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Trends and Challenges in Long-Term Care in Europe

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 ve 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 signicant impact on the
organization and nancial 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,
identied 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.
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 nancing 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 nancing varies highly be-
tween countries and a signicant 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 nancing or regulating the
sector (Rodrigues & Nies, 2013). In terms
of what is nanced 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
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-nancing arrangements and domestic
care is often not nanced 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 nanced 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 nancing means that cost sharing is
a signicant part of long-term care nancing
(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
benet 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.
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
United Kingdom
Czech Republic
United States
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019.
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 nancing, the levels of spending
and the extent of use of formal vs. informal
care. After such a classication, the authors
identied ve 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
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.
the Czech
Slovakia and
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.
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
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
Latvia, Malta,
Romania and
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.
Rev. soc. polit., god. 26, br. 1, str. 255-262, Zagreb 2019. Dokumenti
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 exible 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
identied, 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 nancial 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.
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 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 denition of informal care (Zigante, 2018). The most frequently used denition 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
11,7 17,8 22,4
15,5 16,7
65+ 80+
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, Trifantallou, 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 dened 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%).
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 nancial 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/certication 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
10 10 10 12 13 13 15 15 15 16 16 16 16 16 17 17 17 18 18 19 19 20 21 23
Czech Republic
United Kingdom
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.
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 enets,
allowances, specic 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).
This documentation highlights key
trends in long-term care in EU countries
which are trying to nd cost-effective us-
er-friendly solutions in this eld. 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
nancial 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 nancing
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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Filipovič Hrast, M., & Hlebec, V. (2015). Staranje
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The paper presents the results of the research on the needs of the older people for services from the social welfare system, which was conducted at social welfare centres. 3001 people from all Croatian regions or counties participated in the research. The research was conducted with the aim of determining the needs for services from the social welfare system, in order to improve the quality of life of the older people. The paper presents the socio-demographic characteristics of the surveyed older people, their marital status, number of household members, support provided by their children, sources of income, property and health status, functional status, rights exercised from the social welfare system and the need for missing services. Respondents feel that they need home help services the most, but there is also a significant interest in institutional accommodation services. There are differences in the needs for care services, depending on how big is the respondent’s place of living. The collected data represent the empirical basis for the social welfare system on the older people, aiming to serve as help in adoption of strategic documents that need to protect this vulnerable population. Key words: the older people, social welfare, needs, services
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Monografija Dolgotrajna oskrba – izziv in priložnost za boljši jutri je nastala v okviru Evalvacije pilotnih projektov s področja dolgotrajne oskrbe, ki smo jo v obdobju 2019- 2020 izvajali Inštitut RS za socialno varstvo, Univerza v Ljubljani, Fakulteta za družbene vede in Inštitut za ekonomska raziskovanja. Evalvacijo je v okviru evropskega kohezijskega projekta Model dolgotrajne oskrbe v skupnosti naročilo ministrstvo za zdravje, Direktorat za dolgotrajno oskrbo, z namenom priprave splošne ocene pilotnih projektov, s katerimi so pilotna okolja testirala nove metode, postopke, mehanizme in storitve na področju dolgotrajne oskrbe, in sicer s splošnim ciljem, da bi ugotovitve evalvacije pripomogle k oblikovanju boljših rešitev na področju dolgotrajne oskrbe in morebitnih projekcij prihodnjega sistema dolgotrajne oskrbe.
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A monograph, “Long-term care: A challenge and an opportunity for a better tomorrow,” was drafted as part of the “Evaluation of pilot projects in the field of long-term care,” which was carried out by the Social Protection Institute of the Republic of Slovenia, the Faculty of Social Sciences of the University of Ljubljana and the Institute for Economic Research in the 2019–2020 period. Within the European cohesion project, i.e. the Communitybased long-term care model, the evaluation was commissioned by the Long-Term Care Directorate of the Ministry of Health in order to prepare a general assessment of pilot projects with which the pilot environments could test new methods, procedures, mechanisms and services in the field of long-term care, while the key general objective is for the findings of the evaluation to help create better solutions regarding long-term care and possible projections of the future long-term care system.
Technical Report
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This Synthesis Report produced by the core team of the European Social Policy Network (ESPN) describes the national long-term care provisions in 35 European countries, with a focus on long-term care arrangements for the elderly (65 or over). It analyses the four main challenges which are common to all European countries: the access and adequacy of long-term care provision, the quality of formal home care as well as residential services, the employment of informal carers, and the financial sustainability of national long-term care systems. The report concludes that the 35 countries covered by the ESPN face and will continue to face significant long-term care system challenges and makes a series of recommendations to help overcome them.
Technical Report
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The path to deinstitutionalisation, the hallmark strategy of social and care services for individuals with limited autonomy, has been marked by idiosyncratic developments across European countries. The present Policy Brief capitalizes on this cross-country variability in order to draw lessons from experiences and strategies, which proved to be effective, and proposes a set of core principles for successful deinstitutionalisation. We build on a well-established typology of long-term care regimes and propose four case studies to exemplify the main barriers and drivers to deinstitutionalisation. Austria, the model country for the Standard care mix regime, illustrates the importance of developing strong support systems for informal carers and strengthening home-based care provision. At the same time, its limited success in reducing institutionalisation rates can be traced back to a stringent need to improve care integration. Sweden, typifying the Universal-Nordic regime, has made great strides towards deinstitutionalisation by promoting coordination between care providers and aligning incentives across care settings. However, the coverage and cost of services will soon become unsustainable unless appropriate support for family-based care is provided. Italy and the Czech Republic (representing the Family-based and respectively, the Transition regimes) represent situations where the rates of institutionalisation are relatively low and current policy is challenged to contain future growth. Both systems offer significant support to informal and family carers, but this historic over-reliance on household contributions to care is leading to a widening gap between supply and demand, which needs to be addressed through the strengthening of community-based services. The Policy Brief concludes with a discussion of the core principles for reaching a sustainable balance between different long-term care settings. Among them we emphasize the necessity to support the development of alternatives to residential care both in the family and in the community, the need to integrate and coordinate across settings and the importance of appreciating the complexity inherent to deinstitutionalisation - as no single policy measure, in isolation, is likely to be sufficient.
When Peter Townsend published his landmark study about long-stay institutional care in England and Wales 50 years ago, he could not help calling these institutions ‘The Last Refuge’ (Townsend, 1962). He was ‘both daunted and shocked’ by what he had seen and heard, from overcrowded dormitories ‘with ten or twenty iron-framed beds close together’ (p. 4). He noticed ‘isolated persons sitting alone in a wash-room, standing in a corridor and one looking out of a staircase window weeping silently’ and he found heavily restricted privacy together with authoritarian matrons in uniforms and inappropriate staffing (p. 5f.). A ‘revisiting study’ by Johnson et al. (2010) found that 37 out of the 173 care homes visited by Townsend in the late 1950s were still providing long-term care (LTC) for older people. Results for the 20 homes that were sampled for revisiting revealed that: (…) residential care for older people, insofar as it is now catering for an older and more infirm population has been transformed into a radically different instrument of social policy when compared to the 1950s (…) While the physical environment may have improved, we recorded many institutional features which appear to characterise the twenty-first century care home. These features reflect not only the changed function of residential care but also an increasing concern with risk and safety. (Johnson et al., 2010, p. 209f.)
In old age, reduction in physical function leads to loss of independence, the need for hospital and long-term nursing-home care, and premature death. We did a systematic review to assess the effectiveness of community-based complex interventions in preservation of physical function and independence in elderly people. We searched systematically for randomised controlled trials assessing community-based multifactorial interventions in elderly people (mean age at least 65 years) living at home with at least 6 months of follow-up. Outcomes studied were living at home, death, nursing-home and hospital admissions, falls, and physical function. We did a meta-analysis of the extracted data. We identified 89 trials including 97 984 people. Interventions reduced the risk of not living at home (relative risk [RR] 0.95, 95% CI 0.93-0.97). Interventions reduced nursing-home admissions (0.87, 0.83-0.90), but not death (1.00, 0.97-1.02). Risk of hospital admissions (0.94, 0.91-0.97) and falls (0.90, 0.86-0.95) were reduced, and physical function (standardised mean difference -0.08, -0.11 to -0.06) was better in the intervention groups than in other groups. Benefit for any specific type or intensity of intervention was not noted. In populations with increased death rates, interventions were associated with reduced nursing-home admission. Benefit in trials was particularly evident in studies started before 1993. Complex interventions can help elderly people to live safely and independently, and could be tailored to meet individuals' needs and preferences.
Compa r ing ca re regimes in Eu rope
  • F Bet T Io
  • J Pla Ntenga
Bet t io, F., & Pla ntenga, J. (2 0 0 4). Compa r ing ca re regimes in Eu rope. Feminist Economics, 10(1), 85-113. https://doi. org/10.1080/1354570042000198245
Adequate social protection for long-term care needs in an ageing society
European Commission. (2014). Adequate social protection for long-term care needs in an ageing society. Brussels: European Commission.
Directorate-General for Economic and Financial Affairs
European Commission, Directorate-General for Economic and Financial Affairs. (2018). The 2018 Ageing Report, Economic & Budgetary projections for the 28 EU Member States (2016-2070). Brussels: European Commission.
Joint Report in Health Care and Long-Term Care Systems and Fiscal Sustainability and its country reports
European Commission, Directorate-General for Economic and Financial Affairs, & Economic Policy Committee. (2016). Joint Report in Health Care and Long-Term Care Systems and Fiscal Sustainability and its country reports. Brussels: European Commission.