The main goals of the care reform were to improve access to services and raise their quality. Steps have certainly been taken in the right direction, but it is still too early for final conclusions, as too little time has passed since the reform came into effect, writes Martin Kukk.

One of the key issues the reform aimed to address — the availability of care services and the lack of places — developed over a long period and certainly cannot be solved in just a few years. Most local municipalities have not treated this area as a priority in recent decades and have not invested in creating new care capacity.

The balance between demand and supply for care services can be addressed in only two ways: by developing alternative social services (such as home care) or by creating new care home places.

Based on Südamekodud’s experience, establishing new care home places takes around three to four years from decision to opening. In recent years, we have added nearly 400 new places and have made decisions to create over 300 more. According to the Ministry of Social Affairs, 940 new service recipients were added in Estonia in 2024, 80% of whom gained access thanks to the care reform.

The Price Increase Was Built Into the Care Reform

The reform’s second key goal — to make care home places more affordable by allocating additional state funding to municipalities — has largely been achieved. Before the reform, the average personal contribution to the cost of a care home place was around 80%; now it is about 50%.

At the same time, the price increase in the sector was inevitable. In addition to general inflation, the rise in care service prices was mainly driven by the significant increase in labour costs prompted by the reform.

Another goal of the care reform was to use additional state budget funding to require municipalities and care institutions to create new positions and hire additional staff. In other words, the law stipulates that by July 2026, the number of care workers per resident must be increased.

The state’s goal to ensure better, more person-centred and higher-quality services by requiring care homes to hire and train more staff meant that all care homes began recruiting additional employees as early as 2023. As a result, by 2026 the round-the-clock care sector will need around a thousand additional workers, and Südamekodud across Estonia will hire about a hundred new care staff.

This has already led and will continue to lead to the desired improvement in service quality, but unfortunately also to rising service prices and significant pressure on wages. For example, Südamekodud’s labour costs are expected to increase by around 40 % between 2023 and 2025, taking into account new positions and salary increases. It can be said that the price increase was essentially built into the care reform from the start.

Municipalities Struggle to Develop Home Care Services

Round-the-clock care is an expensive service, as it provides a home-like environment, care, medical support, and opportunities for physical and mental activity.

The National Audit Office is right — the situation is challenging, as demand exceeds supply. To balance this, additional investment in care homes must be complemented by a wider range of social services provided by municipalities. In implementing the care reform, the focus should increasingly shift toward developing home care services.

The advantages of home care hardly need explaining. Living at home is every elderly person’s natural wish and should be the first solution when care needs increase. For the state and municipalities, it can also in many cases be a more affordable option than round-the-clock institutional care.

However, in Estonia, it is still almost impossible to access home care services. There has been no unified funding model, and municipalities have often lacked the time, resources, competence, or motivation to develop such services.

Even when home services are not available, people in need usually remain at home as long as possible, seeking a care home place only as a last resort. Thanks to the reform, some people who had previously lived at home — such as the elderly with mental health issues, complex health conditions, or dementia — have found a place in care homes and can now continue their lives with dignity. However, there are still those who, because of or despite the reform, lack access to services.

Südamekodud has twice tried to launch home care services, but without success. Our attempts ended with feedback from municipalities that post-reform resources are still tied up in assessing people’s care needs and directing them to general care services. Municipalities simply do not have the capacity to develop home care at the moment.

Demand for home care services is growing in society, and to ease the pressure, municipalities would be wise to prioritise the development of such services — they require shorter planning horizons and lower capital costs than building a new care home.