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255
D O K U M E N T I
INTRODUCTION
The 21st century is a century of older
people; the society is becoming long-lived.
We a re wi tne ssi ng r ema rkab le d emograph ic
changes; people are healthier, have higher
quality of life and consequently live longer,
which results in important social conse-
quences at the individual level, as well as
at the level of families and countries (see
Filipovič Hrast & Hlebec, 2015). In the
next five decades, according to the latest
demographic projections of Eurostat, the
structure of the population will change rad-
ically. The proportion of the oldest Europe-
ans (80 years and over) is expected to rise
from 5% in 2016 to 13% in 2070, while the
old-age dependency ratio of older people
will almost double in this period. Europe
is expected to increase public expenditure
on long-term care from 1.6% to 2.7% of
GDP (European Commission, 2018). These
trends will have a significant impact on the
organization and financial sustainability of
long-term care systems. We can expect an
increase in the proportion of people who
will need long-term care and a decrease in
the proportion of those giving care, both
formal and informal.
How national systems of long-term
care are organized across Europe and what
challenges are ahead is well described
and analysed in a recent study on national
policies in different European countries
(35) prepared by the European Commis-
sion (Spasova et al., 2018). In the paper,
we present main challenges and trends,
identified by the mentioned study as those
common to many of European countries:
interinstitutional and geographical frag-
mentation of long-term care provision,
trends toward prioritizing home care and
a high incidence and expansion of infor-
mal care.
FRAGMENTATION OF LONG-
TERM CARE PROVISION
In a number of European countries,
long-term care has evolved from social as-
sistance schemes, rather than from health
care systems. Therefore, means-testing
and out-of-pocket payments are present at
varying degrees in all countries, contrib-
uting to quite a varied picture in terms of
the financing mix of care (state, family or
market) (Rodrigues & Nies, 2013). Long-
te rm ca re is typical ly f unde d from d iffe rent
sources like general taxation, obligatory
social security, voluntary private insur-
ance or out-of-pocket payments (European
Commission, 2014). The extent of public
and private financing varies highly be-
tween countries and a significant share is
still paid out of pocket by users (European
Commission, 2016). Partially because of its
roots in social assistance, the governance
of long-term care is much more decen-
tralized and fragmented, with regional or
local levels of government playing a much
greater role in financing or regulating the
sector (Rodrigues & Nies, 2013). In terms
of what is financed publicly, this basically
differs according to the type of service and
where the service is delivered. There are
three types of services, which are relevant
Trends and challenges in long-term
care in Europe
UDK: 616-082(4)
doi: 10.3935/rsp.v26i2.1655
256
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019. Dokumenti
here1: nursing care, domestic care, board,
and lodging in institutional care (European
Commission, 2016).
Nursing care is mostly covered under
health-financing arrangements and domestic
care is often not financed publicly (but public
coverage may be offered based on means test-
ing), except in the countries that offer com-
prehensive long-term care (the Netherlands,
Sweden). Board and lodging costs for the re-
cipients of ca re i n long-te rm c are institutions
are mostly financed publicly for low-income
pe ople e lig ible to t argete d assista nce (m ostly
means tested). As board and lodging costs
are a high cost component of long-term care,
private financing means that cost sharing is
a significant part of long-term care financing
(European Commission, 2016).
Expenditure on long-term care in terms
of GDP has been increasing over the past
20 years in many European countries and
is nowa day s qu ite het ero geneous. Curre ntly,
Nordic and Continental countries are among
the leaders in the expenditure in long-term
care, while Eastern European countries score
the lowest val ues (Spa sova e t al., 2018). Tota l
public spending on long-ter m care (including
both the health and social care components)
accounted for 1.7% of GDP on average across
OECD countries in 2015 (see Figure 1). At
3.7% of GDP, the highest spender was the
Netherlands, where public expenditure on
long-term care was around double the OECD
average. At the other end of the scale, Hunga-
ry, Estonia, Poland, Israel and Latvia allocat-
ed less than 0.5% of their GDP to the public
provision of long-term care (OECD, 2017).
Universal systems tend to be more generous
in principle and thus devote a bigger share of
their GDP to publicly funded long-term care
(e.g. Sweden, Denmark, and the Netherlands)
(Rodrigues & Nies, 2013).
1 Otherwise, long-term care can be provided in-kind, as an allowance paid to the family carer or as a cash
benefit for the care recipient. In-kind services can be nursing or ADL services (like domestic care) provided
at home, can consist of services which can also have a respite function for he carer, such as day care, and fur-
thermore can include institutional care provision such as in nursing home and palliative care (Colombo, Lle-
na-Nozal, Mercier & Tjadens, 2011).
Figure 1
Long-term care expenditure (health and social components) by government and compulsory insurance
schemes, as a share of GDP (2015 or nearest year)
Note: Retrieved from OECD Health Statistics 2017.
3,7
3,2
2,5 2,5 2,3 2,2 21,8 1,7 1,7 1,7 1,5 1,4 1,3 1,3 1,3 1,2 1,2
0,9 0,8 0,8 0,7 0,5 0,5 0,4 0,4 0,4 0,2 0,2
0
0,5
1
1,5
2
2,5
3
3,5
4
Nethelands
Sweden
Denmark
Norway
Belgium
Finland
Japan
Iceland
France
Switzerland
OECD15
United Kingdom
Ireland
Czech Republic
Germany
Luxembourg
Austria
Canada
Slovenia
Korea
Spain
Italy
Portugal
United States
Latvia
Israel
Poland
Estonia
Hungary
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019.
257
Dokumenti
We can also observe a horizontal divide
between health and social aspects of long-
term care provision. The health system is
responsible for the care provided by health
professionals (i.e. nursing care), while social
sector usually organizes services related to
suppo rting the ca re -dep end ent per son in th e
activities of daily living (i.e. domestic care).
Few countries organize their system in a
way which integrates health and social care
horizontally (e.g. Denmark, Ireland and
Poland). In most countries, this horizontal
split between the health and social sectors
is accompanied by a vertical division of re-
sponsibilities, with powers attributed at dif-
ferent institutional levels: national, regional
and local. Such a horizontal division may
lead to a lack of coordination between enti-
ties, which can have adverse effects for the
recipient: e.g. waiting periods, administra-
tive procedures, fragmentation of services,
and a high risk of non-take up (Spasova et
al., 2018).
Anyway, the complexity of long-term
care systems and the diversity between
countries can be illustrated by groups and
types of countries that are similar in terms
of their characteristics. There are several
different typologies of long-term care sys-
tems (see Bettio & Plantenga, 2004; Kraus
et al., 2010; Colombo et al., 2011; Nies,
Leichsenring & Mak, 2013). The typology
developed by the European Commission
(2016) presented below is an extension of
the typology by Kraus et al. (2010). It in-
cludes the following three dimensions: the
mode of financing, the levels of spending
and the extent of use of formal vs. informal
care. After such a classification, the authors
identified five typical groups of countries
(European Commission, 2016). The char-
acteristics of these groups are outlined in
the Table 1.
Table 1
Typology of long-term care systems (European
Commission, 2016)
Group of
countries Characteristics of the group
Denmark, the
Netherlands
and Sweden
Finance public provision of
long-term care by general
revenue allocations to local
authorities, have high public
and low private spending on
formal care, offer modest cash
benefits and have low use and
high informal care support.
Belgium,
the Czech
Republic,
Germany,
Slovakia and
Luxembourg
Provide for an obligatory
social insurance against long-
term care risks financed from
contributions. Their system
is characterized by medium
public and low private formal
care spending, high use and
high informal care support,
and modest cash benefits.
Austria,
England,
Finland,
France,
Slovenia, Spain
and Ireland
Have medium public coverage
against long-term care risks
financed from contributions
or general revenue. They are
medium spenders in terms of
public and private formal care
financing, have a high use of
and support for informal care,
and high to moderate cash
benefits.
Hungar y, Italy,
Greece, Poland
and Portugal
Provide modest social
insurance against long-
term care risks. They are low
spenders in terms of public
and high spenders in terms of
private formal care financing.
The use of informal care is
high, while support is relatively
low, as is the use of cash
benefits.
Bulgaria,
Cyprus,
Estonia,
Lithuania,
Latvia, Malta,
Romania and
Croatia
Have little social insurance
against long-term care risks
and correspondingly low
public spending on formal
care. The use is high and there
is little to no informal care
support. In addition, cash
benefits are modest/low.
Note: Retrieved from European Commission, 2016,
p. 172-174.
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Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019. Dokumenti
PRIORITIZING HOME CARE
Given a choice between care in an insti-
tution (in a residential setting) or at home,
most people would prefer the latter (Euro-
pean Commission, 2007). The Principle 18
of the European Pillar of Social Rights on
long term care states that “Everyone has
the right to affordable long-term care ser-
vices of good quality, in particular home-
care and community-based services.” Ex-
pectations about the possibilities of aging
at home have grown with a strengthened
role of community care, notions of care
coordination and possibly integration of
care delivery, the technological innova-
tions for distant monitoring, and with
modern, more complex forms of service
delivery available in person’s home. The
growing demand for (home) care services
already exceeds the available supply, and
this trend is expected to continue in the
following decades. This trend is explained
by aforementioned demographic changes
(aging population, dependency ratios), but
also by social changes (female labour mar-
ket participation, smaller family units),
changes in epidemiology, increase in sci-
ence and technical innovations, changes
in people’s expectations and wishes, and
policy priorities (deinstitutionalization,
community-based solutions) (Tarricone &
Tsouros 2008).
The majority of EU countries (i.e.
Austria, Germany, Denmark, Spain, Fin-
land, France, Norway, Sweden, Slovenia
and others (Spasova et al., 2018)) are pri-
oritizing home care in their policy docu-
ments and national strategies, by pursu-
ing the concept of “ageing in place.” The
arguments to strengthening community
care are focused on the people’s quality of
life and protection of fundamental human
rights (Ilinca, Leichsenring & Rodrigues,
2015). The focus on delivering care is
transforming, shifting towards a per-
son-centred care and highlighting the dig-
nity, autonomy, values and choice of the
people. Services therefore need to change
in order to be more flexible in meeting
people’s needs.
Deinstitutionalisation and community
living are generally accepted as princi-
ples that support policy making. A grow-
ing body of literature suggests that com-
munity-based interventions lead to better
outcomes for users at lower or compara-
ble costs (Tarricone & Tsouros, 2008).
Evidence suggests that older adults have
better health outcomes if appropriate pre-
ventative care is provided to them in the
community (Beswick et al., 2008). Alter-
natives to institutional care are therefore
emerging, in a form of different commu-
nity services, intermediate care, day care,
together with the initiative to support in-
formal carers, integrate care, and provide
prevention and rehabilitation. But, as re-
ported by Leichsenring, Billings & Nies
(2013), this process is slow. The evidence
of coordinating care around users can be
identified, but is often limited to individ-
ual short-term projects. Despite deinstitu-
tionalisation tendencies and clear policy
goals, in some cases economic reasons
and measures to ensure financial sustain-
ability, especially austerity measures, steer
direct policies in another direction by ob-
structing access to care. This means that
eligibility criteria get stricter, and home
care focuses more towards persons with
the most severe needs, leaving heavy bur-
den to informal carers. Home care there-
fore remains underdeveloped in numerous
countries, especially in Southern and East-
ern Europe where only a limited number
of people in need can access it. All Nordic
and some Continental countries (the Neth-
erlands, Germany, France, and Belgium)
are more successful in that area (Spasova
et al., 2018).
Across OECD countries, 13% of peo-
ple aged 65 or more on average received
long-term care in 2015. The percentage
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019.
259
Dokumenti
Figure 2
The share of people aged 65 or more / 80 or more, receiving home care across EU countries (2016 or
closest year)
Note: Retrieved from stats.oecd.org. No data for people aged 80 or older are available in France and Italy.
of recipients varies considerably among
countries, with only 2.1% in Portugal to
more than 20% in Switzerland (see Fig-
ure 2) (OECD, 2017). The percentage of
community care recipients corresponds
with service availability; it is the highest
in Nordic and some Continental countries.
People aged over 80 make up on average
more than half of all recipients (OECD,
2017). In countries with available trend
data, we can observe a rise in the propor-
tion of long-term care recipients (65+) at
home in the past ten years, with the excep-
tion of Estonia and Finland (OECD, 2017).
2 There is no standard definition of informal care (Zigante, 2018). The most frequently used definition de-
scribes it as care provided by family members, friends or neighbours to a person who needs help and support at
home. The care they provide is lay and usually unpaid
3 According to EQLS research, an informal carer is someone who provides care at least once per week which
is, compared to other studies where this limit is usually set to 20 hours per week, a low threshold (Zigante, 2018).
11,6 5,7 6,5 6,0 9,5 9,3 5,8 8,7 0,8 6,5 7,1 10,9
34,0
11,7 17,8 22,4
14,2
28,8
1,6
15,5 16,7
29,7
0,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
80,0
90,0
100,0
Denmark
Estonia
Finland
France
Germany
Hungary
Italy
Netherlands
Portugal
Slovenia
Spain
Sweden
65+ 80+
HIGH INCIDENCE AND
EXPANSION OF INFORMAL
CARE
Numerous international studies and au-
thors illustrate informal care2 as the back-
bone or cornerstone of care (Huber, Ro-
drigues, Hoffmann, Gasior & Marin, 2009;
Naiditich, Trifantafillou, Di Santo, Carrete-
ro & Hirsch Durrett, 2013; Verbeek-Oudijk,
Woittiez, Eggink & Putman, 2014; Zigante,
2018). Estimates suggest that informal car-
ers provide around 80% of long-term care
(Hoffmann & Rodrigues, 2010) and that
informal carers account for between 10%
and 25% of the total population in Europe
(Colombo et a l., 2011). The pro portion s va ry
greatly across countries and depend on how
infor ma l ca re is defined and measured. This
strongly supports the most recent study on
informal care in Europe (Zigante, 2018),
where this diversity is shown using the latest
EQLS data3 (see Figure 3). The lowest per-
centage (around 10%) is detected in Roma-
nia, the Czech Republic, Austria, Bulgaria
and Ireland, and the highest (around 35%)
in Greece, followed by Belgium (around
30%) and Malta (around 25%).
260
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019. Dokumenti
Figure 3
Informal carers as a % of total adult population, EQLS 2016
Note: Retrieved from Zigante (2018), EQLS 2016.
rate of carers, their financial well-being and,
therefore, indirectly on their tax receipts.
Informal carers may have to reduce the
working hours at their workplace or stop
working altogether. This puts them at a
higher risk of poverty, often through the re-
duced work and lower pension entitlements
(European Commission, 2016).
Countries in EU set out a number of pol-
icies which recognize and to some extent
‘formalize’ the role of informal carers with
the aim of supporting carers and reducing
a potential negative impact that providing
care can have on them. This takes place
through payments (cash allowances, cash
for care policies), social security (pension
and health insurance), legislation (recog-
nition of status and rights to receive as-
sessment as a carer), statutory employment
related rights and training/certification of
skills schemes (Zigante, 2018).
Countries vary greatly in the extent to
which the informal carer is supported by
public policies, and as it is stated in the re-
port by Spasova et al. (2018), only a limited
99
10 10 10 12 13 13 15 15 15 16 16 16 16 16 17 17 17 18 18 19 19 20 21 23
26
30
34
0
5
10
15
20
25
30
35
40
Czech Republic
Romania
Austria
Bulgaria
Ireland
Sweden
Finland
Portugal
Cyprus
Estonia
Slovenia
France
Spain
Croatia
Denmark
Lithuania
Italy
Latvia
EU28
Netherlands
Hungary
United Kingdom
Slovakia
Poland
Luxembourg
Germany
Malta
Belgium
Greece
The main reason for the expansion
and high incidence of informal care is a
shortage of accessible formal long-term
care facilities. Other reasons include the
poor quality of long-term care (e.g. Ita-
ly, Macedonia, the United Kingdom), the
highly biased subsidization of long-term
care (Cyprus), the shortage of institutional
and community services (e.g. Croatia), the
non-affordability of long-term care (e.g. It-
aly, Macedonia), and the traditional model
of intergenerational and familial relations
(Spasova et al., 2018).
Despite cultural changes, new attitudes
and relative progress in the distribution of
caring tasks, women (mainly wives and
children) continue to take responsibility for
and carry out the bulk of caring (Spasova et
al., 2018). EQLS research shows that in all
countries (expect in two) more women than
men provide care. The gender gap in car-
ing is especially visible in Belgium where
13% more women than men provide care
(Zigante, 2018). The time spent caring can
have a negative impact on the employment
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019.
261
Dokumenti
number of countries have well-developed
services tailored to informal carers. In this
sense, the recommendation is to continue
the support to informal carers for providing
ca re t hrough featur es such as cash b enefits,
allowances, specific rights, respite leave,
counselling and information, and at the
same time to minimize any disincentives
for their labour market participation (Eu-
ropean Commission, 2016). The support
and enabling of informal carers should be
recognized as a key policy goal in relation
to long-term care in Europe in the coming
decades (Zigante, 2018).
CONCLUSION
This documentation highlights key
trends in long-term care in EU countries
which are trying to find cost-effective us-
er-friendly solutions in this field. Notwith-
standing that the organization, funding and
types of long-term care offered vary great-
ly among European countries, the policy
documents (European Commission, 2014;
European Commission, 2016; Spasova et
al., 2018) all very similarly identify main
elem ent s of a re spo nse to th is pr ess ing iss ue.
Policies are generally directed to assuring
financial sustainability, distancing from res-
idential care by strengthening community
care, care coordination and integration be-
tween health and social services, assuring
prevention, rehabilitation and re-enable-
ment, and to improving the status of infor-
mal carers as the backbone of long-term
care. Last but not least, it is important not
to discuss only the quantity and financing
of long-term care, but also its quality and
impact. This should have implication for the
protection of fundamental human rights and
dignity of people needing care. Care should
not be just about giving people whatever
they want, it should also be about empow-
ering them, improving their experience of
care, considering their values, desires, fam-
ily situations and lifestyles.
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Mag. Mateja Nagode,
Inštitut RS za socialno varstvo
Lea Lebar,
Inštitut RS za socialno varstvo