Projections of Demand for Care among the Elderly in Poland

Introduction

The most distinctive feature of demographic developments, debated increasingly since the 1960s, are changes in the age composition of populations. They are manifested by the increasing number of older people and their share in the total population and labelled as population ageing. This process, approached from the perspectives of different disciplines (demography, economics, sociology, psychology, political sciences, social policy, life sciences, etc.), constitutes the leading topic of research and policy debates. While the 20^th century has been marked as the period of the population growth, the 21^st century will be dominated by the global population ageing. Consequently, the population ageing process and its diversity across regions and countries are under focus along with multifaceted consequences at both the macro and micro levels (Kotowska, 2019a).

One of the effects of population ageing is the increasing demand for care among older people – a subject of a scientific debate and public policy concerns. Researchers conclude that requesting a care need by older persons is above all related with their health status (e.g. Czekanowski & Bień, 2006; Doblhammer et al., 2008). Health together with income are also the most important factors determining the use of institutional forms of support (Gaymu et al., 2006), while household composition is a predictor of receiving informal support (Gaugler et al., 2007; Wingard et al., 1987). Meeting care need of dependent older people is becoming more urgent as the pace of population ageing in many developed countries, including Poland, is accelerating. The essential ingredients of population ageing, that is, the increasing number of older people and their proportion in the total population, can be considered as a challenge for care arrangements globally. In most countries worldwide, the supply of formal care services for older people is generally underdeveloped; coverage of not-for-profit organisations is limited, while private markets usually cannot offer sufficient and affordable provision of help (WHO, 2011). That makes older people with functional limitations strongly rely on practical support from others, mainly from their family network members (both close members like spouses, children, siblings, but also more distant relatives), friends and neighbours. However, changes in family-related behaviours, both demographic (associated with timing, frequency and sequence of family events) and organisational (connected with labour market involvement of men and women and patterns of housework division between them) call into question the traditional intergenerational care exchanges and their sufficiency to meet the augmented care needs in the future. Recognition of the future demand for care and its estimation is, therefore, a key priority for social policy considerations.

Estimation of the future demand for care among older people in terms of the number of persons in need should be based on developments in the older population. However, the official population projections are traditionally available only by age and sex. Discussions how to satisfy the future care demand from older people should be based on population projections that go beyond the traditional breakdown. Ideally, they should account for indicators of care needs (e.g. dependency/health status) and care supply (e.g. kinship and social networks) to understand how caring responsibilities could be shared between family members and professional carers. In practice, such projections are rarely prepared with data unavailability being the main limitation. Currently, there are limited examples of studies that would account for both dimensions simultaneously (Eggink et al., 2016; e.g. Gaymu et al., 2008; Geerts et al., 2012; Kingston et al., 2018).

In Poland, the substantial increase in the absolute number of older people and their share in the total population in the coming decades is prominent which makes the country an interesting case study. In recent years Poland’s population has been decreasing – both the natural and the real increase have been negative for 7 and 8 years in a row, respectively. The population as of 31 December 2019 was 38,382.6 thousand people which was less by 28.6 thousand than year before and 147.3 thousand than in 2010. At the same time the population of Poland is ageing – the number of people aged 65 and more was 6,947.0 thousand and was higher by 214.7 thousand than in 2018 and 1,756.6 thousand than in 2010 (GUS, 2020a). Along with the growth in the number of older people there is an accelerating increase in the proportion of older adults. It reached 12.4 % and 13.5 % in 2000 and 2010, respectively, and was already equal to 18.1 % in 2019. Among people aged 65 and above the most numerous (35.4 %) were the youngest older people (aged 65–69 years), while the least numerous (11.7 %) were the oldest persons aged 85 and more years (GUS, 2020a). However, the coming years are projected to bring more balance between the proportions of the subpopulations of the youngest and the oldest of older persons leading to the ‘double ageing’ – an increase in the proportion of the oldest-old among the population aged 65 and above. While the more numerous cohorts will become older and their health will naturally deteriorate due to senescence, an inflated demand for care services among future older people can be expected.¹ In the years 2018–2060, the number of people aged 65 and over will grow by 4.5 million with a simultaneous reduction of people in working age (15–64 years) by 7.9 million (Eurostat, 2019). It determines not only the change in the relation between the number of producers and consumers in the economy but also the shift between the number of potential caregivers and care recipients: the old-age support ratio, defined as the number of the population aged 15 to 64 per member of the population aged 65+​, is projected to go down from 4.0 to 1.6 persons between 2018 and 2060. The analyses dealing with the current resources of care point out that the institutional care supply is already fulfilling just a very small fraction of older peoples’ care needs (ca. 1 % of the population in Poland according to the 2011 population census). Care needs of older people are met mainly by informal caregivers who, first and foremost, are the family network’s members. However, the supply of informal care is predicted to diminish mainly due to changes in the family structures. The ideational changes driving family formation patterns add uncertainty about the intergenerational care exchanges. Moreover, access to informal care is also affected by the changes in older people’s living arrangements.

The aim of this monograph is to estimate future demand for care among people aged 65 years and over in Poland by preparing appropriate population projections. The demand for care is defined as the number of older people in need of care due to their health status. Predicting the number of older people in need of care rather than percentages is legitimate as the stock of middle-aged adults is already known, while percentages depend to a considerable extent on the future numbers of children yet to be born. For that purpose the following partial theses are formulated:

1. 1. Despite the potential health improvement by age, an increase in the demand for care among older people is expected. This is due to the intensity of the population ageing process in Poland, which is leading to a fast increase in the number of older people who are living longer than ever. Therefore, estimation of this demand requires linking changes in the population age structure with changes in the health status. Consequently, the changes in the individual health of older persons should be incorporated into the projection model.
2. 2. The changes in the family model and living arrangements of older adults result in both shrinking (informal) family care resources and the increasing demand for formal care. In particular, the growing number of people living in single households is augmenting the demand for formal care among older persons. Therefore, to estimate the macro-level effects of these developments for care demand, the projection model should take into account changes in living arrangements of older adults observed at the micro-level.

To prepare population projections that would assess the number of people in care need, I propose the analytical approach which integrates microsimulation of health and living arrangements changes with macro-level projections of the population by age and sex. The proposed approach is driven by the following main thesis:

To estimate the future demand for care among older people changes in the age composition of the population should be linked with changes in the individual health status. In addition, developments of living arrangements of older people need to be accounted for. The projection tool with microsimulation modelling of individual-level behaviours incorporated in the population projections at the national level provides better predictions of the future care demand.

There are relatively few studies in the Polish literature dealing with the future demand for care among older people with activity limitations (Abramowska-Kmon, 2011; Bonneux & van der Gaag, 2012; Szukalski, 2004; Szweda-Lewandowska, 2016). This book attempts to contribute to the field by performing a study that combines changes of the population age structure with changes in the health status and the living arrangements status in a dynamic setting using microsimulation methods. The research makes use of a dynamic multistate projection model that takes into account both characteristics at micro-level – the health status and the family situation (living arrangements) of older persons. It allows estimation of the effect of change in the health status by age over demand for care according to morbidity hypotheses used to formulate projection scenarios. Including into the projection the information about older persons’ living arrangements allows assessment of the influence of diminishing informal care resources on the demand for formal care.

Life abhors a vacuum and is difficult to predict, which applies both to the subject as well as the writing period of this book. This monograph is a product of my doctoral dissertation which advanced between 2017 and the beginning of 2020, and, inevitably, had not foreseen two major events that have happened later. Both are critical in the context of care demand and care supply. The first was the outburst of Covid-19 pandemic in 2020 that changed the global landscape in terms of health, but also had its consequences on care provision. The second was the Russian invasion of Ukraine on 24 February 2022, which considerably changed the demographic and labour market situation in Poland, and affected the potential domestic supply of caregivers due to unprecedented forced migration flows from Ukraine. I decided not to revise the main body of the book as it should not affect the perception of the analytical part. However, during the final stage of the book’s compliation, I included my remarks on the above-mentioned events in the epilogue, to keep it up-to-date and inquire the reader for their significance. I hope this structuring will be met with understanding.

The goal of the monograph is achieved through the following basic research tasks:

1. 1. to explore the health and the family situation of older people in Poland and their changes over time based on the available empirical data;
2. 2. to estimate the parameters reflecting the older peoples’ dynamics of health and living arrangements for the population projection model;
3. 3. to formulate a population projection model which accounts for the health status and the living arrangements of older people and aims to project the future demand for care among the older people in Poland.

The structure of the book reflects the subsequent research tasks. It consists of four chapters that are preceded by the introduction and surmounted by the conclusions section and epilogue. In the first chapter, I provide an overview of demographic change in developed countries and its consequences for care among older people. Its goal is to set the stage for the empirical part of the study. In the beginning, I describe historical and projected trends of population ageing and highlight its diversity from the geographical – global and regional – perspective. I also present different methods of measurement of the advancement of population ageing and provide a brief overview of its selected main consequences. Then, I move on to the description of interrelations between the family model and care provision. At first, I look into family changes in developed countries, that is, how behaviours related to family formation, development and dissolution as well as gender roles within families have evolved in the context of the intergenerational exchanges of care. The more detailed description of family networks’ changes in Poland since 1989 follows. In the last part of this chapter I focus on care arrangements for older people. I start with introducing the concept of care to outline different care regimes in Europe and characterise predictors of care provision towards older people. Then, I scrutinise care provision for older people in Poland. Lastly, I review existing pieces of literature about projections of demand for care among older people in European countries and Poland in particular.

The second chapter is devoted to the family and health situation of older people in Poland and basically covers the first research task. In the first subsection the detailed information on living arrangements of older persons is provided. It starts with trends in living arrangements of older persons in a comparative perspective and continues with the summary of the determinants of living arrangements formed of older people. Then, the presentation of living arrangements of older adults in Poland follows by specifying the older population by marital status and their household composition mainly with the use of the available official statistics from registers and censuses. The picture is completed with insights into living arrangements of older people in Poland based on own tabulations of survey data. The second subsection of this chapter mirrors the structure of the first one but describes health status of older people. It starts with clarification about the concept and measurement of health and disability to proceed with description of trends in health and healthy life expectancy among older people. Special attention is paid to the selected theoretical concepts and some empirical findings on the future of morbidity. Next, available survey data on health of older people in Poland is summarised. The chapter closes with a review of the relationship between living arrangements and health.

The aim of the third chapter is to model the dynamics of health and living arrangements of older people in Poland using individual-level longitudinal data. It opens the empirical part of monograph and fulfils the second research task. It begins with the outline of the population projections’ modelling scheme that is realised throughout the last two chapters of the book. Then, in the theoretical subsection I distinguish between the incidence and prevalence measures in population description and consider multistate models as a tool for modelling social processes. In the empirical part, I first discuss datasets considered and used for the analysis. Next, I examine the relationship of health and living arrangements with age, sex and education in separate models and then formulate a joint model of health and living arrangements transitions with sex as covariate. This part indirectly leads to answers on additional research questions, such as: what is the relationship of health and living arrangements status with age at older ages, or what is the influence of sex and education on the risk of change in health or living arrangements status among older people, or what is the relationship, if any, between the health status and family situation of older adults. The chapter closes with the discussion of the estimation results.

The final chapter culminates the previous parts of the research. It fulfils the ultimate goal of the thesis formulated as the preparation of projections of future demand for care among people aged 65 years and over in Poland. The chapter starts with discussing microsimulation for population projections. Then, all the steps of preparation of the population projection model are highlighted. They include overview of the simulation projection model along with discussion of the Eurostat population projections and assumptions about the initial population structure and mortality. The final section of the chapter presents the results of the simulation projection model and compares them with the additionally performed sensitivity tests.