’s Changing Welfare Regime and Long-term Care Policies

Emre KOL Anadolu University, Turkey

Ceyda KÜKRER Afyon Kocatepe University, Turkey

Sessione 21 (a) – Le politiche di cura, tra sviluppo economico e coesione sociale/ Care policies, between economic development and social cohesion

Paper for the IX ESPAnetConference “Welfare models and Varieties of Capitalism. The challenges to the socio- economic development in and ”

Macerata, 22-24 September 2016

Turkey’s Changing Welfare Regime and Long-term Care Policies

Introduction

Social security method is adopted in Turkey which is part of the Southern European welfare model and old age security comes to the forefront in social security management. According to this system, people earn the right for retirement allowance after working for a certain period of time and social security is provided to these people. However, even though in application the ratio of old age security expenses in Turkey which was 3.2% of GDP in 1990 in Turkey increased to 3.7% in 1995 and to 7.8% in 2005 thus increasing by 146%, it is still far from those of Southern European countries. Because, the ratios in 2005 for countries which are accepted to be part of the Southern European model were 14.6% for Italy, 12.3% for , 12.1% for and 9.0% for (Taşcı, 2013: 13-14).

The family structure that the elderly people are part of play an effective role in the shaping of social welfare perception related with elderly people in Turkey. Whether the family structure is traditional or modern can be effective in the perception and application stages related with social welfare for elderly people (Taşcı, 2013: 16).

It is observed that the population of elderly people is increasing rapidly in the world. The number of people over the age of 60 in the world has increased by 178 million during the past decade. The number of elderly individuals was 180 million in 2012 only in . According to the report published by the United Nations Fund for Population Activities (UNFPA); whereas the population ratio of elderly people according to regions varied between 0-9% in 2012 in the world; it is anticipated that this ratio will increase up to 30% in 2050 even though there will be differences among regions (ASPB, 2013: 4).

Law numbered 2022, respecting the grant of allowances to Turkish who are over the age of 65 and who are destitute, infirm and without any means of support which was accepted in Turkey in 1976 is considered as a step forward with regard to providing social assistance to the elderly. In addition, it is also known that municipalities provide real social assistances to elderly and retired people for accommodation, health, feeding and transportation. It is also observed that non-governmental organizations also play active roles related with social assistance to the elderly (Taşcı, 2013: 16).

In the light of these explanations, Long-term Care (LTC) policies continue to gain importance as the elderly population continues to increase in the world along with life expectancy. In this regard, this change in the population structure along with the transformation of the family structure make the LTC policies already being applied in Europen Union countries important for Turkey as well. In this study, LTC systems of EU countries will be taken into consideration with emphasis on issues for which Turkey can make use of the experiences of these countries. In the following section, care policies in Turkey will be handled and suggestions will be provided for the LTC insurance that is planned to be established.

LTC Services

In general, LTC is an alternative care service focusing on the support of an individual by another person for meeting his/her physical or emotional needs over a long period of time or on the long term help provided by another person (Dölek, 2012: 95).

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LTC service can be provided at home, in an institution (nursing home, retirement home, hospital) or at community based care institutions (daycare, night care etc.). Even though healthcare services require intensive expertise, LTC services can generally be provided by family members or workers who have not received any private training in this field (Oğlak, 2015: 180).

Destitute individuals who make use of LTC services are generally disabled individuals, those with chronic diseases or elderly people. Similar to care services, LTC services are generally carried out as services provided at an institution or at home. That is why, LTC services are classified as long-term institutional care or long-term home care (Dölek, 2012: 95).

Long-term Home Care Services

The objective of long-term home care services is to preserve the health of chronic patients, elderlies and disabled individuals who require continuous care services; prevent the increase of their dependency on care services; provide them with skills and training that will enable them to live independently in cases for which the disease or disability cannot be overcome and to provide quality care services in a professional manner. Destituteness is the state of requiring help for at least one daily living activity or instrumental living activities. Experiencing difficulties in carrying out daily living activities and instrumental living activities along with cognitive insufficiency are set as conditions for benefiting from care services in many countries. In some countries, those who are dependent on care due to health and care related problems due to age have also been included within this scope (Oğlak, 2007: 102).

Home Care Services

Home care services in Turkey are organized by the Ministry of Health and priority is given to works carried out to ensure that disabled and elderly people receive healthcare services as well as care services at the location they reside. This service is carried out in accordance with the “Directive on Application Procedure and Principles for Home Care Services Provided by the Ministry of Health” numbered 3895 issued by the Ministry of Health on 01.02.2010.

The objective of this directive is to ensure that the examinations, tests, treatments, medical care and rehabilitations of individuals who need home care services are provided at their homes in their family environments, that home care units are established as part of the healthcare institutions working under the Ministry of Health in order to provide social and psychological support services as a whole to these individuals and their family members, that the minimum physical equipment and tools required for these units along with personnel standards as well as the tasks, authorizations and responsibilities of the related personnel are determined, that the communication, record and follow-up services to be applied are determined in advance and that the procedures and principles for the inspection of this application are determined thus ensuring that home care services are applied effectively and in an accessible manner with a social state understanding (Yıldırım and Şahin, 2015: 71).

Whereas this service provided by the Ministry of Health is focused more on healthcare services, it is observed that local administrations provide home care services to the elderly and disabled individuals. These services differ among municipalities. It is observed that these services include actual and financial assistances to the elderly individuals in addition to home care services along with home cleaning, whitewashing or painting along with taking care of small repairs, provision of social and psychological support and organizing various social and cultural activities with the support of elderly service centers of various municipalities and ensuring that the elderly individuals make use of these services (Yıldırım and Şahin, 2015: 72).

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In addition, another service type is the “Home Care Fee” service provided by the Ministry of Family and Social Policies that destitute disabled or elderly individuals can benefit from in order to overcome their economic poverty while also having the opportunity to continue living in their own homes. This service is arranged in accordance with the principles of the “Regulation on the Identification of Persons with Disabilities who are in Need of Care and on the Determination of the Needs for Care Services” published in the official gazette dated 30.07.2006 and numbered 26244 (2006). If the care service is to be provided at the residence of the elderly or disabled person, it is carried out by giving a monthly fee to the person who will carry out the care services. The care service can be provided by the relative of the disabled person in need of care or by caregiving personnel at the residence of the disabled person or one of his/her relatives under the inspection and guidance of the General Directorate. In this case, the fee for the care service provided to the disabled persons in need of care is paid by the provincial directorate monthly to the relative of the disabled person or the care center that employs the caregiving personnel. (Yıldırım and Şahin, 2015: 72-73).

Upon the demands of the disabled person in need of care or his/her legal representative and the acceptance of the special care center, care services may be acquired from special care centers opened with the permission of the General Directorate. In this case, the fee for the care services is paid monthly by the provincial directorate to the care center for the services provided to the disabled person (Yıldırım and Şahin, 2015: 73).

In general, home care service means the provision at a professional level or by family members of the services needed to preserve the health of an individual and to ensure that he/she regains his/her health at the home or the place of residence of that particular individual. These services also ensure the preservation of the quality of life and social prestige in accordance with the requirements of the individual at a wide range covering both health and social services. In this regard, home care services are in general defined as services that replace institutional care, decrease or delay the necessity to stay at institutions (Oğlak, 2007: 101).

Since developed countries foresee that care loads become insurmountable due to economic and social reasons, they include legal regulations as part of their social policies within the scope of the LTC insurance that aims to support the family. As an example, “LTC insurance” applications are present within the social security system in , , Holland, and . England, , , Germany and Holland also include applications that support the caregiving family members as part of the regulations related with social service applications (Oğlak, 2007: 102).

Care for elderly, disabled and chronic patients is provided mostly by family members or volunteer caregivers in Turkey as well because of the insufficiencies of the government in providing caregiving services as well as the additional cost of caregiving establishments (Oğlak, 2007: 102).

LTC Systems Typology in Countries

LTC policies in European Union (EU) countries have been developed not in a planned, sustainable and transparent manner but rather for the solution of problems caused by political and financial issues. The gaps that could not be met by the families until the recent period have been met via social assistances. Demographic, epidemiologic, social and economic changes have resulted in the need of planning LTC policies and services and their formal presentation. LTC models in EU countries have emerged over time in order to fill the gap caused by unofficial caregiving (Ökem and Can, 2014: 6).

The models applied vary among countries. Countries have been classified according to the properties of their systems as part of the Assessing Needs of Care in European Nations (ANCIEN) project aimed at the examination and better planning of the LTC systems in EU countries. Accordingly, systems of 3 countries where less out-of-pocket expenses are made due to high public expenditures, where cash payments are provided to the people thus providing the opportunity to make a selection and where unofficial care is supported are listed as systems that are more attractive for users. According to this grouping, , Holland and Sweden make high public expenditure and may respond more to the needs of the elderly. Thus, they are ranked first as systems that are easily accessible by users. Systems for which access to services is the most difficult are those of Italy and where out- of-pocket expenses are high due to low public expenditure and unofficial care is frequently observed (Ökem and Can, 2014: 7).

Majority of the elderly people in Turkey live with their families. Elderly people in need of care who live alone or with their families become a problem over time for the family members and at most times they do not know what to do. In this case, the elderly individual is considered as someone whose basic needs are met in the house, who takes no part in any social event or communication, who continuously listens to himself/herself thus making more complaints related with diseases. Having a center where both the current abilities can be preserved while also providing new abilities that will enable the elderly people to live independent of others in addition to ensuring that they take part in social activities during the daytime will increase the quality of life of elderly people while also transforming the perspective of individuals towards the elderly people in their families (Oğlak, 2011: 122).

Day Care Center which is a very important intermediate solution model between home care and retirement homes has been used by all developed countries for 30 years providing benefits to both the families that care for the elderly people as well as the governments, but it is not widely known and applied in Turkey as of yet (Oğlak, 2011: 122).

Home Care Services as Part of Care Insurance

Austria makes caregiving payment since 1994 in accordance with the Federal Care Allowance Law for cases when disabled people who need mental, physical, emotional care require continuous care and in case this goes on for 6 months with caregiving requirement reaching more than 50 hours per month and the financing for this is completely provided by taxes. Whereas the financing structure of the LTC Insurance Law that went into effect in 1995 in Germany is based on obligatory social security premium. In Japan, financing of the LTC Insurance Law that went into effect in 2000 is funded with a mixed structure comprised of 50% from social security premiums from actively employed people and 50% from taxes. Whereas the care services for destitute people in need of care is funded completely by taxes (Oğlak, 2007: 103).

Increase in the participation of women in the labor force along with the aging of the population generates a gap between increasing demand and decreasing supply for the care services traditionally provided by women which is filled by immigrant women labour as a cheap and functional alternative. Whereas the need for LTC in the caregiving services provided to the elderly increases significantly with increasing age of the population; it is observed that these services create a cost pressure on public services (Gökbayrak, 2009: 56-58).

The elderly population (aged 65 and above) in Turkey has reached 6 million 495 thousand 239 people in 2015. Whereas the ratio of the elderly population to the total population was 8 % in 2014, this ratio increased to 8.2% in 2015. Men comprise 43.8% of the elderly population, whereas women comprise 56.2% (TÜİK, 2016).

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LTC Policies

Germany has been successful in creating a comprehensive social system between government support and personal responsibility. This process dates back to the 19th century. In this period, Chancellor Otto von Bismarck placed social regulations into effect against serious crises that might occur in life thus arranging the first large scale social security program. The Health Insurance Law dated 1883, Accident Insurance Law dated 1884 and Old Age and Disability Insurance Law dated 1889 were the starting point for the social policy of the state (Ökem and Cam, 2014: 37).

LTC insurance went into effect on January 1st, 1995 as the fifth pillar of the social security system. This insurance guarantees that the risk of needing care is covered within the scope of the obligatory security system based on the principle that health insurance should be followed by LTC insurance. Different scopes of the social security system are not sub-establishments of the state but autonomous institutions. These institutions regulate the self-sufficiency of individuals by completing the solidarity of families regarding loads that might be too much for the person and his/her family based on solidarity and the sharing of risks (Ökem and Cam, 2014: 37-38).

Even though old age and disability is not perceived of as a threat for today, they will comprise a serious threat in the near future. Hence, the establishment of LTC insurance is a precaution taken for the future. One of the goals included in the Prime Ministry Presidency of the Administration on Disabled People 2011-2013 Care Services Strategy and Action Plan is that it is arranged as part of the social security system so as to encompass the whole population. In addition, it has been committed by the Director of the Administration on Disabled People in May 2011 that the care insurance will be put into effect within three years (Caniklioğlu and Ünal, 2011: 2267-2268).

The fundamental objective of care insurance is to provide the care to the elderly individual in his/her home environment. In this regard, since the traditional family and social structure of Japan has similarities with those of country, the Japanese example is especially important for Turkey (Caniklioğlu and Ünal, 2011: 2269).

When the elderly care services in Turkey are evaluated; Retirement Homes and Retirement Home Elderly Care and Rehabilitation Centers, are establishments where LTC services are provided to elderly individuals. According to the Regulation on Retirement Homes and Rehabilitation Centers, Retirement Home; denotes the boarding social service establishments founded to meet the social and psychological needs of people aged 60 and above and to protect them and care for them in a peaceful environment, Elderly Care and Rehabilitation Center; denotes the boarding social service establishment where rehabilitations are provided to elderly people in order to ensure that they continue their lives healthily, peacefully and in security by themselves and where individuals who cannot be treated are taken into private care (Başak et.al., 2015: 120-121).

One of the most important conditions for gaining the right for care insurance is to be destitute. This concept is a precondition for the provision of a gain from the related insurance. Being destitute is not a new concept. Being destitute is a concept like disease or disability that has been known since a long time. However, when it is considered from the perspective of social security, the concept of being destitute had to be reconsidered as a result of the change in the demographic structure, meaning the increase in the average life expectancy, the change in the family structure as a result of the decrease in birth rates, the shift towards a nuclear family from a multi-generational family living under the same roof, the increase in the ratio of women shifting to the labor force, redefinition of diseases and the results brought about by these diseases (Hekimler, 2015: 60-61). 5

Care Insurance

The convention numbered 102 of International Labor Organization (ILO) defines being destitute as a social risk as well along with health, disease, unemployment, old age and occupational diseases as part of the definition of basic social security rights. Thus, being destitute has been defined as a social problem in many developed countries and regulations that target the supporting of the individual in need of care along with his/her family have started to be included in social policies via various legal regulations. Germany was the first country to officially express being destitute and to include it in its social security system with the Social Care Insurance Law that went into effect in 1995 (Oğlak, 2014: 220-221).

Care Insurance (CI) is an important social protection mechanism that tries to find a solution to the need for care of destitute elderly people within the social security system. CI is an important social policy tool that is based on the understanding that financial and social supports should be provided by the government and society as well to individuals when the need for LTC arises in addition to the individual and his/her family. CI is the result of the social state system understanding for protecting the individual and the family against the cost increases and income losses that will be caused by LTC services provided to the elderly people (Oğlak, 2014: 221).

Medical and social care, home care, retirement home, day-time and night-time care, rehabilitation services, tele care-home care, temporary vehicle provision, support of the caregiving personnel and other social support services can be provided within the scope of CI. CI has been included in the social security systems of many European countries such as Germany, Holland, , Austria, and in addition to Israel, Japan, and . Making use of care insurance can be in the form of only services (Japan) in addition to care allowance (Austria, France) or both care allowance and service (Germany). In addition, private care insurance that individuals form using their own savings have started to take precedence in USA, France and Holland. CI is primarily based on decreasing the care burden on the family and providing support. The experiences in countries with CI have put forth that the decreased informal care (care provided to family members) has strengthened again and that families have once again tended more to care for their elderlies (Oğlak, 2014: 221-222).

One of the most important problems in elderly care services is elderly care staff. The need for care of elderlies resulted in an increase in the demand for professional and semi-professional care staff. However, there are problems in the education and employment of care staff in line with these developments. In this regard, care insurance has also resulted in an increase in the demand for professional and semi-professional care staff. However, there are problems in care staff education and employment in accordance with these developments. Thus, significant results have also been obtained with care insurance for the education of professional and semi-professional care staff, providing employment and opportunities for being active for longer periods of time in the professional world, provision of quality care services, sustainability, protecting and improving the quality of life of individuals (Oğlak, 2014: 222).

When compared with European Union member countries, Turkey has a young population structure which has recently tended to age. The change in the population structure is one of the most important factors with regard to reforms in social security systems and it has already started to take place in Turkey as well. Increase in life expectancy cannot always bring with it the sustainment of a quality of life worthy of people. Emergence of new risks or the increase in the probability of being subject to risks requires taking new precautions. Being destitute is one of the most important risks. Taking the necessary measures and providing the required support for people who have faced and who will face this risk is a necessity for being a social state (Hekimler, 2015: 71). 6

Significant changes have occurred in the family structure as well as the social structure in Turkey. Family structures where two or even three generations lived under the same roof have started to disintegrate and in this scope a transformation to the nuclear family structure has taken place. The nuclear family structure that is dominant in cities has also started to appear in rural areas as well. Even though this disintegration process has not increased in pace as it has done in European countries, it seems as if it will continue (Hekimler, 2015: 71-72).

Care services for the elderly as well as the disabled and children are carried out informally. The dimension that this informality has reached becomes even more different when we take into consideration that these services are also provided by illegal foreigners with no work permit. Demands for the establishment of a care insurance has increased recently in Turkey due to various reasons.

One of the most important problems in case an obligatory care insurance system is established in Turkey will be the financing of the system. The German experience shows that labor costs should not be increased and the competitiveness of establishments should be preserved. Since labor costs are quite high in Turkey, it will be suitable to keep the premium payments at acceptable levels and to project state subsidies when an obligatory care insurance system is established. At first, the focus should be on eliminating the state of being destitute at the minimum level when establishing the system. When the concept of being destitute is defined, it should be kept in mind that not all patients or disabled people are destitute, however that all destitute people are either ill or disabled (Hekimler, 2015: 72-73).

In addition to the increase in the elderly population, changes in the social structure also increase the risk of being destitute as well as the need for care. In line with the tendency in the world, the family structure in Turkey is being transformed from a traditional expanded family to a nuclear family. As a result, when elderly people do not live in the same house with their adult children, there is a decrease in people providing care for them. The increase in female employment also leads to the same result. Hence, there is a decrease in the capacity of potential caregivers when the risk of being destitute emerges (Caniklioğlu and Ünal, 2011: 2284).

Being destitute is tried to be taken into protection within the scope of social assistances and social services in the Turkish Legal system. However, it is not possible to say that this protection is sufficient. Assistances provided in Turkey without social contribution are insufficient both in terms of amount as well as the type of the assistances and the rights gained (Caniklioğlu and Ünal, 2011: 2284-2285).

Arrangements related with social assistance as well as taking destitute individuals under protection have been included within the scope of Law numbered 2022 on Attribution of Allowance for Turkish Citizens 65 Years and Older Who Are Destitute, Need Assistance and Alone. Social assistance have been arranged for the elderly with this law which have been related not with the risk of being destitute but directly with being elderly. People who are aged 65 and older may earn the right for this allowance within the scope of this law when they fulfill the required conditions even if they are not destitute. The law lacks an additional protection for elderly people who are destitute. Because the concept of being destitute requires additional payments apart from those required for the elderly (Caniklioğlu and Ünal, 2011: 2285-2286).

Law numbered 2022 also includes regulations for taking the risk of being destitute under protection. However, the regulations related with this issue do not cover everyone but only a certain group. This protection covers only destitute disabled individuals and takes place only in the form of a monthly allowance for the destitute disabled. Earning the right for this monthly allowance is based on strict 7 conditions. Hence, these individuals also experience difficulties in benefiting from this protection (Caniklioğlu and Ünal, 2011: 2285-2286).

Elderly Care Policies in Turkey

It is observed that significant developments have taken place regarding the solution of health and social care problems in developed countries that have been faced with the aging of their population for many years. The emergence of the need for elderly care as well as problems related with this care have brought with them discussions on the establishment of a care security. It is difficult to say that national and comprehensive care policies have been established in Turkey for the aging population. That is why, anxieties continue to increase regarding risks of facing more complex and more costly problems related with the elderly in case the planning and strategies for care policies are not made on time in this period when Turkey is entering a rapid aging process (Oğlak, 2014: 222-223).

The rapid changes that have taken place in the social structure of Turkey in recent years has increased need of the elderly for traditional family and familial relations as well as state support and professional services. Retirement homes are very common in Turkey as a “Corporate Care Model” that meets the accommodation, resting and basic needs of elderly individuals who experience difficulties in continuing their lives by themselves. However, elderly people consider retirement homes as unfavorable places that distance themselves from loved ones and their living environments causing individuals to be alone (Oğlak, 2011: 120).

Today, it is thought that services that enable elderly individuals to continue their lives under specially arranged conditions in their own environments that ease their lives are better solutions. Even though regulations and applications based on society based care are included more in recent years as part of the social security system in Turkey rather than applications based on institution based care model; the facts that they have not been fully included in the social security system and that they have not reached people in need of these applications are considered as significant deficiencies (Oğlak, 2011: 120-121).

In the light of these findings, being destitute was defined within the scope of the Law on Disabled which was revised and went into effect in 2006 as a result of which elderly chronic patients were also included in this classification. Monthly care allowance was started to be given for the first time in Turkey to family members who take care of destitute disabled and elderly individuals with this regulation that was arranged within the scope of this law. However, the allowance that is given only to family members taking care of economically and socially destitute individuals is given within the scope of social assistance services and does not cover all destitute individuals. Even in this form, it has provided a significant income support to family individuals who experience care problems. The Ministry of Family and Social Policies continues working on putting into effect the care insurance of the General Directorate of Services for Disabled and Elderly that covers everyone regardless of their level of income (Oğlak, 2014: 223).

Policies for the elderly have been included in almost all plans under the heading of both social security and social services within the scope of the planned development efforts that started in Turkey in 1963. However, it is observed that topics of institutional care (retirement home, nursing home) have been the points of focus for all these plans and that issues of strengthening and supporting the family in elderly care have started to be the center of attention after the 2000’s. In 1983, Social Services and Child Protection Institution (SHÇEK) that was founded with the law numbered 2828 has carried out its tasks of putting forth systematic and programmed services for meeting the demands of groups with special demands (family, children, disabled, destitute elderly and other people), preventing and resolving various problems as well as enhancing standards of living. Starting from the year 2011, 8 issues related with social services and policies for the elderly have been assigned to the Ministry of Family and Social Policies (ASPB) General Directorate of Services for Disabled and Elderly (Oğlak, 2014: 223-224).

There are different service models in Turkey depending on the physical, mental and cognitive states of the elderly individuals. These are retirement homes and elderly care and rehabilitation centers. Whereas accommodation and care services are provided under the same roof in some institutions, some provide only a single type of service. The total capacity of the 125 institutions that are active as part of the ASPB General Directorate of Services for Disabled and Elderly is 12.744. Of these institutions, 17 are retirement homes, 4 are retirement homes and rehabilitation centers, 23 are special care centers, 7 are elderly care and rehabilitation centers (ASPB, 2014; Yıldırım and Şahin, 2015: 65).

The government makes payments to public and private care centers for home care that will be provided depending upon the need to elderly individuals who are determined to be socially destitute and in need of care within the scope of Regulation on the Identification of Persons with Disabilities who are in Need of Care and on the Determination of the Needs for Care Services that went into effect in 2007. Care allowance at the level of minimum wage was started to be paid to caregiving family member within the scope of this regulation in order to encourage the home care of the elderly individual by family members. Whereas the number of family members in need of care was 30.638 in 2007, this number increased to 408.165 in 2013 (Oğlak, 2014: 227-228).

It is difficult to say that elderly care policies are developed at the desired level in Turkey. An important reason for this is that the ratio of elderly individuals in the total population is still low and that the family still carries out its primary function regarding the care provided to the elderly individuals. However, events that had an impact on the social and familial structure such as the greater participation of women in labor force as a result of industrialization and urbanization, decrease in birth rates, migrations to big cities, extended family has transformed into the nuclear family (68.6%) and even divided family structure has reached a significant percentage (21.2%).

On the other hand, the facts that elderly individuals have remained outside the local migration process along with the increase in the ratio of people living alone have had significant effects on the families playing the primary role in the care and protection of elderly individuals. However, it is an important finding that despite all these changes, the traditional responsibility of the family related with the care of the elderly individuals is still present (Oğlak, 2014: 224).

The relative decrease in the role of the family increases the need for professional and semi- professional care staff in addition to traditional family and kindred relations. However, it is observed in recent years that the government is changing the elderly care policies to support the role of the family related with the care. This is actually preferable both socially and economically and family care is tried to be made more attractive in all developing and developed countries (Oğlak, 2014: 224- 225).

Services and assistances provided in Turkey within the scope of the related legal legislations by the Ministry of Family and Social Policies (ASPB) cover elderly and disabled individuals within their scope similar to France along with corporate and home care within the framework of service provision. In addition, some municipalities also provide home care services through their own measures (Bal, 2016: 187).

The changes that occurred in the social structure in Turkey have also changed the needs of individuals for getting service outside of family members as well as expectations. These expectations have taken 9 place as corporate care services in addition to social care models that will ensure that elderly individuals spend their free times as good and efficiently as possible without being separated from social life, daily habits, friends, neighbors and relatives. (Oğlak, 2014: 225).

Municipalities and non-governmental organizations are other actors that play an important role in elderly care. There are decrees encouraging home care for the elderly individuals especially within the scope of Municipality Laws numbered 3030, 1580 and 5216. In addition, municipalities also carry out functions such as building retirement homes for the accommodation of destitute elderly individuals, provision of free physical examination and pharmaceuticals, food and fuel assistances. Whereas municipalities that have developed significantly with regard to economy and culture distribute food to the homes, provide cash assistances, pick up elderly individuals from their homes with an ambulance for the provision of health services in addition to organizing cinema, theater and travel tours. Non-governmental organizations also play important roles in the home care of elderly individuals. However, a cooperation has not been attained related with the services provided by the government, municipalities and non-governmental organizations (Oğlak, 2014: 228).

Services by the Ministry of Family and Social Policies Provided to Elderly Individuals

Based on the statutory decree numbered 663 on the Organization and Tasks of the Ministry of Family and Social Policies, General Directorate of Services for Disabled and Elderly has been established. The tasks of the General Directorate related with elderly individuals are as follows: • Coordinating works carried out to determine national policies and strategies related with social services for elderly individuals, putting these determined policies and strategies into effect, monitoring and evaluating their application. • Developing social service models provided to elderly individuals. • Establishing the mechanisms required to ensure that elderly individuals and destitute disabled individuals carry out their lives at their homes and without leaving their social environments, standardizing the already existing mechanisms, monitoring and inspecting their application. • Establishing mechanisms to ensure that elderly individuals are integrated with the society, can re- earn their status and roles in the society, increase their functions and use their free times effectively. • Determining the principles, methods and standards regarding the social care activities for disabled and elderly individuals provided by state institutions and organizations, volunteer organizations in addition to real and legal entities; ensuring that these methods and standards are used (Yıldırım and Şahin, 2015: 67).

Retirement Homes Social service establishments within the scope of the Ministry of Family and Social Policies that work to protect elderly individuals over the age of 60 in a peaceful environment and to meet the social and psychological needs of these individuals.

Elderly Care Centers These centers may also provide Home Care Services for enhancing the living environments of elderly individuals so that they can continue living in their own homes, ensuring that they can continue their daily living activities when the household remains insufficient by themselves or despite other supporting factors (neighbors, relatives) for the care of elderly individuals who enjoy good bodily and mental health, who do not require any medical care and who do not have any disabilities (ASPB, 2013: 15).

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However, it is stated for the following stages in the 1st Provisional Clause of the Social Service Centers Regulation dated 09.02.2013 and numbered 28554 as such, “Buildings of family consulting and society centers, daycare service centers for children in addition to youth centers and elderly service centers active at the time which are considered by the Ministry as appropriate for providing service as center buildings continue their services as social service centers without the need for any additional process. Otherwise, these locations are closed at most within a year following the date when the Regulation has went into effect. The services provided by the institutions that have been closed will be provided by the nearest social service center. Accordingly, elderly service centers were closed as of 2014 and their tasks were assigned to social service centers. However, it is observed that social service centers cannot carry out the tasks that were provided by the elderly service centers due to overload and lack of sufficient number of staff (Yıldırım and Şahin, 2015: 70-71)

Five Elderly Service Centers within the scope of the Ministry of Family and Social Policies are currently active based on membership and currently 1076 are benefiting from these centers. The private elderly service center in Istanbul has 15 members. Only elderly individuals with Alzheimer’s disease benefit from this private center (ASPB, 2013: 16).

Daycare Centers for Elderly Individuals with Alzheimer’s Disease They are centers established to eliminate the risks due to the Alzheimer patient elderly individuals living with their families staying alone at the house thus ensuring their safety, decrease the possible hostility of elderly individuals with Alzheimer’s disease by making them active with various activities, decreasing desperateness and guilt by cooperating with the families of these patients, preventing the overuse of retirement homes and nursing homes by directing the families to day care centers and to support the elderly individual as well as his/her family by providing day care for the Alzheimer patient.

Care Services

General Directorate of Services for Disabled and Elderly have been assigned responsible from the institutional care of disabled and elderly individuals with the Social Services Law numbered 2828. Within the framework of this responsibility, social services are provided via daycare and boarding institutions to individuals who are destitute, who need protection or care. Income level of destitute individuals is taken into consideration regarding the provision of care services at government or private care centers or their own places of residence.

Care services are classified into two types as institutional care or home care services. 27% of people who benefit from care services are aged 60 +.

Institutional Care Service It has been envisioned with the Law for Disabled number 5278 which went into effect on 07.07.2005 that institutional care services for the disabled shall be provided by real and legal entities who have received the required license from the Ministry of Family and Social Policies along with state institutions and organizations.

A payment worth two minimum wages including VAT is paid every month to the private care centers by the Ministry of Family and Social Policies for the services provided to the disabled individuals who receive these services (ASPB, 2013: 17).

Home Care Service Home care service option has been made available with the Law for Disabled numbered 5378. Accordingly, arrangements have been put into effect for the provision of quality and systematic care 11 services for destitute disabled individuals and rather than institutional care model, priority is given to the home care model which ensures that the individual does not leave his/her social and physical environment.

According to the provision of the law in this issue, the condition is that the income per person of the family where the disabled individual resides should be lower than 2/3rd of minimum wage and that the individual should have a report stating that his/her disability is 50 % + serious disability. Monthly home care allowance is paid to the person who is responsible from taking care of the disabled individual and who carries out his/her care actively.

According to the provisions of the regulation related with home care application; one month worth of minimum wage is paid every month as allowance by the General Directorate of Services for Disabled and Elderly (ASPB, 2013: 17-18).

Monthly Elderly Allowance Applications of the law numbered 2022 respecting the grant of allowances to Turkish citizens who are over the age of 65 and who are destitute, infirm and without any means of support have been ongoing since 1977. This policy sets an example for the Social State understanding.

Monthly allowances paid by the Ministry of Labor and Social Security, Directorate of Social Security Institution, General Directorate of Non-Contributory Payments within the scope of the Law numbered 2022 on Attribution of Allowance for Turkish Citizens 65 Years and Older Who Are Destitute, Need Assistance and Alone have been paid by the Ministry of Family and Social Policies since 2012 within the scope of the statutory decree numbered 633 (ASPB, 2013: 18).

Suggestions Related with Care Insurance

Care insurances should have three attributes in order to be successful. The first is that the protection provided by this insurance should cover everyone; the second is that there should be sufficient financial resources for LTC services and the third is that it should take into consideration the preference of the insured and that it should be flexible (Caniklioğlu and Ünal, 2011: 2292).

It is not sufficient to establish care insurance within Turkish Legal system, the real objective is to ensure that this insurance type is sustainable. Hence, it is important to focus on the financing of the care insurance. Premium payments that vary according to the age and income level can be suggested similar to the Japanese care insurance. In addition, the premium payments can be ascribed to the employer and the State instead of only on the insured individual. When we take into consideration that the provision of social security is the responsibility of not only the insured and the employee but also governments that have the attributes of social states, it is important that the State also contributes to these premium payments (Caniklioğlu and Ünal, 2011: 2293).

It will be better to prefer a mixed system in Turkey by including a certain contribution margin in case the service is used instead of financing the care insurance for LTC services by social security premiums or taxes. Private care insurance should also be suggested for LTC services (Oğlak, 2007: 106).

Individuals should have the right to choose when benefiting from the rights provided by the care insurance; however arrangements that encourage real assistances should also be included. Thus, the gender discrimination which emerges in the traditional Turkish family structure in the form of placing all care services on women will have been prevented. In addition, the possibilities of destitute 12 individuals being subject to violence and abuse by the family members will also be prevented. Since the care services will be provided by experts either at homes or at the institution, individuals will be able to leave the house and thus socialize (Caniklioğlu and Ünal, 2011: 2294).

Conclusion

LTC of elderly and disabled individuals is mostly provided at homes by the family members due to economic, social and cultural reasons and it is considered that providing this care is the basic task of the family. However, the care provided by the family has started to become insufficient as a result of the transformation in the family structure, the fact that women have become part of professional life and so institutional care services have started to come into effect.

The need for care personnel with the required knowledge and tools has increased as a result of various reasons such as the insufficiency of family members with regard to quality and quantity, increase in the demand for institutional care services and the increase in institutional service costs (Oğlak, 2008: 1127).

Even though home care is thought to be the primary choice in Turkey due to the insufficiency of institutional care as well as the demand due to cultural structure, it will be beneficial with regard to service quality in the long run to encourage institutional care in the medium and long term by taking into consideration the financing of the system (Bal, 2016: 192).

LTC services are aimed at ensuring that economically destitute elderly and disabled individuals who require care services for long period of times can carry out their daily activities. However, adults and young people who may be dependent on assistances may also require LTC services just like elderly people. In addition, being destitute is a risk that every individual might face regardless of their economic status. LTC services should be established within the internal dynamics of Turkey by evaluating these issues.

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References

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