Cansu Erdoğan (Bielefeld University, Germany)

Başak Akkan (PhD, İstanbul Bilgi University, Türkiye)

The main components of the formal long-term care (LTC) system in Türkiye include cash-for-care benefits for informal carers of persons with disabilities, rehabilitation centres and care homes for persons with disabilities and nursing homes and rehabilitation centres for older persons. There are also services such as respite care, day care, and home health and social care targeting both groups. The care services for persons with disabilities and persons aged 60 and over are regulated by the Ministry of Family and Social Services (RoT MoFSS). The formal LTC system for persons with disabilities was introduced in 2005 under the Disability Act and became part of the Social Services Law. Even until today, the LTC system has remained as an Additional Clause as part of the Social Services Law in the absence of separate legislation regulating the LTC system. Other emerging areas in the LTC system include home health care and palliative care regulated by the Ministry of Health.

While formal residential LTC institutions have had limited capacity, despite expanding recently, informal care provided within families, predominantly by women, has remained the main form of LTC in Türkiye. In recent years, the shortage of LTC services has also been mitigated by live-in migrant care workers from neighbouring countries. Although the LTC system was initially designed for persons with disabilities, there has been a notable increase in both public and privately owned residential care facilities and home care services for older persons, and persons with disabilities over the last decade [1].

The recent official reports on persons with disabilities are based on the results from the 2011 Population and Housing Census of Türkiye conducted by TurkStat. Despite the lack of data for the current period, these results indicate that 6.9% of the population in Türkiye is affected by at least one disability [2]. Additionally, 16% of people aged 65 and above need care support at home, with this percentage increasing to 27% for those aged 75 and above [3]. Hence, there is a clear necessity for a well-performing home health and social care system that integrates both formal and informal care, alleviating the burden on the families.

The LTC system in Türkiye is highly fragmented, and the governance structure is not straightforward, which causes complications in terms of system organisation and service provision. The LTC system is governed by the Ministry of the Family and Social Services (RoT MoFSS). The General Directorate of Services for Persons with Disabilities and Older Persons (EYHGM), under the RoT MoFSS, is the primary governing authority responsible for overseeing residential care facilities, home care services catering for persons with disabilities and, for those aged 60 and above, respite care and day care. Although the LTC system for persons with disabilities was institutionalized through the Disability Act in 2005 (Law No. 5378), which became part of the Social Services Law (Law No. 2828), the legislation regulating public nursing homes for older persons was enacted by a 1987 by-law, with private nursing homes and rehabilitation services for older persons being introduced through a separate by-law in 2001.

In addition, the Ministry of Health (RoT MoH) governs home health care services for patients and persons in need of long-term or short-term care as well as palliative care centres that are integrated into the hospital system. Home health care services also fall under the governance of municipalities in accordance with the provisions outlined in the Municipality Law of 2005 (Law No. 5393). Curiously, cash-for-care benefits for the carers of persons with disabilities under 18 are regulated by another legislation that also regulates Social Pensions for older persons and adults with disabilities (Law No. 2022).

The LTC system is tax-financed and covers cash-for-care benefits for informal carers of persons with disabilities, rehabilitation centres and care homes for persons with disabilities, nursing homes and rehabilitation centres for older persons. It also covers respite care, day care, and home health- and social care for these two groups. The publicly financed LTC system is strictly means-tested and only those whose median household income (but not the individual income) is below two-thirds of the net minimum wage in Türkiye are eligible for cash-for-care benefits. This threshold is equivalent to about US$335 per month (converted from Turkish lira, equivalent to approximately US$34 as of August 2024). Public nursing homes charge a monthly fee, but those who meet the means-tested threshold are entitled to receive these services without charge. Individuals requiring social and psychological support, aged 60 and over and who meet the income eligibility criteria could be eligible for admission to public nursing homes. Furthermore, individuals meeting these criteria are eligible for nursing home admission only if they are able to carry out their daily activities, and if they do not suffer from mental illness or have any addiction. In addition to these aforementioned criteria, older persons seeking admission to a public rehabilitation centre must demonstrate a need for rehabilitation due to physical and cognitive deterioration on a temporary or long-term base. It is important to note that public nursing homes and rehabilitation centres are available for individuals who meet the eligibility criteria and have been assessed as requiring such care. A case worker on-site conducts an assessment to evaluate the socio-economic condition of the person with disabilities and their families, as well as their psycho-social and physical condition. People aged 55 and over have access to private nursing homes by paying out- of-pocket. However, it is a regulatory requirement that every private nursing home must provide accommodation for a minimum of 5% of its capacity for those who are unable to pay for the care they require. Those whose costs are to be financed by the state are determined by the Provincial Directorates of Family and Social Services [4].

Public LTC insurance has been under consideration by the government for some time, but it is not currently in place.

The LTC programmes are regulated by the General Directorate Services for Persons with Disabilities and Older Persons (EYHGM) under the Ministry of Family and Social Services (RoT MoFSS). After the introduction of legislation in 2005 regulating the LTC policy field, a by-law (No. 26244) was introduced in 2006 to set out the principles. Although the LTC system was introduced and institutionalized within the framework of the Disability Act in 2005, a guideline to assure the quality of public and private services (including LTC services) provided to persons with disabilities was not issued by the Ministry until 2019. This guideline was prepared by the Department of Quality Monitoring and Evaluation that is part of the EYHGM and responsible for the quality assurance [5].

As described earlier, the LTC system in Türkiye is highly fragmented, and care services for persons with disabilities and older persons are regulated separately.

Home care (in the form of cash-for-care benefits), which was first introduced in the 2005 Disability Act, is the most widely used program. The cash-for-care scheme has been one of the main LTC policy priorities for supporting home care since its introduction in 2005. It is a means-tested cash transfer provided to the care provider, who could be a family member, including a (distant) relative, offering ‘round-the-clock’ care seven days a week. To qualify for cash-for-care, individuals must present a medical report demonstrating at least a fifty percent disability level, indicating their inability to lead an independent life without the assistance of a care provider. The household income must not surpass a poverty threshold of two-thirds of the net minimum wage. As of June 2024, 555,166 people benefit from the cash-for-care scheme [1]. Persons aged 60 and above constitute the largest number of beneficiaries of the cash-for-care scheme women represent 44.18% and men 55.82% of the beneficiaries. Also, 32% of the beneficiaries are persons with learning disabilities [2].

It is important to highlight ongoing developments in the LTC system in Türkiye: palliative care and the expansion of home health care. Home health care is provided by both public and private hospitals. It is a growing sector with various small and large-scale private entities, some of which own nursing homes as well as offering health care services at home. Home health care is under the regulation of the Ministry of Health (RoT MoH), since the introduction of the first regulation (No. 25751) in 2005. Later regulations in 2015 and 2023 have defined and extended the quality standards in home health care while also extending the regulatory framework. In 2023, the RoT MoH expanded the scope of home health care services in line with the service standards for individuals in need of home health care. Persons aged 80 and above now have access to home healthcare services without requiring any specific medical report or dependency on supporting devices.

In 2010, the RoT MoH initiated the Palya-Turk project, and since then, palliative care services have been established in public and private hospitals. In 2017, The Home and Palliative Care section was established under the RoT MoH, Public Health Directorate. Palliative care services were included in the home health care services in 2010. There are 437 palliative care centres providing a total of 6,397 beds as of 2023 [6].

The municipalities also offer home health and social care services for individuals in need of care. There is no publicly available administrative data on the capacity of municipal care services. Day care centres operated by the RoT MoFSS cater to persons with disabilities, offering care services alongside social and cultural activities. Day care services are provided at 136 rehabilitation and care centres serving 1,904 individuals. There are a limited number of day care services incorporated within nursing homes catering to those aged 60 and above, totalling 40 centres with a combined capacity of 1,037 [1].

For persons with disabilities, there are different public residential care services. For instance, there are residential care homes and rehabilitation services, “Home Type Social Service Units” (Umut Evleri) that are flats or detached houses accommodating 4-6 people with professional staff, and respite care homes. As of June 2024, according to the available data, there are 106 public rehabilitation and care centres where 6,886 persons with disabilities live. Last but not least, there are 145 home type social service units where 594 persons with disabilities live [1]. The state operates under a public-private partnership model, where it procures services from private centres through monthly payments including care fees and a clothing allowance for each care user holding a medical disability report and falling below the means-tested poverty threshold. Most of the rehabilitation and care centres for younger persons with disabilities are privately owned, with a total of 315 centres; 29,574 people residing in these private care homes [1].

Residential LTC for individuals aged 60 and above involves public and privately owned nursing homes, day-care and home-type social service units (Gündüzlü Bakım ve Aktif Yaşam Evleri) that are integrated into nursing homes that cater to the needs of older persons where they can live alone or with their spouse, and “other nursing homes”. A law passed in 2008 permitted private providers to establish residential homes which cater to individuals aged 55 and above. Since then, privately operated nursing facilities have outnumbered public nursing homes. However, in comparison to the discrepancy between the numbers and residents of rehabilitation and care homes for persons with disabilities, the difference here is much less pronounced. In exact numbers, as of June 2024, there is a total of 504 care facilities for older persons with a combined capacity of 30,883 individuals all over the country. Among these, 168 are publicly owned nursing homes with a total capacity for 14,757 people. 268 are privately owned nursing homes where 13,097 people live. In addition, there are 40 day-care and home-type social service units (Gündüzlü Bakım ve Aktif Yaşam Evleri), which represent a relatively recent model. There are only 1,037 people in these units. Lastly, there are also 27 “other nursing homes” under other ministries or municipalities where 1,972 persons live [1]. As can be seen the residential LTC options for persons with disabilities and older persons are very heterogenous.

In the last five years, the population of older persons has increased by 22.6% and as of 2023 it constitutes 10.2 % of the country’s population [3]. Due to the growing share of older persons in the population of Türkiye, the internationally prevalent concept of “Active Ageing” has been embedded in the national policy discourse on ageing. The policy recommendations outlined in the First Council on Ageing held on 20-22 February 2019 emphasise age-friendly cities, which need to be implemented at the municipal level. The accessibility of cities for older persons, older persons’ mental and physical health, which needs to be improved through advanced day care, companion care and counselling, among others, play a crucial role. Although it could not be entirely stated that older persons are part of the decision-making processes at the local level, four municipalities in Türkiye could be given as an example of an interesting initiative that joined the World Health Organization’s “Age-friendly Environment Network” [7, p. 24] in response to the ageing of the population, which needs to be addressed at the local level.

The LTC sector is facing a significant shortage of workforce, which is exacerbating an already heavy workload at public institutions. This is further compounded by the prevalence of contract-based employment, which poses notable difficulties for carers in terms of social rights and remuneration [8,9]. Furthermore, the LTC system in Türkiye continues to rely heavily on unpaid care within families, placing a significant burden on women who are the primary carers. In recent years, the shortage of LTC services for the wider public has also been mitigated by live-in migrant informal care workers from neighbouring countries. The family-based informal home care system is reinforced by prioritising the cash-for-care system for informal carers, which operates as a social assistance scheme, thus strengthening the reliance on informal care within the LTC system. This approach has several shortcomings. The quality of care remains unevaluated, carers lack access to essential information, professional counselling and social protection. In a rapidly ageing population, the diverse needs of persons with disabilities of different age groups and older persons may not be adequately met by informal care within the family.

Digitalisation has been a defining force in Türkiye’s health and social care sector since the 2000s when the RoT MoH introduced digital technology tools. One novel example is E-Nabız (e-pulse), a personal health record system that stores encrypted personal health records, introduced in 2015. The “e-Health Transformation Program” of the RoT MoH intends to build an electronic health record system for all residents. There is a rapidly growing market of digital solutions for the health and social care industry, including telemedicine, telecare, electronic health records, AI machine learning, etc. There is also a software ABS (Family Information System) established by the Ministry of Family and Social Services for monitoring social services processes. As of 2022, this software introduced a new module to track the processes of the cash-for-care system for persons with disabilities.

Expanding the formal care system is also hugely important, as Türkiye is not just experiencing population ageing but is also witnessing a transformation in family structures marked by a large reduction in the number of extended families over the last two decades. The proportion of extended-family households, defined as at least one nuclear family residing together with one non-family member, declined from 16.7% to 12.8% between 2014 and 2022 [10]. Accordingly, there is a need for increased public spending on LTC, a sustainable social insurance system and extended coverage and quality assessment in residential care, day care centres, rehabilitation and live-in care. The strict means-tested cash-for-care system which targets very poor people excludes the wider population with LTC needs.

During the COVID-19 pandemic older persons experienced prolonged periods of lockdown, which highlighted the urgent need for the expansion of psychosocial support for older persons, early   measures for residential homes, coordination of different sectors of LTC, and improvement of care workers’ working conditions. Given that residential care is only a small part of the Turkish LTC system, the pandemic also highlighted the importance of widely accessible home care services. Despite the limited capacity of LTC in Türkiye, it is a growing social and health policy area that will become increasingly important since the population is ageing. Furthermore, as the system involves a variety of actors, “sustainable coordination” is essential [11].

The feasibility of long-term care insurance (LTCI) in Türkiye has been discussed by scholars and the public, also within the framework of the German LTC social insurance system as one of the pioneers in this field. The Medium-Term Program 2024-2026 published by the Presidency of Strategy and Budget in Türkiye states that the number of day care centres will be increased so that informal caregivers, who are mostly women, can take part in the labour market. Also, the plans for the establishment of supplementary LTCI were indicated, although no further details were given on this subject [12]. Although the details have not been represented in detail yet, this model is expected to be based on the partnership between state and private insurance companies [13].

The implications of the rapid development of digital health and social care markets for long-term care arrangements raises significant policy questions. As long-term care becomes a pressing issue in the wake of the digital transformation, effective and responsible incorporation of digital technologies in Türkiye’s health and social care services emerges as a priority policy area, reflected in key policy documents. The recently published Development Plan for the period of 2024-2028 [14] refers to the effective and efficient use of digital health solutions and expansion of digital health technologies, including the support for the digitalisation infrastructure of hospitals and the development of “telehealth” systems. The plan foresees necessary legislative arrangements, raising public awareness of digital technologies and improving digital health literacy. According to this Plan, an integrated long-term care model is a priority for the government, combining health and social care services. The Plan foresees the widespread availability of health technologies for the older population, such as the efficient use of “telecare” facilities incorporated into home-based care services. The Plan also emphasises improving the older population’s digital skills for the effective and safe usage of health and social care technologies.

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