the disability allowance for children with profound disabilities will be raised to 270 euros per month and for severe disabilities to 180 euros per month. Additionally, the eligibility for assistive devices will no longer be tied to disability status, and out-of-pocket payments will be reduced. This will result in an annual cost to the state budget of around 7,5 MEUR.  In 2023, over 13,356 individuals used inpatient nursing care, with the Health Insurance Fund covering 48 million euros while persons contributed 8 million euros, with an average out-of- pocket payment of 657 euros. The political analysis of Estonia's healthcare financing was completed in 2023, with discussions scheduled in the Cabinet of Ministers in IV quarter of 2024. By the end of 2024, the Health Insurance Fund will develop an analysis and implementation plan for measures to reduce out-of-pocket payments in healthcare, where among other things will explore options to reduce persons' out-of-pocket payments for inpatient nursing care. Timeline 2023-2028 Financial resources Both national and EU funding are used to implement these activities. (both national and EU funding) Implementing Implementers are local municipalities, Ministry of Economic Affairs and body(ies) and Communications, implementing agencies of ministries, Social Insurance cooperation with Board, Health Insurance Board. stakeholders The preparation of measures involves a broad range of stakeholders, including representatives of the target group, advocacy organizations, and other relevant stakeholders. Collaboration with implementers is facilitated through regular meetings, seminars, contracts, and partnerships. 20 Evaluation Indicators: Initial level Target level 2023 2028 Percentage of people 16 and over who provide care to their family members, % 5 decreases Source: Statistics Estonia, Estonian Labour Force Survey Percentage of people aged 16 and over with a high caring burden (20 hours or more per week), % 2,4 1,8 Source: Statistics Estonia, Estonian Labour Force Survey Ratio of recipients of services that support independent living at home to recipients of 24-hour institutional care services 1,1 1,3 Source: Ministry of Social Affairs welfare statistics, Social Insurance Board Cross-linkages with Measures 1, 2, 3, 4, 6, 7, 9 other measures Measure 9 Long-term care management and monitoring Aim Policy development is based on evidence-based and high-quality data. Type (e.g. legislative Investment (IT development) reform, investment, etc.) Target group Measure across target groups (definition and size) Results and impact Expected outcomes: (expected or achieved)  There are high-quality data available for policy development and monitoring, resulting in reduced workload for data providers and processors due to the availability of user-friendly tools. Overall framework: The development of LTC policy falls under the responsibility of the Ministry of Social Affairs, healthcare and social welfare are overseen by two ministers. The Social Welfare Department includes a role focused on developing LTC policy in social sector. The strategic goals of LTC (social sector) are set in Welfare Development Plan 2023-2030 and National Health Plan 2020-2030, and their subprograms implemented over the 4 years. Additionally, development objectives for the LTC sector, including coordinated provision of social and healthcare services and sustainability of funding, are reflected in the Estonia 2035 strategy. The Ministry of Social Affairs collects data on social services and other welfare measures organized by local governments and the state, and regularly conducts sectoral studies. Statistics Estonia publishes data on general care service, special care services, and social protection expenditures. The website minuomavalitsus.fin.ee provides an overview of the situation and development opportunities for services in each municipality, serving as a basis for local development. 21  Key interventions:  In 2024-2025 the Ministry of Social Affairs is preparing a data strategy and action plan with the aim of mapping the aspects related to data collection and use. The data strategy helps determine which data is collected, how it is stored, and who has access to it. This allows for more efficient data management and reduces duplication. Well-structured data enables more informed decisions in policy making and service development. In summary, the creation of a data strategy and action plan is an important step towards more efficient and secure use of data in the social sector, enabling better service delivery and supporting evidenced-based policy making.  Transition to registry-based data collection. Municipalities use daily Social Services and Benefits Registry (STAR), which is digital workspace for social work professionals, streamlining case management and documentation. STAR is linked to various national data registries, including the Population Register, Unemployment Insurance Fund, Tax and Customs Board, Health Information System, Education Information System, and Social Protection Information System etc. By the end of 2027, all social service data, including applications and service details, must be entered into STAR as per legal requirements. The goal by 2028 is to start obtaining data through this registry and eliminate the current manual data submission process via the S and H web database used by local governments and service providers. Registry-based data collection reduces the administrative burden on local governments and service providers while enabling the collection of higher-quality data.  Ensuring readiness for crises involves supporting and preparing responsible authorities and municipalities in the social sector. This includes managing new tasks from legislation and the new Civil Crisis and National Defence Act, which is currently under preparation and scheduled to come into effect by the end of 2025. Key activities include staffing crisis teams, training, exercises, and preventive measures for service continuity. Clear legal frameworks will be established for local governments, agencies, and service providers to develop crisis plans and solutions for various threat scenarios. Timeline 2023-2028 Financial resources Both national and EU funding are used. Approximately 6 MEUR have been (both national and EU allocated for the development of information systems and the funding) implementation of smart IT solutions necessary for the implementation of LTC (social sector) measures (i.e. STAR) in 2024-2025. Implementing Implementers: Ministry of Social Affairs, Social Insurance Board, Health body(ies) and and Welfare Information Systems Centre (TEHIK), local municipalities, cooperation with service providers. stakeholders The preparation of measures involves a broad range of relevant stakeholders, including research institutions, IT companies, social partners, local governments, etc. Collaboration with implementers is 22  facilitated through regular meetings, seminars, contracts, and partnerships. Evaluation  The data strategy and action plan have been developed by 2026  Social Services and Benefits Registry (STAR) first phase development will be in use by 2028 Cross-linkages with Cross-linkages with all other measures described in action plan other measures 3. Remaining challenges and needs for EU support 3.1. Remaining challenges The welfare policy aims to help older people maintain independence at home for as long as possible. To achieve this, there is a need to enhance preventive efforts systematically. It is crucial to emphasize the use of community resources to prevent social exclusion and increase older people’s participation in voluntary activities. However, significant challenges persist, including inadequate recognition of prevention benefits, funding shortages, and legal issues concerning data. Addressing mental health support for the elderly and preventing abuse in both homes and institutions requires greater attention. Another challenge lies in addressing the issue of workforce shortages from third countries. Recruitment faces hurdles such as labour import quotas and the requirement to pay wages significantly higher than the average in the care sector. While short-term employment is permitted, its adoption in long-term care, particularly in the social sector, remains limited. The labour migration policy, traditionally geared towards high-skilled sectors, needs adjustment to alleviate shortages in low-skilled sectors like caregiving. Although Ukrainian workers have been employed under international protection schemes, a more systematic approach is necessary, contingent on political backing, to integrate third-country labour effectively. This effort requires a long-term, multifaceted implementation strategy, considering the readiness of the current elderly population to be cared for by foreign caregivers. A critical challenge ahead is the need to focus not just on structure and process indicators but also on outcome indicators when evaluating care quality, especially in the context of long-term care. There is a clear trend towards prioritizing aspects like quality of life and person-centred care in these assessments. Developing strong models and indicators for measuring these outcomes is crucial for ensuring that care services meet the holistic needs of individuals. This shift is essential because it ensures that care is not just about procedural efficiency or facility standards but genuinely enhances the well-being and dignity of those receiving care. Addressing this challenge comprehensively and proactively is imperative for advancing the standards and effectiveness of LTC in the future. 3.2. EU support We consider it important and necessary to receive support through soft measures, such as funding mechanisms, collaborative meetings, expert exchange programs, peer reviews, voluntary guidelines, and tools. For instance, in 2010, the EU introduced a voluntary quality framework for social services, which significantly contributed to fostering a unified understanding of social service quality in Estonia. Estonia does not support the introduction of binding regulations at the EU level. 23 Like other countries, Estonia also could benefit from effective voluntary guidelines and tools to address gaps in statistics, interventions, and outcomes, emphasizing best practices. We eagerly anticipate the development of a self-assessment tool at the EU level to assess progress in long-term care. We also highly appreciate the exchange on best practices between Member States, as well as analytical reports and studies that are carried out by the Commission or in cooperation with Member States and other international organisations (e.g., OECD). 4. Annex Figure 1. Persons at risk of poverty or social exclusion in Estonia (%), 2017-2023 60 50 47 42,5 40 41 38,5 30 23,3 24,2 20 10 0 2017 2018 2019 2020 2021 2022 2023 whole population (aged 16 and over) persons aged 65 and over persons with disabilities Source: Eurostat 24 Figure 2. Estonian population in 2015-2050 1380000 1 374 687 1370000 1360000 1350000 1340000 1330000 1320000 1 318 087 1310000 1300000 1290000 1280000 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037 2039 2041 2043 2045 2047 2049 Actual population figure Projection Source: Statistics Estonia Figure 3. Life expectancy and heathy life years, 2004-2024 Source: Statistics Estonia 25 Figure 4. Limitations in daily activities in adults aged 65 and over, 2015-2023 50,0 44,8 45,0 40,0 40,8 35,0 33,9 28,7 30,0 26,5 25,4 25,0 20,0 15,0 10,0 5,0 0,0 2015 2016 2017 2018 2019 2020 2021 2022 2023 Severe limitations Some limitations No limitations Source: Statistics Estonia 26