This report is the outcome of a collective effort with contributions from a team of policy analysts from the OECD Social Policy Division and the Jobs and Income Division of the Directorate for Employment, Labour and Social Affairs (ELS). Hervé Boulhol led the team and co‑ordinated the project and the publication. The overview Chapter 1 was written by Hervé Boulhol and Wouter De Tavernier drawing on the analyses carried out in other chapters. Principal authors of the chapters were Maciej Lis: Chapters 2 and 5; Wouter De Tavernier and Andrea Garnero: Chapter 3; Wouter De Tavernier and Andrew Reilly: Chapter 4. Other contributors to the report include Sandrine Cazes, Yuta Fujiki and Sebastien Martin. The authors are very grateful to Monika Queisser, Head of the Social Policy Division, for supervising the preparation of this report and providing in-depth comments on all chapters.

It started in New York City. At the height of the first wave of COVID‑19 in March 2020, New Yorkers applauded daily at windows, on balconies and in the streets to thank doctors, nurses, paramedics and others for their tireless efforts to fight the pandemic. Cities in France, Italy, Spain, the United Kingdom and other countries quickly followed their example. Residents stood at the window every evening in the lockdown, joining their neighbours from across the street in clapping hands together for all the people whose work had suddenly become vital to survival, central to the functioning of our societies, and who were on duty day and night despite high risks of infection. With vulnerable older people at highest risk of dying from COVID‑19, managing caregiving both in long-term care (LTC) institutions and in people’s homes became a huge challenge for LTC staff, whose working conditions and pay became a focus of public discussions and policy debate.

The COVID‑19 pandemic put a huge strain on the health and care systems, and it was thanks to the strenuous work and commitment of care workers that many lives were saved and people in need got support. We regularly applauded them from our windows, but a few years later we seem to have forgotten about them. Working conditions in long-term care (LTC) generally remain poor and it is difficult to attract and retain LTC workers. The situation is particularly dire for personal care workers who make up about four‑fifths of them in the OECD, the other fifth consisting of nurses. This challenge will grow tremendously with ageing prospects. We need to go Beyond Applause and this requires taking significant measures to improve wages and working conditions more generally in order to ensure that people requiring assistance in their daily lives receive the care they need. This report describes what these measures should be.

This introductory chapter gives an overview of the entire publication drawing on analyses carried out in the other chapters, and discusses policy implications. It documents the past evolution of employment in long-term care and projects demand for long-term care workers, which highlights the risk of substantial shortages over the next decades. The chapter flags tough working conditions for long-term care workers, including high physical and mental health risks, low wages in particular for personal care workers and a lack of recognition of both the workers and their competences. It discusses why wages have remained low despite persistent labour shortages in the sector. The chapter concludes with policy measures to improve working conditions and mitigate shortages in long-term care.

This chapter discusses LTC work today. It starts by looking into the tasks LTC workers do, and the skills and level of education that LTC work requires, before showing descriptive statistics of LTC employment, including recent trends related to demographic changes and to the composition of LTC between residential and home‑based care. The chapter then focuses on wages. New results are presented to shed light on the determinants of individual hourly wages of LTC workers. Finally, factors that may explain low wages of LTC jobs beyond the factors identified in the quantitative analysis are discussed.

This chapter provides an overview of the work environment and of collective bargaining in long-term care. It shows that long-term care workers have somewhat shorter tenures than other employees. It reveals that the quality of the working environment in long-term care is rather poor, as the work is both physically and mentally arduous, often takes place at burdensome times, and that training opportunities and enforcement of labour regulations are limited for some groups of long-term care workers, in particular personal care workers providing home care. Finally, the chapter analyses collective bargaining in long-term care, revealing that in several countries workers’ representatives in the long-term care sector are not strong enough to negotiate tangible improvements in wages and working conditions.

This chapter first examines the lack of recognition of long-term care workers and its origins and presents measures countries have taken to boost social recognition of these workers. It then moves to gender issues within the LTC sector including the over-representation of women and the gender wage gap. The chapter finally explores the role of migrant workers in the LTC sector, and shows that they are filling employment gaps in particular as live‑in carers, making them vulnerable to abuse.

This chapter presents evidence on current and future labour shortages in the LTC sector. The first section presents evidence on unmet LTC needs and existing staff shortages in LTC. The second section discusses recent policies implemented to mitigate staff shortages. The third section shows projections of labour demand in the LTC sector for the next two decades, as driven by population ageing and economic growth, pointing to the need for strong policy action to prevent staff shortages from accumulating at a very fast pace towards a socially unacceptable level. The last section discusses the potential of new technologies to help address the increasing demand for LTC workers.