COMMISSION STAFF WORKING DOCUMENT Accompanying the document Commission proposal for a Council Recommendation on access to affordable high-quality long-term care
Date: 2022-09-07
Institutions: Directorate-General for Employment, Social Affairs and Inclusion, European Commission
Subjects: care for the elderly, care of people with disabilities, home care, home help, long-term care, population ageing, service occupation, social facilities, social rights, working conditions

EN 

  EN 

   EUROPEAN COMMISSION  Brussels, 7.9.2022  SWD(2022) 441 final  COMMISSION STAFF WORKING DOCUMENT   Accompanying the document Commission proposal for a Council Recommendation on access to affordable high-quality long-term care {COM(2022) 441 final}  
 
 
Table of Contents 

1. 

Introduction ................................................................................................................ 1 

2.  Context of the initiative ............................................................................................. 2 

2.1.  Demographic trends ......................................................................................... 3 

2.2.  Social and labour market trends ..................................................................... 5 

2.3.  The digital transition ........................................................................................ 7 

3.  State of play of long-term care – challenges in Member States ............................. 8 

3.1.  Organisation and financing of long-term care ............................................... 8 
3.1.1.  Organisation of long-term care systems ........................................................... 8 
3.1.2.  Public expenditure on long-term care ............................................................. 10 
3.1.3.  Financing long-term care ................................................................................ 12 

3.2.  Social protection for long-term care ............................................................. 15 
3.2.1.  Eligibility for social protection for long-term care ......................................... 16 
3.2.2.  Coverage of social protection for long-term care ........................................... 16 
3.2.3.  Adequacy of social protection for long-term care .......................................... 19 

3.3.  Availability and accessibility of long-term care ........................................... 22 
3.3.1.  Availability of long-term care services ........................................................... 22 
3.3.2.  Accessibility of long-term care services ......................................................... 24 

3.4.  Quality of long-term care ............................................................................... 24 
3.4.1.  Defining the quality of long-term care ........................................................... 25 
3.4.2.  Quality assurance in long-term care ............................................................... 26 
3.4.3.  Drivers of quality ............................................................................................ 28 

3.5.  Long-term care workforce and informal carers .......................................... 28 
3.5.1.  The long-term care workforce ........................................................................ 29 
3.5.2.  Untapped job creation potential and labour shortages in the sector ............... 30 
Informal carers ................................................................................................ 32 
3.5.3. 

3.6.  Impact of COVID-19 on long-term care systems ........................................ 34 

4.  Current Union support and the case for reinforced action at EU level .............. 38 

4.1.  EU initiatives relevant to long-term care ..................................................... 38 

4.2.  EU analytical work ......................................................................................... 43 

4.3.  The social Open Method of Coordination .................................................... 44 

4.4.  The European Semester ................................................................................. 45 

4.5.  Funding opportunities at EU level ................................................................ 46 
4.5.1.  Structural funds ............................................................................................... 46 
4.5.2.  The European Agricultural Fund for Rural Development .............................. 48 
4.5.3.  The Just Transition Fund ................................................................................ 48 
4.5.4.  EASI social innovation projects on long-term care ........................................ 48 
4.5.5.  Technical Support Instrument ......................................................................... 49 

 
 
4.5.6.  The Recovery and Resilience Facility ............................................................ 49 
4.5.7.  Horizon Europe ............................................................................................... 51 
4.5.8.  Digital Europe ................................................................................................. 51 

4.6.  Why and how the EU should act now ........................................................... 51 

5.  Policy options for addressing the challenges of long-term care ........................... 52 

5.1.  Social protection for long-term care ............................................................. 52 
5.1.1.  Providing adequate social protection for long-term care ................................ 53 
Illustrating the impact of improving social protection for long-term care ...... 57 
5.1.2. 

5.2.  Availability of long-term care ........................................................................ 62 
5.2.1.  Expanding long-term care services ................................................................. 62 
Illustrating the impact of expanding the availability of home care ................ 65 
5.2.2. 
Increasing access to long-term care via digitalisation .................................... 66 
5.2.3. 
5.2.4.  Strengthening the accessibility of long-term care ........................................... 70 

5.3.  Quality of long-term care ............................................................................... 71 
5.3.1.  Long-term care quality framework ................................................................. 71 
5.3.2.  Long-term care quality principles ................................................................... 73 
5.3.3.  Long-term care quality assurance ................................................................... 76 
5.3.4.  Drivers of quality improvement ...................................................................... 78 
5.3.5.  Quality of informal care .................................................................................. 79 

5.4.  Long-term care workforce and informal carers .......................................... 79 
5.4.1.  Attracting a skilled long-term care workforce ................................................ 79 
5.4.2.  Tapping into the potential of digitalisation ..................................................... 85 
5.4.3.  Measures to support informal carers ............................................................... 86 

5.5.  Long-term care governance and funding ..................................................... 89 
5.5.1.  Sound policy governance in long-term care ................................................... 89 
Investing in long-term care ............................................................................. 91 
5.5.2. 

6.  Conclusion ................................................................................................................. 93 

Annex 1  Key Definitions .............................................................................................. 94 

Annex 2  Quality assurance bodies and responsibilites ............................................. 97 

 
 
 
 
 
 
 
List of figures 

Figure 1: Share of people aged 65+ living in private households with a severe level of difficulty with 

personal care or household activities ....................................................................................... 4 
Figure 2: Expected median share of people 65 years and older by degree of urbanisation..................... 5 
Figure 3: Public spending on long-term care as % of GDP, current and projections ............................ 11 
Figure 4: Share of expenditure by financing schemes for the health component of long-term care 

expenditure ............................................................................................................................. 15 
Figure 5: Share of potential dependants aged 65+ who receive public care or cash benefits ............... 18 
Figure 6: Out-of-pocket costs of home care as a share of income (after public support), for care 

recipients with a median income and with no net wealth, by severity level .......................... 20 

Figure 7: Share of the old age population that would be at risk of poverty after paying for the out-of-

pocket costs of home care for moderate needs ...................................................................... 22 
Figure 8: Main reasons for not using (more) professional home care services ..................................... 24 
Figure 9: Number of (full-time equivalent) long-term care workers per 100 people aged 65+, 2019 .. 30 
Figure 10: Share of population 18-74 providing informal care, by gender ........................................... 33 
Figure 11: ESF Investment priorities and operations (2014-2020) ....................................................... 47 
Figure 12: Simulated out-of-pocket costs of care, as a share of disposable income after public support, 
averaged across respondents who take up formal care services under policy scenario 1 ...... 59 
Figure 13: Simulated out-of-pocket costs of care, as a share of disposable income after public support, 
averaged across respondents who take up formal care services under policy scenario 2 ...... 60 
Figure 14: Dimensions of quality of life (The Netherlands) ................................................................. 73 

List of tables 

Table 1: Overview of EU-27 average outcomes, at baseline and under different policy scenarios ...... 61 
Table 2: The potential of digital technologies in improving access to long-term care .......................... 68 
Table 3: The potential of digital technologies in improving the quality of long-term care ................... 70 
Table 4: Potential drivers of quality improvement ................................................................................ 78 
Table 5: The potential of digitalisation to support the workforce ......................................................... 85 

 
 
 
 
 
1.  INTRODUCTION  

‘For nights on end [during the pandemic], we all stood at our windows and doors to applaud 
critical workers.  We felt how much we relied on all those women and men who work for 
lower wages, fewer protections and less security. The applause may have faded away, but 
the  strength  of  feeling  cannot.  This  is  why  the  implementation  of  the  European  Pillar  of 
Social  Rights  is  so  important  –  to  ensure  decent  jobs,  fairer  working  conditions,  better 
healthcare and better balance in people's lives. […] 

We will  come forward  with a new European  care  strategy to  support men and women in 
finding the best care and the best life balance for them.’  

President Ursula von der Leyen, 2021 State of the Union speech1 

In her 2021 State of the Union speech, Commission President Ursula von der Leyen announced 
a European care strategy to support both carers and care receivers, from childcare to long-term 
care (LTC). The strategy sets out a holistic and lifelong vision for care that enables everyone to 
access  and  afford  the  high-quality  care  they  need.  It  also  aims  to  help  improve  working 
conditions  in  the  care  sector,  close  the  gender  employment  gap,  increase  women’s 
empowerment, and make the most of the benefits of the ‘silver economy’ and digitalisation.  

The initiative will support the implementation of the European Pillar of Social Rights2, notably 
principle 18 that states that  ‘Everyone has the right  to  affordable  long-term care services of 
good  quality,  in  particular  home  care  and  community-based  services’.  It  follows  up  on  the 
European Pillar of Social Rights action plan, the gender equality strategy3, and the Green Paper 
on Ageing4, which highlighted the need for integrated and person-centred long-term care that 
is accessible, affordable and of high quality. It also respects the United Nations Convention on 
the Rights of Persons with Disabilities5, which recognises the equal right of all persons with 
disabilities to live independently in the community, with choices equal to others. 

The  preparatory  work  for  the  initiative  built  on  the  2021  Joint  Report  on  Long-Term  Care 
prepared by the Social Protection Committee (SPC) and the Commission (Directorate-General 
for Employment, Social Affairs and Inclusion). This report analysed the common challenges in 
related to the provision  of  long-term  care  and set  out  key messages on the way  forward.  In 
addition,  several  studies  (e.g.  Social  protection  in  long-term  care  (by  the  OECD))  and  EU 
publications  (e.g.  long-term  care  workforce  (by  Eurofound))  as  well  as  European  statistics 
provide the analytical underpinning for this staff working document. A range of collaborative 
processes  in  the  context  of  the  European  Semester  process  and  the  social  Open  Method  of 
Coordination  enriched  the  knowledge  base  for  the  initiative.  To  complement  this  input,  the 

1 European Commission, 2021, State of the Union Address by President von der Leyen.  
2 Commission (COM/2021/102 final), The European Pillar of Social Rights Action Plan. 
3 Commission (COM/2020/152 final), A Union of Equality: Gender Equality Strategy 2020-2025. 
4 Commission (COM/2021/50 final), Green Paper on Ageing.  
5 UN, 2006, Convention on the Rights of Persons with Disabilities. 

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Commission  published  a  call  for  evidence  and  a  targeted  stakeholder  consultation  between 
February  and  April  2022.6 The  initiative  consists  of  a  Commission  Communication  on  the 
European care strategy7, a Commission proposal for a Council Recommendation on access to 
affordable  high-quality  long-term  care 8 ,  and  a  Commission  proposal  for  a  Council 
Recommendation on  the revision of the Barcelona targets on early childhood education  and 
care 9 .  On  long-term  care,  the  aim  is  to  address  the  common  challenges  and  structural 
weaknesses10 that  were highlighted by the COVID-19 pandemic. To do so,  the Commission 
sets out a framework for policy reform  to ensure better and more affordable access to high-
quality long-term care services and improve working conditions in the sector.  

This  staff  working  document  provides  the  analysis  and  evidence  underpinning  the 
Commission’s proposal for a Council Recommendation on long-term care. It also illustrates the 
policy narrative  on long-term  care  as formulated  in  the Commission  Communication on the 
European care strategy. For the purposes of this document, long-term care means a range of 
services  and  assistance  for  people  who,  as  a  result  of  mental  and/or  physical  frailty  and/or 
disability over an extended period of time, depend on help with daily living activities and/or 
are in need of some permanent nursing care. The daily living activities for which help is needed 
may be the self-care activities that a person must perform every day (Activities of Daily Living, 
such as bathing, dressing, eating, getting in and out of bed or a chair, moving around, using the 
toilet, and controlling bladder and bowel  functions) or may be related to  independent  living 
(Instrumental Activities of Daily Living, such as preparing meals, managing money, shopping 
for groceries or personal items, performing light or heavy housework, and using a telephone)11. 

Following the introduction, chapter 2 gives the wider socio-economic and political context of 
the initiative. Chapter 3 summarises the common challenges of long-term care at Member State 
level and the status quo underpinning the initiative. Chapter 4 describes the current support and 
initiatives available at EU level. Chapter 5 identifies different policy scenarios and practical 
examples of policy responses to address the common challenges of long-term care. 

2.  CONTEXT OF THE INITIATIVE 

Care is one of the foundations of a social Europe. Policy developments in this regard are 
deeply  inter-linked  with  demographic,  social  and  labour  market  trends,  as  well  as  with  the 
digital  and  green  transition.  Against  the  background  of  population  ageing,  geographic 
mobility, increased share of single person households and increasing women participation on 
the  labour  market,  Member  States  are  confronted  with  significant  challenges  to  meet  the 

6 Commission staff working document (SWD/2022/440 final), Summary of consultation activities.  
7 Commission Communication (COM/2022/440 final), The European care strategy.  
8 Commission (COM/2022/441 final), Proposal for a Council Recommendation on access to affordable high-quality long-
term care.  
9 Commission (COM/2022/442 final), Proposal for a Council Recommendation on the Revision of the Barcelona Targets on 
early childhood education and care. 
10 Council (9144/21), Endorsement – Key conclusions on 2021 long-term care report of the Social Protection Committee and 
the European Commission.  
11 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and opportunities 
in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 

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increasing  demand  for  long-term  care.  The  COVID-19  pandemic  has  further  exposed  the 
structural weaknesses of long-term care systems.  

2.1.  Demographic trends 

Consistently  low  birth  rates  and  higher  life  expectancy  are  transforming  the  shape  of  the 
EU’s age pyramid. Europe is transitioning to a population structure with more older people, a 
development  which  is  already  apparent  in  several  EU  Member  States  today.  As  a  result  of 
demographic change, the proportion of people of working age in the EU is shrinking, while the 
relative number of those retired is expanding. In 2021, more than one fifth (20.8%) of the EU’s 
population was 65 years and over, while young people (0 to 14 years old) made up 15.1 % and 
people of working age 64.1%.12 The share of people aged 65-79 years and over is projected to 
increase by 23% over the next 30 years13, while the share of people aged 80 or over of the total 
population is projected to almost double.14 As a consequence, the old-age-dependency ratio15 
is projected to increase significantly from 32.5% in 2021 to 52.0% in 2050.16  

Despite progress in healthy life years, as well as in preventive approaches and use of digital 
technologies, the ageing of the population will lead to a growing need for long-term care. The 
prevalence of physical or mental disability, which increases with age, often leads to dependency 
on help with activities of daily living (ADLs) and/or instrumental activities of daily living 
(IADLs), thus corresponding to a need for long-term care. 

Although  there  is  no  single  internationally  accepted  and  standardised  definition  of  what 
constitutes  long-term care needs, Member States  usually take into account  the presence  and 
extent of difficulties with personal care (ADLs) and household activities (IADLs). Thus, data 
from the European Health Interview Survey (EHIS) can be a proxy for the number of people in 
need of long-term care.17  

On average, 26.6 % of people aged 65 or over  and 39.4% aged 75 or over  living in  private 
households were in need of long-term care, according to 2019 data for the EU-27.18 These self-
reported long-term care needs ranged from 11.6 % in Luxembourg to 56.5 % in Romania (see 
Figure  1).  In  the  first  (i.e.  lowest)  income  quintile,  35.9 %  were  in  need  of  long-term  care, 
compared with 17.2 % in the fifth income quintile across the EU-27.19 Comparing data for 2019 
and  2014  shows  that  self-reported  needs  for  long-term  care  among  people  aged  65  or  over 
slightly decreased from 27.2 % in 2014.  

12 Eurostat, 2022, Population Structure and Ageing.  
13 From 14.8% in 2021 to 18.2% in 2050. 
14 From 6.0 % in 2021 to 11.3% in 2050. The population aged 65+ is projected to be 30.3% in 2070, while the population 
aged 80+ is projected to be 13.2% of the total population.  
15 The number of people aged 65+ (the age when they are generally economically inactive) for every 100 of people of 
working age (15-64). 
16 Eurostat, 2022, Population Structure and Ageing.  
17 In line with the usual eligibility conditions of public schemes that define a minimum threshold for long-term care needs, it 
is common to focus on difficulties categorised as ‘severe’.  
18 A key limitation of this survey-based measure is, however, the fact that it only captures people living in private 
households, thus neglecting the very relevant group of long-term care users living in residential care settings. More 
information can be found here. 
19 EHIS, 2019, indicator hlth_ehis_tadli. 

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Figure 1: Share of people aged 65+ living in private households with a severe level of difficulty 
with personal care or household activities 

70%

60%

50%

40%

30%

20%

10%

0%

Women 65+

Men 65+

Total 65+

Source: EHIS wave 3, 2019, hlth_ehis_tadle. 

Across the EU, according to the projections20 from the 2021 Ageing Report21, the number of 
potential dependants of all ages, defined as people with a disability, is expected to rise from 
about 30.8 million in 2019 to 33.7 million in 2030 and 38.1 million in 2050, corresponding to 
an overall increase of 23.5%. In 2019, 17.0 million of those dependents (10.8 million women 
and 6.1 million men) were above 65 years old, a share of 55% of all dependants; however, this 
age group accounts for only 4% of the general population.22 Therefore, while acknowledging 
that people of all ages may require long-term care services, most of the statistical data in this 
document linked to long-term care concerns the group of older people 65 years and over.  

The demographic profiles of EU regions vary widely, notably between urban and rural areas, 
with  some  places  ageing  significantly  and  others  expanding  their  working  age  population. 
However,  the  demographic  projections  of  the  Atlas  of  Demography23 show  that  patterns  of 
ageing  do  not  necessarily  follow  the  urban-rural  classification  of  territories  (see  Figure  2). 
Although rural areas have a higher share of older adults, there is no clear-cut pattern where rural 
areas  would  be  ageing  faster.  The  population  is  ageing  faster  in  the  areas  affected  by 
depopulation, including in some small towns and cities. In rural areas, the share of older people 
is projected to increase from 19% in 2011 to 30% in 2050. During that same time period, the 
share of older people would proportionally even increase more in towns (from 17% to 29%) 

20 Ageing Working Group (AWG) reference scenario assumes that half of the expected gains in life expectancy are spent 
without disability (i.e. not demanding care). 
21 European Commission and Economic Policy Committee, 2021, The 2021 Ageing Report – Economic and budgetary 
projections for the EU Member States (2019-2070), Publications Office of the European Union, Luxembourg.  
22 As an underlying difficulty in the analysis of all aspects of long-term care is the limited availability of comparable data, a 
variety of data sources, including national and non-harmonised data, are used in this document. 
23 European Commission, 2022, Atlas of Demography, Interactive tool.  

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and cities (from 15% to 27%). Consequently, the difference between the share of older people 
in  rural  areas  and  in  cities  could  become  smaller  in  several  Member  States  over  the  next 
decades. 

Figure 2: Expected median share of people 65 years and older by degree of urbanisation 

Source: JRC Atlas of Demography 

2.2.  Social and labour market trends 

Old-age poverty or social exclusion slightly increased since the mid-2010s. Almost 20.2 % 
(18.1 million) of people aged 65 and above in the EU-27 in 2020 were at risk of poverty or 
social  exclusion,  while in  some  countries  the  share  is  much  higher.24 The  monetary  poverty 
risks25 among older people have slightly risen over the past three years, while severe material 
and  social  deprivation  has  continued  decreasing 26 .  Gender  inequalities  become  more 
pronounced  in  old  age.  In  the  EU-27,  the  gender  gap  in  old-age  poverty  is  larger  than  in 
working age, and more so among those aged 75 and above (almost 1.4 pps, i.e. 16.8% among 
men, 18.2%  among women)27. The  gender pension gap  caused by the aggregated impact  of 
labour market inequalities remains significant (27.7 % in 2020 among those aged 65-79) despite 
a slight decrease (from 31.9 % in 2016).28  

More older women than older men are in need of long-term care, while being less able to 
afford it. Women live longer than men29, and men tend to spend a greater proportion of their 

24 EU-SILC, 2020, Persons at risk of poverty or social exclusion (AROPE) by age and sex, ilc_peps01n. Please note that the 
AROPE indicator is flagged with break in series for EU-27, DK, DE, IE, FR, LU. 
25 EU-SILC, At-risk-of-poverty rate (AROP), ilc_li02. 
26 EU-SILC, Severe material and social deprivation rate, ilc_mdsd11. 
27 EU-SILC, 2020, Relative at risk of poverty gap by poverty threshold, ilc_li11. 
28 EU-SILC, 2020, Gender pension gap by age group, indicator ilc_pnp13. Please note that the indicator is flagged with break 
in series for EU-27, DK, DE, IE, FR, LU. 
29 Eurostat, 2020, Life expectancy at birth, indicator SDG_03_10, men 77.5 years and women 83.2 years in 2020. 

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somewhat shorter lives in good health.30 In addition, women have lower earnings (including 
pensions) across the EU and are exposed to a higher risk of poverty or social exclusion in all 
Member States. At the same time, older women31 are more likely to live alone and thus may 
not be able to rely on support from other household members.  

Old-age poverty and social exclusion also aggravate older people’s loneliness and isolation, 
affecting their well-being and social engagement. This is often linked to poor access to social 
care  and  healthcare,  transport  and  housing  services.  Loneliness  increases  the  likelihood  of 
admission to long-term care facilities and sometimes affects older people in need of long-term 
care, despite social activities, potential company with peers and the care provided.32 

Women are increasingly participating in the labour market – a positive development in the 
context  of  the  increasing  importance  of  equality  of  opportunities,  ageing  societies  and  a 
decreasing working-age population33. However, women also carry the bulk of informal caring 
activities  (and  almost  90  %  of  workers  in  the  formal  long-term  care  sector  are  women). 
Therefore, in 2020, 6.3 % of women aged 50-64 wanting to work did not seek employment 
due  to  caring  responsibilities,  compared  to  only  2.5  %  of  men  in  this  age  group.34 Informal 
carers play an important role in long-term care, as they provide an estimated 33-39 billion hours 
of  care  worth  around  2.7%  of  GDP  across  the  EU-27  (compared  to  public  long-term  care 
expenditure of 1.7% of GDP, see chapter 3).  

While older people were severely impacted by the COVID-19 crisis in general, the recovery 
on the labour market was more dynamic for older workers after the COVID-19 crisis than 
for the economy as a whole. After a dramatic contraction in 2020, the EU economy rebounded 
strongly in 2021 with an 1.4 pps increase of the employment rate after the earlier drop of 1 pps. 
Older workers aged 50-64 weathered the crisis better than average, as their employment rate 
only grew less fast, by 0.6 pps in 2020, than it did earlier during the 2010s (by a yearly 1.4-
2.2 pps).  As  a  result,  their  employment  rate  reached  60.5%  in  2021  against  46.6%  in  2012. 
Although the recovery was stronger for men than for women in this age group, employment 
rates of women grew more, by 37% over this period (vs 24% for men) reducing the gender 
employment gap from 14.2 pps to 12.7 pps. 

Changing and more diverse family structures and more individuals and couples remaining 
childless also lead to increased need for formal care services, as the traditional capacity of the 
family to provide informal care is decreasing. In 2020, 40 % of older women were living alone, 
double the share for men.35 While the total number of households rose by 7.2% between 2010 
and 2020, single adult households without children grew by 20.3% across the EU. Moreover, 
households  with  two  or  more  adults  not  being  a  couple  (e.g.  older  person  living  with  other 

30 Eurostat, 2020, Healthy life years at birth, indicator SDG_03_1, men 63.5 years; women 64.5 years in 2020.  
31 In 2019, 40 % of older women were living alone, double the share for men. See Eurostat, 4 in 10 women aged 65 or over 
live alone (press release of 23 June 2020).  
32 Casabianca, E. and Kovacic, M., 2022, Loneliness among older adults - A European perspective, JRC Policy brief. 
33 The employment rate of women increased from 60.7% in 2010 to 66.2 % in 2020 (Employment rate by sex, indicator 
SDG_08_30). 
34 EU-LFS, 2020, indicator, lfsa_igar. 
35 EU-LFS, 2020, indicator lfst_hhindws. 

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members of the family, economically independent roommates), decreased by 7.4 % over the 
2010-2020 period in the EU36.  

Increased  labour  market  participation  by  women,  who  are  the  majority  of  informal  carers, 
means  that  they  become  less  available  to  provide  long-term  care  to  others  in  their  social 
environment. While increasing retirement ages grant higher pensions and allow providing better 
support, they also keep people busy working for longer. Adequate and affordable formal long-
term care services and policies helping to reconcile paid employment with caring/familial 
responsibilities help meeting the rising demand for care and sustaining the growth in women’s 
labour  market  participation,  while  keeping  in  mind  work-life  balance  and  the  health  of  all 
involved. 

2.3.  The digital transition 

Digital  technologies,  especially  artificial  intelligence,  are  transforming  the  world  at  an 
unprecedented speed and present manifold opportunities. They have changed our societies 
and  our  economies  and  are  increasingly  changing  the  way  long-term  care  is  provided.  This 
includes  fostering  independent  living,  improving  access  to  high-quality  and  affordable  care, 
while  tapping  into  the  potential  of  the  Single  Market  and  facilitating  upscaling  of  digital 
solutions for the benefit of people in need of care and their caregivers. Effective deployment of 
new technologies may also boost the efficiency of  long-term  care expenditure. The way the 
digital transition impacts the care economy is documented in recent research. The global market 
for ICT solutions for healthcare monitoring in private homes was projected to grow from nearly 
EUR 11 billion in  2016 to  roughly  EUR 32  billion by  2021, while the European market  for 
robots and other devices assisting older people is estimated to be worth about EUR 13 million 
in 2016, with clear prospects for further growth37.  

The growth of the platform economy in the recent years brought forth the development of 
digital care platforms, such as in private household childcare or care for older people. The size 
of the EU platform economy in the domestic and home services sector has grown to an amount 
of  EUR 1.5  billion  in  2020  from  EUR 0.8  billion  in  201638,  and  is  expected  to  continue  to 
expand in size39. Digital labour platforms in the care sector provide a digital infrastructure to 
match supply and demand in the field of private household care. They provide a flexible and 
easily accessible way to access work in this field and facilitate access to care for consumers. 
Digital labour platforms can play an important part in formalising work in this sector40. 

36 Eurostat, 2021, Household composition statistics.  
37 Technopolis Group and Oxford Economics, 2018, The Silver Economy, study prepared for the European Commission DG 
Communications Networks, Content & Technology. 
38 PPMI, 2021, Study to support the impact assessment of an EU initiative on improving working conditions in platform 
work, p.81. 
39 Ibid. 
40 Ticona, J., and Mateescu, A., 2018, Trusted strangers: Carework platforms’ cultural entrepreneurship in the on-demand 
economy, New Media & Society, 20(11), 4384, 4385. 

7 

 
 
                                                 
3.  STATE OF PLAY OF LONG-TERM CARE – CHALLENGES IN 

MEMBER STATES 

Member States face similar challenges and structural weaknesses of care systems, which 
have been brought to the fore by the pandemic. The analysis in this chapter describes the 
status quo in Member States structured in five sub-sections: organisation and financing of long-
term care systems, social protection for long-term care, availability and accessibility of long-
term  care,  quality  of  long-term  care,  long-term  care  workforce  and  informal  carers. 
Subsequently, chapter 5 builds on these identified common challenges by showcasing examples 
and opportunities how to address them.  

3.1.  Organisation and financing of long-term care 

There are substantial differences across the EU in terms of how long-term care is funded, 
organised,  delivered  and  monitored.  Member  States  are  at  different  maturity  levels  with 
regard  to  long-term  care  policy  and  the  organisational  framework.  Some  Member  States 
currently  allocate  relatively  low  levels  of  expenditure  to  long-term  care,  which  might  be 
indicative of long-term care being a low policy priority or of a heavy reliance on informal care 
(sometimes expressed as a legal obligation for family members to take care of their dependent 
relatives). Few Member States have long responded to the need to address long-term care as an 
important social risk by mitigating individual needs either through universal or at least partial 
coverage and public support in cash or in-kind. In these countries, long-term care is integrated 
into social security systems (next to health, accident/disability, retirement and unemployment) 
and/or an important part of social assistance schemes.  

3.1.1.  Organisation of long-term care systems 

Long-term care is organised in an often complex system of services across health and social 
care  and  sometimes  other  types  of  support,  such  as  housing  and  local  activities  (e.g. 
volunteering). According to a recent report by the ESPN41, only 10 out of 27 Member States 
(AT, BE, DE, DK, ES, FI, FR, LU, NL, SE) have an ‘integrated’ public system, (i.e. having a 
dedicated public social protection branch for long-term care) while out of these 10 countries, at 
least  two  feature  either  not  totally  integrated  systems  (AT)  or  a  division  of  responsibilities 
among subnational levels (BE). The other 17 Member States42 have a public system usually 
split between social care/social assistance and healthcare and between authorities in charge of 
providing cash benefits and authorities in charge of providing in-kind services.  

There are differences in terms of the territorial level at which long-term care is organised. In 
most of the Member States (AT, DE, LU, NL, IE, MT, CY), the national level plays a pivotal 
role in the organisation of long-term care. Here, an important complementary role is played by 
local and regional authorities running services. Belgium, being a federal state, is a specific case 
where long-term care organisation has been mostly devolved to the regions (federated entities). 

41 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union.  
42 Recently, in May 2022, Estonia changed its legislation to introduce a definition of long-term care that includes healthcare 
services, care services and support services for everyday coping. 

8 

 
 
                                                 
In France, regional administrations implement national health policies defined centrally by the 
government, whereas the decentralised local authorities are responsible for social policy. In the 
Nordic  countries  (DK,  FI,  and  SE)  municipalities  are  in  charge  of  ensuring  an  integrated 
healthcare and social care long-term care system. In 15 Member States (BG, CZ, EE, EL, ES, 
HR,  IT,  LV,  LT, HU, PL, PT, RO, SI, SK),  long-term care organisation responsibilities are 
allocated to different layers of government depending on the type of provision (healthcare 
services, social care services, and cash allowances). 43  

This horizontal fragmentation between the healthcare and social care systems, as well as the 
vertical  fragmentation  between  the  national,  regional,  and  local  levels  implies  different 
organisational structures and conditions of services not only across, but also within different 
Member States. As a consequence, the comparability of administrative data are limited, and 
sometimes data are even not available at national level.  

Formal long-term care services are organised as home, community-based or residential care. 
Home  care  means  long-term  care  provided  in  the  recipient’s  private  home,  by  professional 
long-term care workers. Community-based care means long-term care provided and organised 
at  community  level,  for  example,  in  the  form  of  adult  day  services  or  respite  care  (semi-
residential care), meaning that people in need of long-term care continue to live in their private 
homes  but  receive  long-term  care  services  outside  of  their  home  in  a  building  within  their 
community. By comparison, residential care is provided to people staying in a residential long-
term care setting. In practice, these services are available in all Member States, alongside other 
in-kind contributions (e.g. house adaptations) or technological devices, but to a different extent. 
Home care is for example the main setting in a number of Member States (AT, CZ, DE, EE, 
EL,  FI,  IT,  SE),  while  in  others  (FR,  RO)  most  recipients  of  formal  care  are  cared  for  in  a 
residential care setting.44  

Long-term care services provided by the national and/ or local authorities and associations are 
primarily  considered  as  social  services  of  general  interest 45,  as  they  have  a  clear  social 
function:  facilitate  social  inclusion  and  safeguard  fundamental  rights  of  older  people; 
complement and support the role of families in caring for the oldest members of the society; 
provide assistance for people in permanent or temporal need etc. 

Member States provide long-term care services in-kind and via cash benefits. An important 
distinction  among  these  schemes  is  between  ‘bound’  cash  benefits  (beneficiaries  have  to 
document how the resources that they received are spent) or ‘unbound’ benefits (beneficiaries 
are free to use the resources as they prefer without any form of accountability). Most countries 
with cash benefits (12 out of 19) use ‘unbound’ cash benefits (AT, BE, BG, CY, CZ, DE, FI, 
HR, IT, PL, PT, SI). Only 7 (ES, FR, LT, LU, LV, NL, SK) use ‘bound’ ones. Schemes based 
on ‘bound’ cash benefits usually ensure coordination between the beneficiary and the long-

43 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union.  
44 KPMG, 2021, Study on the long-term care supply and market in EU Member States.  
45 Commission Communication (COM/2006/177 final), Implementing the Community Lisbon programme: Social services of 
general interest in the European Union.  

9 

 
 
                                                 
term care public system (in terms of social workers and health professionals’ supervision, and 
in  terms  of  integration  with  the  provision  of  long-term  care  services).  Schemes  based  on 
‘unbound’ cash benefits leave more freedom of choice and flexibility to beneficiaries, but 
they do not often foster coordination and there is less leverage for public intervention for quality 
assurance of the care received.46  

Across the EU, significant differences exist also in the market structure for long-term care 
services.  A  recent  study47 covering  16  Member  States48 showed  significant  changes  in  the 
supply structure with more market-based provision through private actors (both for-profit and 
non-profit) over the last three decades in the countries studied. The quantitative data from five 
countries  showed  a  trend  towards  privatisation  in  the  market,  with  an  increasing  number  of 
private for-profit and private non-profit providers – for example, in Italy (residential and semi-
residential care), Germany (residential, home, and semi-residential care), Romania (residential 
care), Belgium (residential care), and Ireland (residential care and homecare). Marketization 
and privatisation can affect different dimensions of long-term care, including the supply and 
affordability of care as well as the quality of care provided and working conditions for care 
workers. 

Whereas formal care provision was initially offered or organised mainly by public authorities, 
and sometimes also by non-profit institutions and organisations, in some Member States (e.g. 
SE) private for-profit institutions have developed as a result of policies to increase freedom of 
choice in long-term care provision. At the same time, for-profit providers have also emerged 
or increased their presence in other Member States, even in the absence of similar policies. 
Altogether, different forms of long-term care provision co-exist in the Member States: these 
include  public  providers,  private  providers  (both  for-profit  and  not-for-profit),  and  informal 
care providers – with the share of each of these forms differing widely across Member States. 
Also, the shares of residential care, community care, and home care in the long-term care market 
differ significantly between the Member States analysed.  

Long-term care stakeholders are manifold. They include people in need of long-term care, 
their  family  members  and  organisations  representing  them,  relevant  authorities  (national, 
regional, local), social partners, civil society organisations, social economy actors, providers of 
different long-term services (residential, home care, community-based care) and with various 
legal  status  (public,  private  for-profit,  private  non-profit),  as  well  as  bodies  responsible  for 
promoting  social  inclusion  and  integration  and  protection  of  fundamental  rights,  including 
national equality bodies. 

3.1.2.  Public expenditure on long-term care 

Population ageing will significantly increase demand for long-term care over the next decades. 
On average in the EU, public expenditure on long-term care is projected to increase from 
1.7 % of GDP in 2019 to 1.9 % in 2030 and 2.5 % of GDP in 2050, with marked variations 

46 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union. 
47 KPMG, 2021, Study on the long-term care supply and market in EU Member States.  
48 AT, BE, BG, CZ, DE, EE, EL, ES, FI, FR, IE, IT, NL, PL, RO, SE  

10 

 
 
                                                 
 
across the Member States (AWG reference scenario). The projections in this reference scenario 
are based on the assumption that there is no policy change in relation to the current long-term 
care systems in Member States and that half of the projected gains in life expectancy are spent 
without disability (i.e. not demanding care). Figure 3 shows the current (2019) public spending 
on long-term care as a share of GDP and corresponding projections for 2030 and 2050 based 
on the latest EU Ageing Report49.  

An alternative ‘risk scenario’ additionally assumes an extension of formal care in a number of 
Member States, implying a doubling of expenditure on average in the EU-27 by 2050. Building 
on the AWG reference scenario, the scenario is based on the additional assumption that the unit 
costs  of  long-term  care  and  the  social  protection  coverage  for  long-term  care  will  converge 
upwards  to  the  current  EU  average,  incorporating  the  effects  of  such  possible  key  policy 
changes. The increase in public expenditure on long-term care is therefore projected to be more 
pronounced with public long-term care expenditure increasing from 1.7 % in 2019 to 2.1 % in 
2030 and 3.3 % of GDP in 2050 for the EU-27 as a whole.  

Figure 3: Public spending on long-term care as % of GDP, current and projections 

Source: 2021 Ageing Report (European Commission and EPC, 2021); base data for 2019. 

Out of total current public long-term care expenditure in the EU-27 in 2019, 26 % went on cash 
benefits, 26 % on home care, and 48 % on -residential care, with marked variations from these 
averages across the Member States. Typically, the average cost of residential care per person is 
higher than in home care, but that is also influenced by the fact that the population in residential 
care has a greater degree of dependency.  

Higher levels of public long-term care expenditure also translate into better social protection 
coverage  for  long-term  care  and  access  to  long-term  care  services  in  general.  Nevertheless, 

49 European Commission and Economic Policy Committee, 2021, The 2021 Ageing Report – Economic and budgetary 
projections for the EU Member States (2019-2070), Publications Office of the European Union, Luxembourg.  

11 

 
 
 
                                                 
public  expenditure  needs  to  be  fiscally  sustainable  to  ensure  the  ability  of  a  government  to 
sustain its current spending, tax and other policies in the long run. Moreover, also the wider 
macroeconomic policies, such as fiscal, monetary and trade policies, shape long-term care in 
the  context  of  women’s  and  men’s  opportunities  in  paid  employment  and  the  resources 
available for policies aimed at reducing gender inequalities.  

3.1.3.  Financing long-term care 

Long-term  care  is  either  financed  by  public  expenditure,  which  can  be  tax-based  or  social 
insurance-based social protection, or via private expenditure, which includes compulsory and 
voluntary  private  insurance  schemes  and  out-of-pocket  payments.  However,  in  most  cases, 
long-term  care  is  financed  through  a  mix  of  public  and  private  sources.  Data  regarding  the 
financing sources of long-term care is only partial, as many Member States report expenditure 
on the category long-term care (health) in the System of Health Accounts50, but no data for the 
category  long-term  care  (social).  As  it  can  be  seen  in  Figure  4,  taxation  rather  than  social 
insurance  is  the  predominant  form  of  public  financing  of  long-term  care  in  the  EU  (for  12 
MS51), while a number of Member States mix social insurance schemes with tax-financing (10 
MS 52)  and  five  Member  States 53 use  predominantly  compulsory  social  contributions.  The 
specific design usually is grounded in the historical and institutional context of the Member 
State.  

Social  insurance  systems  are  financed  from  contributions,  generally  from  employees  and 
employers in the form of payroll taxes. A main advantage of social insurance-based systems is 
that funds are ear-marked for long-term care and the contributions give a person the entitlement 
to  receive  long-term  care  when  they  need  it,  thus  likely  increasing  residents’  willingness  to 
finance long-term care. With their contributions, the public expects clear eligibility criteria and 
a right to a level of benefits that is not means tested.54 At the same time, caps on the contribution 
basis  (income  thresholds  above  which  no  contributions  are  paid),  and  the  focus  on  labour 
income, limit the redistributive effects within cohorts and are sensitive to changes in the labour 
market and the wage share of national income. Childless contributors may be required to pay a 
top-up on their contribution rate (e.g. DE), thereby introducing redistributive effects between 
people with and without children. However, also social insurance systems incorporate either 
user charges or the benefit rates are not necessarily sufficient to fund the full care package a 
person requires.55 

50 The System of Health Accounts (SHA) 2011 is a statistical reference giving a comprehensive description of the financial 
flows in healthcare and long-term care. It provides a set of revised classifications of healthcare functions, providers of 
healthcare goods and services, and financing schemes. The SHA is currently used as a basis for joint data collection by 
OECD, Eurostat, and WHO on healthcare expenditure. 
51 AT, BG, CY, DK, ES, FI, HR, IE, IT, LV, RO, SE 
52 CZ, EE, FR, HU, LT, MT, PL, PT, SK, SI 
53 BE in the Flemish Federated entity, DE, EL, LU, NL 
54 Karagiannidou, M. and Wittenberg, R., 2022, Social Insurance for Long-term Care, LSE Care Policy and Evaluation 
Centre, forthcoming.  
55 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and opportunities 
in an ageing society, Volume I, Publications Office of the European Union, Luxembourg.  

12 

 
 
                                                 
In tax-financed systems, the costs of long-term care are met out of the general revenues from 
taxes  levied  on  a  national,  regional  or  local  level.  These  taxes  can  include  taxes  on  labour, 
consumption, capital, etc. and it is the discrete and flexible choice of governments how much 
funds  to  allocate  to  long-term  care.  The  broad  tax  base  is  often  cited  as  one  of  the  main 
advantages, as funding is not solely generated from labour income (wages) as is usually the 
case for social insurance, but also relies on capital income (e.g. capital gains), thus spreading 
the  cost  across  production  factors  and  mitigating  fluctuations  in  the  labour  market.  A  well-
diversified taxation system thus implies a lower cost on labour compared with insurance-based 
systems, supporting employment and growth.56  

It  can  be  distinguished  between  universal  tax-funded  systems  and  safety  net  tax-funded 
systems. Nordic countries (e.g. SE, DK, FI) are typical examples of universal tax-funded long-
term care systems with generous coverage and low out-of-pocket payments. Nordic long-term 
care  systems  are  usually  decentralised  and  municipalities  and  local  governments  have  some 
autonomy in determining the needs assessment and eligibility criteria and providing long-term 
care services. By contrast, safety net tax-funded systems provide long-term care services only 
based  on  assessment  of  care  needs  and  an  assessment  of  the  person’s  (and  sometimes  their 
family’s) income and assets. Thus, publicly funded long-term care is prioritised to those with 
the highest care needs and with less income and assets. The principle aim of the means-test is 
to  protect  those  individuals  who  would  otherwise  be  unable  to  pay  for  long-term  care 
themselves  and  would  have  unmet  needs  for  care.  However,  such  systems  may  result  in 
increasing unmet needs if the threshold is set to low that the lower middle class is not poor 
enough to be eligible but nevertheless struggle with care expenses.57  

Private long-term care insurance can take the form of either compulsory or voluntary schemes. 
Compulsory  private  insurance  exists  mainly  as  a  substitute  for  social  health  insurance  in 
countries where some population groups can opt out of public insurance if they obtain private 
coverage  instead  (e.g.  DE).  Voluntary  private  insurance  generally  complements  existing 
coverage from a publicly financed benefit package, but play only a limited role in a number of 
Member States (e.g. AT, DE, FR), except for Cyprus, where voluntary insurance schemes for 
long-term care account for 26.4 % of expenditure.  

Practically  all  EU  Member  States  apply  some  form  of  cost-sharing  or  fees.  The  very  few 
countries with safety net schemes that do not rely on fees, have high means testing thresholds 
that limit the beneficiaries’ access to the public long-term care system.  

Compared to the risk sharing approach of the other financing sources, out-of-pocket payments 
do not feature any pre-payment and funds are not pooled across the population. Figure 4 shows 
that the share of reported out-of-pocket payments for health-related long-term care expenditure 
ranges from 77 % in Bulgaria to 0.2 % in Czechia. The unweighted average of absolute out-of-
pocket health long-term care expenditure in the EU is equal to 0.1% of GDP. However, there 
are six EU countries where this value is equal to at least 0.3% of GDP (AT, DE, ET, FI, FR, 
MT). The OECD (section 3.2.3) analyses to what extent people in need of long-term care would 

56 Ibid. 
57 Karagiannidou, M. and Wittenberg, R., 2022, Social Insurance for Long-term Care, LSE Care Policy and Evaluation 
Centre, forthcoming. 

13 

 
 
                                                 
be able to pay the out-of-pocket costs of long-term care, as the costs of long-term care in many 
cases exceed a person’s income.  

The minor role voluntary private insurance schemes play in Europe may reflect the fact that the 
costs  of  voluntary  private  insurance  are  very  high,  while  it  usually  provides  only  limited 
coverage. Technical problems, largely in terms of information for both providers and potential 
buyers, suggest that the actuarial mechanism is not well suited to addressing risks associated 
with  developing  long-term  care  needs. 58  These  include  problems  of  adverse  selection,  in 
particular when people buy premiums later in life; and the fact that people may not adequately 
plan for the risk of long-term care in old age, leaving it too late to take out voluntary private 
insurance. At the same time, the existence of minimum provisions for long-term care via public 
funding may reduce incentives for people to invest in voluntary insurance. In addition, private 
long-term care insurance policies may be regressive in that the premiums may not be affordable 
to all across the income distribution. The premiums are typically based on a person’s age and 
risk profile rather than income (as is the case of social insurance), limiting redistributive effects. 
Because of inherent difficulties in calculating a premium that is reasonable based on what the 
long-term  expenditure  could  be  on  an  aggregate  level  in  30  years’  time,  voluntary  private 
insurance usually pays a monthly compensation for long-term care needs, rather than covering 
the full care costs. In addition, the capital requirements may become prohibitive for insurers 
when mortality and morbidity rates are taken into account in long-term care insurance in some 
markets.59 Nonetheless, as even the most generous public long-term care systems impose some 
degree of cost-sharing or fall short of covering all long-term care needs, there may be a role for 
voluntary private long-term care insurance in supplementing them.60  

58 Barr, N., 2010, Long-term Care: A Suitable Case for Social Insurance, Social Policy & Administration 44 (4), pp. 359-374.  
59 OECD, 2021, Public and Private Sector Relationships in Long-term Care and Healthcare Insurance. 
60 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and opportunities 
in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 

14 

 
 
                                                 
Figure 4: Share of expenditure by financing schemes for the health component of long-term care 
expenditure 

Source: Eurostat, SHA61 2019, hlth_sha11_hchf, data for long-term care (health). No information available forMalta and EU-
27; voluntary healthcare payment schemes for CZ, SK and SE; and rest of the world financing scheme for BE, BG, CY, CZ, 
ES, FI, FR, HR, IE, IT, LV, PT, RO, SE, SI, and SK (assumed as 0 in figure). 

3.2.  Social protection for long-term care 

Social  protection  coverage  is  an  important  factor  for  determining  the  affordability  of 
long-term  care  services  and  ultimately  access  to  long-term  care.  Although  all  Member 
States  offer  some  social  protection  coverage  for  long-term  care,  in  many  Member  States, 
financial constraints are the most important reason why households do not use (more)  home 
care services if needs are present (see Figure 8). The generosity of social protection can play a 
key role in addressing such financial risks. At the same time, long-term care is less developed 
in many countries than other social protection branches (e.g. pensions and healthcare). Social 
protection for long-term care needs is highly fragmented among different  branches of social 
protection, which are not always integrated with one another. In addition, public expenditure is 
often too limited to provide the services people would need. 

61 Government scheme: a healthcare-financing scheme whose characteristics are determined by law or by the government and 
where a separate budget is set for the programme and a government unit that has an overall responsibility for it; 
Compulsory contributory health-insurance scheme, and social health-insurance scheme: a financing arrangement to ensure 
access to healthcare for specific population groups through mandatory participation determined by law or by the government 
and eligibility based on the payment of health-insurance contributions by or on behalf of the individuals concerned; 
Compulsory private insurance scheme: a financing arrangement to ensure access to healthcare for specific population groups 
through mandatory participation determined by law or by the government and eligibility based upon the purchase of a health-
insurance policy; Voluntary health-insurance scheme: a scheme based upon the purchase of a health insurance policy, which 
is not made compulsory by government and where insurance premiums may be directly or indirectly subsidised by the 
government. 

15 

 
 
 
                                                 
3.2.1.  Eligibility for social protection for long-term care 

Individual needs assessments form the basis for the provision of long-term care benefits and 
usually take into account the presence and extent of difficulties with ADLs/IADLs, along with 
cognitive and/or other limitations. The common denominator for standardised assessments in 
Member States is the measurement of dependency on help with ADLs and IADLs, sometimes 
weighting needs differently in the final assessment. Several Member States (e.g. BE, HU, MT) 
use rather quantitative overall assessments based on the degree of need of an individual, using 
a scale of point values and calculating a final score. Similarly, Germany uses a qualitative and 
individual-based assessment tool, translating the outcomes into a points scheme leading to a 
measure of the grade of an individual’s self-reliance and abilities. For example, needs for self-
care  account  for  40 %  of  the  overall  assessment,  while  cognitive  and  communication  skills 
account  for  15 %.62 On  the  other  hand,  some  Member  States  (CZ,  EE,  FR,  LV)  use  more 
qualitative scales in assessing to what extent an individual is dependent or autonomous in daily 
activities. 63  Estonia  modified  legislation  in  May  2022  that  obliges  local  governments  to 
identify/assess the need for support for a person with a care burden and liberates second degree 
relatives from the requirement to provide maintenance. 

In relation to the way they define eligibility to long-term care social protection, EU countries 
differ as to whether they adopt a universalist approach (characterised by high social protection 
coverage for all residents, and universal publicly provided services and benefits) or a selectivist 
one  (characterised  by  targeting  or  customising  services  and  policies  for  particular  groups, 
usually safety net tax-funded systems). A ‘selectivist model is present in  10 Central-Eastern 
European and Southern European countries (BG, CY, EE, EL, HR, HU, PL, PT, RO, SI); in 
these  countries,  access  to  long-term  care  public  provision,  either  cash  benefits  or  in-kind 
services, is dependent not only on an assessment of care needs, but  also on financial means 
testing (usually based on income, and in some cases property, often including close relatives’ 
economic resources).64 

3.2.2.  Coverage of social protection for long-term care 

Member States provide long-term care services either in-kind or via cash benefits that enable 
the recipient to cover (part of) the costs of long-term care, or via a combination of both. In-kind 
services usually include home care or a place in residential care, but in some countries it may 
also cover other necessities such as adaptations of the home (e.g. lift) or technical devices (as 
part  of  home  care).  Cash  benefits  are  funds  that  recipients  can  use  to  purchase  services 
themselves, and are often used to compensate informal carers. Differences in the depth of social 
protection stem rather from the level of service coverage than from the different ways in which 
social  protection  is  provided.  In  some  (mostly  Nordic)  Member  States,  social  protection  is 
mostly delivered in the form of services (e.g. DK, FI, SE); in others, long-term care coverage 

62 Medizinischer Dienst der Krankenversicherung, 2021, Richtlinien des GKV-Spitzenverbandes zur Feststellung der 
Pflegebedürftigkeit.  
63 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and opportunities 
in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 
64 Ibid.  

16 

 
 
                                                 
is  predominantly  based  on  cash  benefits  (e.g.  AT,  CY,  IE,  IT,  RO);  and  in  yet  others, 
beneficiaries have a choice between cash benefits, in-kind services, or a combination of the two 
(e.g. DE)65.  

The large majority of EU countries also offer cash benefits for carers, either through specific 
ad hoc programmes (DK, EE, HU, IE, MT), or by allowing informal carers to receive the cash 
benefit allocated to individuals with long-term care needs.66 Figure 5 shows that the estimated 
number of potential dependants aged 65 or over receiving publicly provided or funded home 
care  varies  between  132 %  (NL)  and  3 %  (PT).  The  EU-27  average  stands  at  31 %. 67 By 
comparison,  the EU-27  average for publicly provided or funded residential care coverage is 
19 %, and for cash benefits is 46 %. The lowest rate of public residential care coverage is 0.2 % 
(EL), and the highest is more than 39 % (LT, NL) for potential dependants aged 65 or over. 
Although several Member States do not provide cash benefits to finance long-term care needs, 
in  Poland  nearly  184 %  of  potential  dependants  aged  65  or  over  receive  them.  The 
fragmentation  of  long-term  care  systems,  implying  different  organisational  structures  and 
conditions of services in different Member States, limits the comparability of corresponding 
administrative data (for instance, some Member States may focus more on specific care settings 
than others) and will lead to some double-counting if the coverage of the three different care 
settings is aggregated without adjustment68.69 

Some  Member  States  that  indicate  a  high  coverage  of  the  population  with  long-term  care 
benefits may only provide benefits at a low level and they may not be targeted specifically to 
people with long-term care needs. In the case of Poland, for example, a cash allowance is paid 
to  all  people  above  the  age  of  75  independently  of  their  disability  status.  Therefore,  it  is 
important to also consider the generosity of the long-term care benefits (see section 3.2.3).  

65 Spasova, S., Baeten, R., Coster, S., Ghahilani, D., Peña-Casas, R., Vanhercke, B., 2018, Challenges in long-term care in 
Europe. A study of national policies, European Social Policy Network (ESPN), Brussels: European Commission. 
66 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union. 
67 The high coverage rates, exceeding 100 %, for home care (DK, NL, SE) and cash benefits (PL) can be explained by the 
fact that, on the one hand, cash and in-kind benefits can be cumulative, and on the other hand, in these Member States, 
coverage for these types of care is provided in relation to non-severe limitations as well as severe limitations (whereas people 
with non-severe needs are not included in the reference group of potential dependants that is used to estimate the number of 
potential dependants). In the case of Poland, a cash allowance is paid to all people above age 75 independently of their 
disability status. This may also be the case for other Member States. For instance, in, Bulgaria, 85 % of the cash benefits are 
cash allowances paid on top of the disability pension to people with high degree of disability (90 % or more).  
68 For instance, it is possible in some Member States for the same recipient to receive both in-kind and cash benefits, and as 
the statistics on each type of care tend to be collected and managed separately by different public bodies or government 
departments, aggregation issues may exist.  
69 European Commission and Economic Policy Committee, 2021, The 2021 Ageing Report – Economic and budgetary 
projections for the EU Member States (2019-2070), Publications Office of the European Union, Luxembourg.  

17 

 
 
                                                 
Figure 5: Share of potential dependants aged 65+ who receive public care or cash benefits 

Note:  Coverage  rates  in  the  base  year  of  2019.  Coverage  estimated  as  ratio  between  recipients  aged  65+  and  potential 
dependants aged 65+. Recipient data provided by Member States. Coverage may be above 100 %, as the EU-SILC variable 
used to define dependency status focuses on (self-reported) ‘severe’ limitations only, whereas some social protection systems 
may  also provide  coverage  for less  severe  needs,  such  as people  who need  help  with  IADLs: this  biases  the  estimation of 
coverage upwards as it under-estimates the dependent population. In addition, adding the coverage across settings would in 
many cases yield coverage rates above 100 %, as some recipients may receive cash benefits and in-kind benefits at the same 
time.  The  population  of  potential  dependants  based  on  the  2015-2018  average  of  EU-SILC  data  on  ‘self-perceived  long-
standing limitation in activities because of health problems [for at least the last 6 months]’ is used and adjusted for the number 
of people living in residential homes. For Germany, coverage refers to the social insurance funds’ members only. 

Source: 2021 Ageing Report (European Commission and EPC, 2021), for potential dependants aged 65+. 

The European Social Policy Network (ESPN) analysed Member States’ long-term care systems 
and proposed an analytical framework with a typology of public long-term care models in 
the EU70. Interestingly, each model includes countries adopting different sources of funding. 
The choice of how to finance public long-term care systems seems almost independent from 
the choice of how much to spend and on which type of provision. The six identified models are: 

1.  A limited State intervention model: one third of all EU Member States falls under this 
category, which is characterised by a very low level of public expenditure on long-term 
care (on average 0.4% of GDP). The countries belonging to the cluster are exclusively 
either  Southern  European  (CY,  EL,  PT)  or  Central-Eastern  European  countries  (BG, 
EE, HR, HU, LV, RO). 

2.  A  mild  State  intervention  through  cash  benefits  model:  around  one  fifth  of  EU 
Member  States  belong  to  this  second  model,  where  public  expenditure  on  long-term 
care is higher than in the previous one (on average 0.8% of GDP), and almost half of 
this expenditure is channelled through cash benefits (46.0%); Spain and four Central-
Eastern European countries (LT, PL, SI, SK) belong to this cluster. 

70 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union.  

18 

 
 
 
                                                 
3.  A mild State intervention through services model: around one Member State out of 
ten belongs to this cluster, where countries invest more resources in long-term care than 
the previous models but still below the EU-27 average level; at the same time, funding 
goes essentially to home care and residential care services; (IE, LU, MT). 

4.  A strong State intervention through cash benefits model: Austria, Germany,  Italy 
and Czechia share a model where financial support for long-term care needs is relatively 
consistent (1.7% of GDP), and often takes the form of cash transfers. 

5.  A strong State intervention through services model: Belgium, France, and Finland 
spend a relatively high share of their GDP on long-term care policies (2.0% of GDP), 
using mostly services as a tool of provision. 

6.  A very strong State intervention through services model: two Nordic countries (DK 
and SE), together with the Netherlands, are part of this last group investing a very high 
share  of  public  resources  in  coverage  of  long-term  care  needs  (3.5%  of  GDP),  and 
mostly counting on in-kind provision in order to support individuals and households. 

ESPN analysis indicated that the limited State intervention model has the weakest performance: 
it provides the lowest coverage rate of long-term care needs and has a very high share of older 
people with severe activity limitation who are at risk of poverty and social exclusion. The model 
based on mild  State intervention through cash benefits  offers a higher coverage of potential 
beneficiaries than the previous model, but at the same time, being an older person with severe 
activity  limitation  is  still  a  strong  predictor  of  poverty  or  social  exclusion  compared  to  not 
having  activity limitation.  The mild  State intervention through services  and the strong State 
intervention through services models provide a high coverage of potential beneficiaries through 
services. At the same time, they help to strongly reduce the impact of activity limitation on the 
risk of poverty and social exclusion. The model based on strong State intervention through cash 
benefits covers a large part of potential beneficiaries, more often through cash transfers rather 
than through services. At the same time, it produces relatively good results in terms of reducing 
the risk of those with strong activity limitation being poor or socially excluded. The very strong 
state intervention through services model covers practically all potential beneficiaries, and can 
intervene and provide services also to individuals with medium-low levels of long-term care 
needs. At the same time, it helps to strongly reduce the impact of activity limitation on the risk 
of poverty and social exclusion. 

3.2.3.  Adequacy of social protection for long-term care 

To measure the depth of social protection for long-term care in old age and compare it across 
Member States, with the support of the European Commission, the OECD71 developed a set of 
eight typical cases of long-term care needs. The cases vary according to the types and severity 
of their needs, the professional services required, and the level of income and assets of older 
people in need of care. 

71 Cravo Oliveira Hashiguchi, T. and Llena-Nozal, A., 2021, The Effectiveness of Social Protection for Long-term Care in 
Old Age: Is social protection reducing the risk of poverty associated with care needs?, OECD Health Working Papers No 
117, OECD Publishing, Paris.  

19 

 
 
                                                 
The OECD analysis reveals that without social protection, the estimated total costs of long-term 
care  often  exceed  the  disposable  income  of  people  in  need  of  long-term  care  and  can  push 
individuals into poverty. Furthermore, it suggests that even after social protection, the out-of-
pocket costs for care can be very high especially for older people with severe long-term care 
needs receiving home care. It is assumed that all eligible people take up social protection for 
long-term care and that long-term care services are also available to them.72  

Across countries and subnational areas, out-of-pocket spending as share of income is lowest 
for low needs and highest for severe needs. Figure 6 shows that the out-of-pocket costs of 
home care for low and moderate needs are lower than the median income among older people 
in 19 countries or subnational areas. Out-of-pocket spending on home care generally represents 
less than 50% of the median income among older people with low needs, and in a majority of 
countries and subnational areas out-of-pocket costs are lower than disposable incomes. In seven 
countries or subnational areas (HU, South Tyrol in IT, FR, SI, HR, LV and Tallinn in EE) the 
out-of-pocket costs of home care for severe needs are higher than the income for an older person 
earning a median income. In these cases, care recipients may have to turn to family members, 
friends and others for financial support or informal care as a way to receive long-term care, or 
they will have unmet care needs.  

Figure 6: Out-of-pocket costs of home care as a share of income (after public support), for care 
recipients with a median income and with no net wealth, by severity level  

Source: OECD analyses based on the OECD long-term care social protection questionnaire, the OECD Income Distribution 
Database and the OECD Wealth Distribution Database 

72 In reality, determining current availability and uptake of public social protection for long-term care in old age in all 
Member States is challenging, given limited detailed data on the existence and geographical location of public social 
protection offices in Member States, and their capacity to handle requests for support (e.g. conduct needs assessments). Even 
then, assuming full availability of public social protection for long-term care, effective use also depends on availability of 
providers, whose availability and geographical distribution is also difficult to establish across all Member States. Finally, 
even if public social protection offices and providers are available, older people with long-term care needs may choose not to 
use the public sector, in which case they will not take up public formal long-term care services. 

20 

 
 
 
                                                 
It is important to consider whether existing social protection systems for long-term care could 
guarantee that no older person is at an increased risk of poverty due to developing long-
term care needs. While people may be able to pay for care, it is often that they cannot afford 
care without going below a certain level of income. This remaining income is needed to cover 
all other normal expenses of life, like housing, food, clothing, transport, etc. In a next step of 
the project, the theoretical typical cases were matched with responses from the SHARE and 
TILDA surveys (waves 7 and 3 respectively), thus estimating the size of the group that would 
fall into the different typical cases across the 20 Member States, and also making it possible to 
determinate their socio-economic characteristics.  

Whether social protection can prevent people from being at an increased risk of poverty due to 
developing long-term care needs, can be analysed by comparing the observed risk of poverty 
among older people with a hypothetical measure of the risk of poverty if all older people 
estimated to have long-term care needs received public support. This comparison gives an 
indication of the hypothetical  impact on poverty risks if  everyone  who is estimated to  have 
long-term care needs sought formal care and had access to public social protection. It should 
not  be seen as reflecting the actual impact  of  long-term care provided through public social 
protection systems on poverty rates in countries today, as many older people with long-term 
care needs do not receive formal care.  

Across  the  20  jurisdictions  assessed,  in  15  jurisdictions  a  majority  (50%  or  more)  of  older 
people with low needs would not be able to afford home care from their income alone without 
social protection (i.e. they would be at risk of poverty), in all 20 jurisdictions a majority with 
moderate or severe needs would be in this position for home care. If it were not for public social 
protection for long-term care in old age, the majority of older people in the EU jurisdictions 
analysed would thus not be able to pay the out-of-pocket costs of care from their incomes alone 
without  being  at  risk  of  poverty.  Even  with  social  protection,  the  estimated  share  of  people 
facing a relative risk of poverty in many EU jurisdictions is still higher for those with long-
term  care  needs  than  in  the  older  population  in  general.  Figure  7  shows  the  poverty  risk 
associated with long-term care for people with a median income and moderate needs. 73  

73 Conclusions are drawn on the assumption that the rules applicable in the jurisdictions considered would apply to the entire 
Member States concerned. 

21 

 
 
                                                 
Figure 7: Share of the old age population that would be at risk of poverty after paying for the 
out-of-pocket costs of home care for moderate needs 

Source: OECD analyses based on the OECD Long-Term Care social protection questionnaire, the OECD Income Distribution 
Database and the OECD Wealth Distribution Database 

3.3.  Availability and accessibility of long-term care 

Long-term  care  services  must  not  only  be  affordable,  but  also  available  and  accessible  for 
people in need of long-term care. However, the availability of formal long-term care services 
still differs greatly among Member States and the variety of long-term care options is often 
insufficient, despite formal long-term care becoming even more important in the future due to 
population ageing and changing family structures. More person-centred care options, such as 
home care and community-based care, have started to expand, though not evenly, across the 
EU. Furthermore, persons with disabilities, who represent a large proportion of those in need 
of long-term care, are also confronted with accessibility challenges. 

3.3.1.  Availability of long-term care services 

The  availability  of  long-term  care  refers  to  the  relationship  between  volume  and  types  of 
services and resources that are offered by the system and users’ needs. Already now the 
supply  of  formal  care  services  is  restricted  due  to  both  financial  constraints  and  workforce 
shortages. Within the formal provision, there is a diversity of models for the delivery of care 
services, combining to different extents home care, community-based care and residential 
care.  

Although home care services were used by on average 28.6 % of people aged 65 or over 
living in private households who needed long-term care (at least one severe difficulty in ADLs 
or IADLs), the share ranged from 4.7 % in Romania to 53.7 % in Belgium in 2019. Among the 
respective populations with long-term care needs, slightly more women than men used home 
care  services  (29.9 %  vs  25.7 %) 74.  The  use  of  home  care  services  is  also  influenced  by 

74 EHIS, 2019, indicator hlth_ehis_am7ta. 

22 

 
 
 
                                                 
household  composition.  Although  37.2 %  of  older  people  with  long-term  care  needs  living 
alone used home care, only 22.4 % of people living with others did so75. Furthermore, there 
was a regional dimension in the coverage by home care services.  In cities, 29.7 % of older 
people in need used home care services, compared with 28.7 % in towns and suburbs, and only 
26.4 % in rural areas76. Coverage by home care services fell slightly during 2014-2019, from 
29.8 % to 28.6 %77.  

Data on residential care infrastructure suggest very heterogeneous availability across the 
EU. The number of long-term care beds per 100 000 residents of all ages78 ranged from 27.4 in 
Bulgaria to 1378.4 in the Netherlands in 2019, underlining the fact that some Member States 
have  a  highly  developed  residential  long-term  care  sector  for  older  people.  In  some  other 
Member States, residential care facilities are historically underdeveloped, while in yet others 
the supply of residential care has been reduced as a result of deinstitutionalisation policies. But 
even when residential care infrastructure exists, it often operates at limited capacity due to staff 
shortages. In Austria, for example, thousands of long-term care beds in particular in more rural 
areas  cannot  be  filled  due  to  staff  shortages  and  relatives  report  difficulties  to  organise 
residential care for people in need.79  

Differences between countries in care provision and care use are also affected by institutional 
and  cultural  factors.  The  willingness  to  use  care,  particularly  institutional  is  influenced  by 
cultural reasons and attitudes. In southern and some eastern European countries, for example, 
family relationships are closer than in western or northern countries, social protection is not as 
well developed and an expectation towards being cared for by family is expressed.80  

People in need of care mainly do not use professional long-term care services because they are 
unaffordable or unavailable. Figure 8 shows that for 35.7% of households with a person in need 
of long-term care, the costs of the services where the main reason for not using (more of) 
them although they would require (more) assistance; 9.7% mentioned shortages in supply and 
2.1% cited quality concerns as main reasons across the EU-27. Besides, the lack of care services 
is more pronounced in towns and suburbs (12.3%) and rural areas (10.4%) compared to cities 
(7.4%). Also, in rural areas professional care is more often refused by the person needing them 
(5.9%) than in cities or in towns and suburbs (4.6%). If formal care services are not needed or 
refused by the person needing them, it is implying that the care tasks are taken over by informal 
carers or that people have an unmet need for care. In the 2019 data, 46.6% of people aged 65 
or over with severe difficulties in personal care or household activities reported that they had 
an unmet need for help in those activities. This lack of help was more pronounced for older 
women (47.7 %) than for older men (44.2 %)81, and for the lowest income quintile (51.2 %) 
compared with the highest (39.9 %).82  

75 EHIS, 2019, indicator hlth_ehis_am7th 
76 EHIS, 2019, special extraction for degree of urbanisation 
77 EHIS, 2019, indicator hlth_ehis_am7ta 
78 Eurostat, 2019, Long-term care beds in nursing and residential care facilities, indicator hlth_rs_bdsns. 
79 Thalhammer, A, 2021, Tausende Pflegebetten wegen fehlenden Personals gesperrt, DiePresse. (accessed on 7 June 2022)  
80 Spasova, S., Baeten, R., Coster, S., Ghahilani, D., Peña-Casas, R., Vanhercke, B., 2018, Challenges in long-term care in 
Europe. A study of national policies, European Social Policy Network (ESPN), Brussels: European Commission. 
81 EHIS, 2019, Indicator hlth_ehis_tadlh. The self-reported lack of help does not distinguish between formal or informal care.  
82 EHIS, 2019, Indicator hlth_ehis_tadlhi. 

23 

 
 
                                                 
Figure 8: Main reasons for not using (more) professional home care services 

Source: EU-SILC ad hoc module, 2016, ilc_ats15.83  

3.3.2.  Accessibility of long-term care services 

Accessibility to long-term care refers to the prevention and removal of barriers that people 
with disabilities face to participate and access such services on equal basis with others. It 
concerns the design of products/devices, services, and infrastructure so that they can be used 
by people with disabilities, regardless their age, on an equal basis with others. Accessibility 
concerns the buildings where the services are provided, the transport from home to the delivery 
place and the information and communication about the services.  

The lack or limited accessibility of long-term care services prevent people with disabilities from 
using long-term care services. Further, objective barriers and subjective motives can prevent 
people with disabilities from accessing long-term care. The geographical distance and travel 
costs  in  case  the  place  of  service  provision  is  not  the  care  user’s  home  may  be  prohibitive. 
Waiting time for the initial long-term care needs assessment by the competent authorities or 
between the initial contact between service provider and user and the date of actual service is 
also  an  element  that  can  limit  accessibility.  The  overly  complex  application  procedure  for 
benefits may be disproportionate with the time and ability of people in need of care to cope 
with this. Besides, people may lack awareness of, or have misperceptions about, eligibility or 
application procedures. Stigma as well as a desire to protect their privacy may play also a role. 
While  there  is  no  EU-wide  data  on  the  accessibility  of  long-term  care  services  in  the  EU, 
anecdotal evidence suggests that people with disabilities can face obstacles. 

3.4.  Quality of long-term care 

Member States employ a mix of policies and practices to improve the quality of long-term care, 
but long-term care quality standards and their assurance mechanisms are often weak. A 

83 Data for Denmark are not available. Long-term care services are mostly free of charge in Denmark. 

24 

 
 
 
                                                 
few have quality frameworks dedicated specifically to long-term care, setting out the quality 
principles  that  long-term  care  services  should  fulfil.  More  often,  minimum  standards  and 
requirements usually operate through registration and accreditation processes. Among different 
approaches, the person-centred model, based on the needs and preferences of the person in need 
of care, seems to be gaining attention. Quality of care is also affected by factors that include 
workforce, organisation (e.g. integration of services to cater for complex needs), technology, 
and funding. The efforts to ensure quality are mixed and mainly focus on residential care, thus 
more attention is needed also on home and community-based care. 

3.4.1.  Defining the quality of long-term care  

For people receiving long-term care, its quality is critically important, and in some cases can 
be the difference between life and death. For society as a whole, the quality of long-term care 
services, determines its ability to uphold fundamental rights and dignity. Quality long-term care 
can  improve  as  much  as  possible  and/or  prevent  the  deterioration  of  physical  and  mental 
condition of people in need of care, enable their independent living and personal well-being, 
safeguard  their  dignity  and  protect  them  from  harm  and  abuse.  Better  quality  care  can  help 
avoid unnecessary hospital or residential care admissions or can slow down the deterioration of 
physical condition, thus potentially alleviating the pressure on resources. 

There is no common definition of long-term care quality at the EU level, but breaking down the 
concept of quality into a number of principles helps to build a more comprehensive picture and 
to better target policy tools. The principles of the voluntary European Quality Framework for 
Social Services agreed in 201084 apply to long-term care services, in particular the principles 
of  prevention,  respect,  person-centredness,  comprehensiveness,  continuity  and  transparency 
(see section 5.3.2 for more on quality principles). 

As quality is multifaceted, it is difficult to define indicators to measure and monitor it. One way 
to operationalise the concept is by looking at the structure, process and outcomes85. ‘Structure’ 
refers to inputs and resources, e.g. physical facilities, equipment, human resources, including 
training,  working  conditions  and  pay.  ‘Process’  is  the  way  care  is  delivered,  e.g.  diagnosis, 
treatment,  preventive  care,  patient  education,  obtaining  information  from  medical  records, 
interviews with patients and doctors, or direct observations. ‘Outcomes’ are the effects of care 
on patients, e.g. changes to their health status or functionality.  

There is an emerging consensus that there is a need to measure quality based not only on clinical 
indicators, but also by taking a person-centred perspective and including measurements of the 
users’  quality  of  life86.  This  is  in  line  with  the  shift  to  a  more  holistic  view  in  which  older 
people’s  well-being  and  quality  of  life  and  their  preferences  regarding  care  and  support  are 

84 Social Protection Committee, 2010, A voluntary European quality framework for social services, SPC/2010/10/8 final. 
These principles were adapted to long-term care further in 2012 by the WeDO project: Principles and guidelines for the 
wellbeing and dignity of older people in need of care and assistance.  
85 For an overview of indicators used to measure long-term care quality see chapter 3 of European Commission and Social 
Protection Committee, 2021, Long-term care report: trends, challenges and opportunities in an ageing society, Volume I, 
Publications Office of the European Union, Luxembourg. 
86 Zigante, V. and King, D., 2019, Quality Assurance Practices in Long-term Care in Europe, Research note for the Social 
Situation Monitor.  

25 

 
 
                                                 
central to the design of services in line with existing human rights standards.87 The latter include 
the rights of people with care needs, including people with disabilities, to live independently 
and  be  included  in  the  community,  with  choices  equal  to  others,  to  have  the  opportunity  to 
choose  their  place  of  residence  and  where  and  with  whom  they  live  on  an  equal  basis  with 
others and not to be obliged to live in a particular living arrangement. Independent living applies 
equally  to  private  and  residential  homes.  It  requires  a  differentiated  landscape  of  quality, 
accessible,  person-centred  and  affordable,  community-  and  family-based  services  to  allow 
people in need of long-term care to have control over their daily lives, in particular those living 
in residential care homes. However, the situation is particularly difficult in remote and rural 
areas and the COVID-19 pandemic highlighted and intensified the challenges faced by people 
living in institutions8889. 

3.4.2.  Quality assurance in long-term care 

Quality  assurance  practices  vary  between  and  within  Member  States  due  to  various  factors, 
including  quality  assurance  mechanisms  themselves,  which  may  be  different  at  national, 
regional and local levels, the nature of quality standards and how they apply to different types 
of care providers, whether public, private for-profit or non-profit.90 Quality assurance in long-
term care is a point of debate in a number of countries, including due to a string of cases of poor 
care  and  mistreatment91.  This  has  caused  substantial  debate  over  how  quality  can  be  better 
assured  and  monitored  in  both  public  and  private  care  settings.  A  EUROFOUND  report92 
highlighted few challenges linked to expansion of private provision increases, indicating that 
costs to users are likely to become a more significant issue unless there is an increase in public 
benefits to subsidise funding. There are also differences in the location of different types of care 
homes, with private care homes more likely to be found in affluent urban areas. The types of 
residents prevalent in each type of care home are influenced by the profitability of the services 
they require – residents who require less profitable care services are more likely to be in public 
care homes. In most countries where information about staff-to-resident ratios was available, 
there were more staff per resident in public care homes. 

The  main  elements  of  long-term  care  quality  assurance  systems,  namely  the  setting  and 
monitoring  of  quality  standards,  improving  current  practice  and  involving  relevant 
stakeholders, are briefly discussed below93. 

87 Birtha, M., Rodrigues, R., Zólyomi, E., Sandu, V. & Schulmann, K., 2019, From disability rights towards a rights-based 
approach to long-term care in Europe: Building an index of rights-based policies for older people. Vienna: European Centre 
for Social Welfare Policy and Research.  
88 N. Crowther (ANED synthesis report), 2019, The right to live independently and to be included in the community in 
European States. The right to live independently and to be included in the community in European States.  
89 European Commission, 2021, Union of Equality: Strategy for the Rights of Persons with Disabilities 2021-2030.  
90 For more information on quality assurance practices of long-term care provided by private providers, see Zigante, V. and 
King, D., 2019, Quality Assurance Practices in Long-term Care in Europe, Research note for the Social Situation Monitor. 
91 Ibid. 
92 Eurofound (2017), Care homes for older Europeans: Public, for-profit and non-profit providers, Publications Office of the 
European Union, Luxembourg. 
93 Based on Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., 
Schepers, W., 2022, Analytical support under VC/2020/066. 

26 

 
 
                                                 
Although countries have different approaches to quality assurance in long-term care, the most 
common  approach  is  establishing  mandatory  quality  standards  as  well  as  monitoring 
procedures and enforcement or remedy measures to ensure that providers comply with them. 
Quality  standards  usually  address  the  structural  features  and  can  refer  to  input  /  physical 
environment  (e.g.  fire  and  safety  concerns,  room  size,  common  space  available,  number, 
training  and  education  of  staff  caring  for  recipients),  process  of  care  (e.g.  documenting  the 
frequency with which staff apply creams and/or turn bed-bound resident to prevent pressure 
ulcers), and outcomes to which providers should aspire, most often clinical (e.g. occurrence of 
skin  pressure  ulcers  or  uncontrolled  pain)94.  Regulation  of  residential  care  is  more  common 
than  regulation  of  home  and  community-based  care.  At  the  same  time,  key  criticism  of 
residential care quality standards is that they are too ‘medical’, rigid, not evidence-based and 
do not measure what is important, which is now increasingly understood as the quality of life 
of the person receiving care.  

The  next  step  in  the  regulatory  process  is  the  authorisation  and  accreditation  of  provider 
organisations.  Authorisation  usually  confers  the  right  to  operate  a  facility  or  service,  while 
accreditation  also  entitles  providers  to  receive  public  funding.  Both  procedures  are  usually 
linked, and quality is assessed before a service is delivered. For instance, in DE, where only 
accredited providers can offer their services on the market, this procedure has been delegated 
to the regional branches of the long-term care insurers. In other Member States such agreements 
are linked to distinct accreditation or licensing procedures and may be administered at one of 
different levels: national (MT),  regional (e.g. AT,  IT) or municipal (e.g.  DK,  SE). Regional 
instead of national authorisation may lead to regional variations of quality, both in the definition 
of standards and regarding the implementation of quality assurance procedures. There are also 
variations in terms of requirements and standards applied to different care settings, with such 
standards being more developed for residential rather than for home-based care settings. 

Following the initial assessment of compliance with quality standards, the next step is to aim 
to monitor and constantly improve results. This could be done through follow-up to proposals 
for improvement resulting from systematic self-assessment of long-term care providers and/or 
inspections and/or reviews by third party that has been employed to certify the organisation’s 
quality  management  system.  The  design  of  enforcement  systems  needs  to  be  carefully 
considered. While shortcomings and errors must be identified to be overcome and addressed, 
enforcement  measures  and  penalties  could  also  reduce  the  resources  of  already  ‘low 
performing’ organisations, thus leading to even lower performance and further harming care 
recipients.  Still,  while  enforcement  of  measures  is  necessary  to  sanction  abuses  and  they 
therefore  exist  in  most  countries  (e.g.  AT,  BE,  BG,  DE,  FI,  MT,  PT,  RO,  SE),  economic 
incentives  for  quality  improvement  and  collaborative  approach  (inspectors  working  with 
providers  to  solve  problems)  should  be  further  fostered,  to  increase  ownership  towards 
continuous improvement of quality.  

In addition to a strict regulatory approach to quality assurance, there are different mechanisms 
that allow relevant stakeholders, first of all people receiving care and their family members, to 

94 V. Mor, T. Leone, A. Maresso (ed), 2014, Regulating Long-Term Care Quality: an international comparison, for the 
European Observatory on Health Systems and Policies. 

27 

 
 
                                                 
have a say on quality of care. Complaint mechanisms for users and their families are widely 
established  instruments  at  organisational  level,  though  more  developed  in  residential  care 
settings. At national level, mechanisms are put in place at the level of the ombudsperson and 
now also of OPCAT commissions95, albeit, and again, focusing on residential care. The OPCAT 
commissions  are  now  in  place  in  all  Member  States  to  combat  the  worst  cases  of  non-
compliance, namely abuse and neglect of residents in care homes. Mutual agreements among 
stakeholders,  though  not  widespread,  provide  the  opportunity  to  reflect  upon  mutual 
expectations and the involvement of the various stakeholders in existing care arrangements and 
individual  care  planning.  At  an  organisational  level,  users  can  be  involved  via  satisfaction 
surveys. However, these tools have their limits in long-term care, particularly when it comes 
to involving people with cognitive difficulties or simply because users might fear to say what 
think really think. A way out, though also limited, could be to have quality assessed by proxies 
(friends, family), but this also has its caveats as interests may sometimes diverge.  

3.4.3.  Drivers of quality 

Quality  is  affected  by  a  number  of  factors,  including  funding,  workforce  and  technology. 
Adequate  funding  is  key  to  ensure  long-term  care  quality,  but  even  with  limited  public 
expenditure (see section 3.1.2), it is still possible to find ways to achieve better outcomes with 
resources  at  hand.  Better  targeting  care  to  individual  needs  and  involving  all  relevant 
stakeholders (including informal carers) and services (including healthcare) that cater for these 
needs in a coordinated way via integrated care provision and the expansion of case and care 
management could improve the efficiency of resources. Also, when long-term care services are 
commissioned or procured, including quality indicators and performance standards focusing on 
positive outcomes  for  people receiving care in public procurement  contracts  could help to 
move from fee-for service to outcome based financing96. The availability and expertise of care 
workers has a major impact on the quality of care and the quality of life of those being cared 
for.  This  calls  for  policy  measures  to  ensure  adequate  human  resources  for  long-term  care, 
including  ensuring  adequate  staff  ratio,  providing  quality  management  training  for  care 
managers and workers and involving care staff in the assessment, monitoring and improvement 
of care quality. Technology could help to improve care quality, including by making services 
more personalised and increasing users’ independence. However, beyond cost considerations 
and the acknowledgement that technology cannot replace human contact, there are challenges 
regarding insufficient availability, accessibility, reliability, and acceptance of new technologies 
as well as concerns about the protection of personal data. 

3.5.  Long-term care workforce and informal carers 

Carers are the backbone of long-term care systems. Meeting the rising demand for long-term 
care  can  support  job  growth,  but  Member  States struggle  to  attract  and  retain  care  workers. 
Difficult working conditions and relatively low wages are drivers for labour shortages in the 

95 The Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or 
Punishment. The OPCAT was signed by all EU Member States, only Ireland and Belgium are still in the process of 
ratification. 
96 European Social Network, 2021, Putting Quality First: contracting for long-term care.  

28 

 
 
                                                 
sector.  Skills  requirements  in  long-term  care  are  becoming  increasingly  complex.  Informal 
carers,  mostly  women,  carry  out  the  bulk  of  caregiving  in  many  Member  States.  Informal 
caregiving often comes with significant consequences for the carers, including difficulties to 
reconcile work and caring responsibilities as well as consequences on health and wellbeing.  

3.5.1.  The long-term care workforce  

The long-term care workforce consists of a range of professions, most importantly personal 
care workers97 and nurses98. In 2019, an overwhelming majority of 88% of  long-term  care 
workers were women in the EU99. In 2019, the share of foreign-born long-term care workers 
(from within and outside the EU) was close to 20%100. 

Most  long-term  care  workers  have  a  medium  education  level101 102.  Skills  requirements  in 
long-term care are becoming increasingly complex, including the need for case management, 
soft  and  digital  skills  as  well  as  geriatric  and  special  knowledge  (e.g.  Alzheimer,  chronic 
diseases). Despite the relatively high rate of training (58% of long-term care workers received 
training paid for or provided by their employer, compared to 38% overall), 24% of long-term 
care workers felt that they ‘need further training to cope well with duties’ (15% overall)103. 

Live-in carers are a particularly vulnerable subgroup of long-term care workers prevalent in a 
number of EU Member States (e.g. AT, CY, DE, EL, ES, IT, MT)104. In most cases, they are 
mobile (intra-EU mobile workers) or migrant workers. Undeclared work among live-in carers 
can  be  a  common  issue  in  some  Member  States105.  Live-in  carers  may  face  extremely  low 
wages, sometimes not even receiving the applicable minimum wage in the country106. Given 
that live-in carers usually live with the care recipient (who is sometimes but not always their 
employer) under the same roof, working time arrangements, including adequate rest periods, 
may be blurry107 and sometimes not compliant with labour law, while enforcement of rights of 
live-in  carers  may  be  limited  due  to  limitations  on  inspecting  private  households  in  certain 
Member States108.  

While data on this is still sparse, domestic work, including the provision of long-term care, is 
increasingly provided via online platforms, bringing along risks for the workers such as lack 
of security, guaranteed hours or minimum pay rates, constraints on collective bargaining and ratings 

97 In this analysis defined per ISCO-08, falling under codes 5321 and 5322. 
98 In this analysis defined per ISCO-08, falling under codes 2221 and 3221. 
99 EU Labour Force Survey.  
100 Ibid.  
101 Upper secondary educational qualification or equivalent. 
102 OECD, 2020, Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Publishing, Paris. 
103 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 
104 Ibid.  
105 Ibid.  
106 Rogalewski, A. and Florek, K., 2020, The future of live-in care work in Europe. European Economic and Social 
Committee. 
107 Ibid. 
108 International Labour Office, 2015, Labour Inspection and Other Compliance Mechanisms in the Domestic Work Sector: 
Introductory guide, ILO, Geneva. 

29 

 
 
                                                 
and reviews to discipline workers109. Undeclared work is a challenge in particular in care services 
that are part of the personal and household services sector. 2.1 million people are estimated to work 
undeclared in the personal and household services care sector (including both childcare and long-
term care), which account for 34% of the overall workforce working in this sector110.  

3.5.2.  Untapped job creation potential and labour shortages in the sector 

The long-term care sector already accounts for a substantial number of jobs in many Member 
States. In 2019, there were 6.3 million long-term care workers in the EU (3.2% of overall 
workforce)111. As shown in Figure 9, the number of full-time equivalent long-term care workers 
per 100 people aged 65+ was 2.4 on average in the EU-27 in 2019. However, there were large 
differences across Member States from fewer than 0.2 long-term care workers per 100 people 
in Greece to 12.5 in Sweden112. 

Figure 9: Number of (full-time equivalent) long-term care workers per 100 people aged 65+, 
2019 

14

12

10

8

6

4

2

0

E
S

I

K F
D

K
S

T
M

L
N

E
D

E
B

T
P

U
L

T
A

S
E

7
2
-
U
E

R
H

Z
C

I

E S
E

T
I

R
F

U I
E
H

G
B

V
L

O
R

Y
C

T
L

L
P

L
E

Residential care

Home care

Source: EU Labour Force Survey, 2019, in: Barslund, M., et al., 2021. 

The  long-term  care  sector  has  an  untapped  job  creation  potential,  driven  in  particular  by 
population ageing. In order to keep the current level of long-term care provision, many countries 
will have to significantly expand the long-term care workforce in the coming decades. More 
than 1.6 million long-term care workers would have to be added by 2050 to keep long-term 
care coverage at the same level. Most Member States would have to increase the number of 
long-term care workers by more than 15% by 2030, and for eight countries the figure is 30% or 

109 Sedacca, N., 2022, Domestic Work and the Gig Economy. Forthcoming in “A Research Agenda for the Gig-Economy and 
Society”. 
110 European Labour Authority, 2021, Tackling undeclared work in the personal and household services sector. 
111 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 
112 Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., Schepers, 
W., 2022, Analytical support under VC/2020/066.  

30 

 
 
 
                                                 
more113/114. In a scenario, where Member States converge upwards in their number of  long-
term care workers per 100 people aged 65+ (reaching 5.6 workers by 2050), 150 000 long-term 
care workers would have to be added yearly for the next 30 years to the current long-term care 
workforce to keep service provision at 2019 level within the EU. This would amount to around 
4.5 million additional long-term care workers by 2050.  

However, many countries struggle to attract a sufficient number of workers into the long-term 
care sector. A large majority of Member States have reported significant numbers of unfilled 
vacancies, or have estimated expected  staff shortages in  the long-term  care sector115. More 
than one in  six of the 24.3 million  online job  advertisements  analysed  by Skills  OVATE in 
2021 116concerns  the  long-term  care  occupations 117.  Personal  care  workers  were  the  most 
requested (39%), followed by nursing and midwifery associate professionals (33%) and nursing 
and  midwifery  professionals  (28%).  In  2020,  nursing  professionals,  nursing  associate 
professionals and home-based personal care workers were among the 19 occupations for which 
‘high magnitude shortages’118 were identified in a number of EU Member States119. As a result 
of the difficult working conditions during the pandemic, labour shortages in the sector became 
even more severe (for more information see section 3.6).  

Low  wages  are  a  main  reason  for  labour  shortages  in  the  sector.  Analysis  from  Eurofound 
shows  that  on  average  in  2018,  wages  for  social  services  workers  (close  to  70%  of  which 
worked in the long-term care sector) were 21% lower than the average national hourly earnings. 
The high prevalence of part-time work (42%) in the long-term care sector implies even lower 
monthly  earnings  for  many.  The  wage  difference  was  smallest  in  the  Netherlands  (96%  of 
average earnings), Austria and Luxembourg (both 92%)120; three countries where almost 100% 
of long-term care workers are covered by social partner agreements121. 

Across the EU, social dialogue plays a mixed role in the long-term care sector. Only in some 
Member States, close to 100 % of long-term care workers are covered by collective agreements 
(AT, BE, DK, ES, FR, LU, NL, SI), while in others social dialogue in the sector is almost absent 
(CZ, EL, PL)122.  

113 CY, DK, FI, IE, LU, MT, NL, SK 
114 Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., Schepers, 
W., 2022, Analytical support under VC/2020/066.  
115 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 
116 Analysis from Cedefop 
117 Reliable data is not available at the ISCO 4-digit level, therefore this analysis focuses on 3 occupations that are connected 
to provision of long-term care: These will be referred to as “long-care occupations” in this note: Nursing and midwifery 
professionals (ISCO 222); Nursing and midwifery associate professionals (ISCO 322); Personal care workers in health 
services (ISCO 532). 
118 lack of employees amounting to more than 3% of the current employment in that occupation 
119 McGrath, J., 2021, Report on Labour Shortages and Surpluses November 2021, European Labour Authority.  
120 Eurofound, Living conditions and quality of life: Wages in long-term care and other social services 21% below average. 
(accessed on 25 March 2022) 
121 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 
122 Ibid.  

31 

 
 
                                                 
Difficult working conditions further contribute to the low attractiveness of the sector. Evening, 
night  or  weekend  shifts  are  common  in  the  long-term  care  sector,  affecting  working  time 
quality. The large share of part-time work among the long-term care workforce (42%) is not 
always  voluntary,  as  30%  of  part-time  long-term  care  workers  in  home  care  and  20%  in 
residential care work part-time because they could not find a full-time job123. A significant share 
of  long-term  care  workers  (33%)  have  been  exposed  to  adverse  social  behaviour,  including 
verbal  abuse,  unwanted  sexual  attention,  threats,  physical  violence,  humiliating  behaviour, 
bullying, and sexual harassment (compared to 16% in the overall workforce)124. Challenging 
working conditions take their toll on the health of  long-term  care workers. In 2015, 37% of 
long-term care workers reported that their job had a negative effect on their health, compared 
with 25% among the overall workforce. 38% of long-term care workers believed they would 
not  be  able  to  continue  doing  their  job  until  they  were  60  years  old  (compared  to  27% 
overall)125. Occupational health and safety risks for long-term care workers include in particular 
lifting and moving people and handling materials that can be infectious, but also psychosocial 
risks126.  Furthermore,  lower  staff  ratios  can  cause  a  precarious  burden  of  work,  which  puts 
employees  under  constant  time  pressure.  A  recent  study  analysing  the  occupational 
precariousness of nursing staff in nursing homes in Catalonia in Spain127 found also that staff 
in  privately  owned  facilities  suffer  greater  precariousness  with  the  main  reasons  for  the 
precariousness being low wages and temporality of contracts. 

3.5.3.  Informal carers  

Despite increased social and political acceptance of the need for the state to guarantee access 
to formal care services, informal carers continue to provide the largest bulk of care in the 
EU. In 2018, about a third of the EU adult population (around 100 million people) had caring 
responsibilities. The majority of them took care of children below 15 (84 %), for incapacitated 
relatives (12 %) or for both at the same time (4 %)128. On average around 52 million Europeans 
(14.4% of the population aged 18 to 74) provide informal long-term care to family members or 
friends on a weekly basis. When using full-time equivalents, informal carers account for close 
to 80% of care providers at EU level129.  

123 Ibid. 
124 Ibid.  
125 Ibid.  
126 Ibid.  
127Occupational Precariousness of Nursing Staff in Catalonia's Public and Private Nursing Homes - PubMed (nih.gov). As 
limitations of the study, the authors mentioned that the small sample size and its contextualization do not allow inferences to 
be made at the national or international level. 
128 Eurostat, Statistics Explained: Reconciliation of work and family life. (accessed on 11 April 2022) 
129 Van der Ende, M. et al., 2021, Study on exploring the incidence and costs of informal long-term care in the EU.  

32 

 
 
                                                 
Figure 10: Share of population 18-74 providing informal care, by gender 

Source: Van der Ende, M. et al., 2021. 

Informal care has strong implications for gender equality, as a  majority of informal carers 
(59%) are women. Women also provide more hours of care (17 hours per week for women, 
compared to 14 hours for men). The majority of informal carers (54%) provide less than 10 
hours of care per week, while 25% provide between 10 and 20 hours, 11% provide 20-40 hours 
and 10% provide more than 40 hours per week. 5.3 million people in the EU are intense informal 
carers, providing more than 40 hours per week, of which 3.8 million are women130. A large 
share of people providing informal long-term care are also engaged in childcare for children 
under 18, thus facing a double care burden (71% of women and 79% of men providing informal 
long-term care)131. Fewer women (36%) than men (51%) who provide informal care use support 
from formal care services132.  

Informal  care  has  a  large  economic  and  societal  value.  Informal  carers  provide  33  to  39 
billion  hours  of  informal  care  per  year.  These  hours  can  be  associated  with  a  certain  value, 
applying different methods. When applying the proxy good method133, the most likely value of 
these hours is  2.7% of EU GDP. When applying the opportunity  cost  method134, their most 
likely value is 2.4% of EU GDP135. Both methods reach a value that is much higher than current 
public expenditure on long-term care (1.7% of GDP in the EU136).  

130 Ibid. 
131 EIGE, 2022, Gender inequalities in long-term care – draft statistical brief, forthcoming. 
132 Ibid.  
133 The proxy good method values the hours with the gross wages of care professionals providing similar activities.  
134 The opportunity cost method values hours with the gross wage rate of what informal carers could have earned in their 
“real” professions, and with the value of leisure for people past the age of 65.  
135 Van der Ende, M. et al., 2021, Study on exploring the incidence and costs of informal long-term care in the EU.  
136 European Commission and Economic Policy Committee, 2021, The 2021 Ageing Report – Economic and budgetary 
projections for the EU Member States (2019-2070), Publications Office of the European Union, Luxembourg.  

33 

 
 
 
                                                 
The  majority  of  informal  carers  are  employed,  but  labour  market  participation  decreases 
with intensity of care provided. 64% of informal carers are employed, compared to 67% of 
the overall population aged 18-64. While 71% of informal carers providing less than 10 hours 
per week of care are employed, the employment rate of informal carers providing more than 40 
hours per week is only 35%. Women, in particular in the age group 45-64, are more likely to 
drop out of the labour market as a result of caring responsibilities (their employment rate is 
54% compared to 59% overall in this age group). Women with caring responsibilities in this 
age  group  who  drop  out  of  the  labour  market  face  on  average  an  annual  wage  loss  of 
EUR 18 000 net137/138. This is also later on translated into lower pensions, and more difficulties 
in affording the costs of long-term care, once the informal carers become themselves dependent 
on receiving care. 

Informal care is also associated with costs for society as a whole. Such costs include losses of 
tax and social security revenues due to informal carers’ lower labour market participation, and 
expenditure  on  allowances  for  carers.  Care  responsibilities  are  still  predominantly  borne  by 
women, keeping  7.7  million women out of the labour market  (compared to  only 450,000 
men)139 and contributing to the gender employment gap. Estimates conclude that public costs 
associated with informal care could amount to around 1 % of GDP140, more than half of current 
public expenditure on long-term care (1.7% of GDP).  

3.6. 

Impact of COVID-19 on long-term care systems 

Long-term care systems have been strongly affected by the COVID-19 crisis in view of their 
users’ high vulnerability to the virus and the impact on the carers. The pandemic has reinforced 
the already existing structural challenges regarding the availability, accessibility and quality 
of care as well as the situation of formal and informal carers.  

In general, the pandemic has disproportionately hit older people who are at a higher risk of 
developing severe disease and more likely to die due to COVID-19 because of being frail and 
having underlying medical conditions141. Available cumulative data142 up to spring 2021 has 
shown that COVID-19 deaths of people aged 60+ (IE, LT, ES, IT, DE, FR, CZ, NL, PT, SE, 
DK) or 65+ (AT, BE, SI) represent at least 90% of total registered COVID-19 deaths143.  

Around half of Member States144 (BE, DK, EE, FI, DE, EL, HU, LT, LV, NL, PT, ES, SE) had 
in place emergency guidelines on infection control in long-term care before the outburst of 

137 Corrected for purchasing power. 
138 Van der Ende, M. et al., 2021, Study on exploring the incidence and costs of informal long-term care in the EU. 
139 EIGE elaboration of ISSP 2012 data. 
140 Van der Ende, M. et al., 2021, Study on exploring the incidence and costs of informal long-term care in the EU. 
141 OECD, 2021, Rising from the COVID 19 crisis: Policy responses in the long-term care sector.  
142 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
143 While reported COVID-19 deaths are an important measure, accuracy and comparability of this indicator is limited across 
countries due to differences in registration, coding practices, level of testing as well as the share of older people in the 
population, the share of the risk-factor conditions such as obesity and diabetes, or intensity of tourism. Yet, the above figures 
give a sense of the enormous magnitude of the impact that the pandemic has had on older people. 
144 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  

34 

 
 
                                                 
the  COVID-19  crisis.  Some  EU  countries  (AT,  FR,  IE,  IT,  SI)  had  developed  emergency 
preparedness systems for the healthcare sector in general, but not for the long-term care sector 
in particular. The ones with emergency preparedness, though, were not necessarily less affected 
by the COVID-19 crisis. The lack of collaboration and coordination between the health and 
social sectors was shed light on during the pandemic145. Most of the nursing homes were not 
medically prepared to meet the challenges of the pandemic. Before the outbreak, only several 
Member  States  (CZ,  DK,  FI,  FR,  DE,  FI,  LU,  PT,  SI)  had  reported  having  guidelines  or 
legislation on the integration of long-term care and primary care. 

The availability and accessibility of care have been impacted in different ways as a result the 
COVID-19 pandemic. More than half of the Member States limited access to long-term care 
services  during  the  crisis146.  In  order  to  reduce  the  risk  of  spreading  COVID-19,  day  care 
centres were temporarily closed or made subject to limited access in a number of EU countries 
(CZ, DE, HR, HU, LU, NL, PL, RO, SI, SK), at least during the first wave of the pandemic. 
Similarly, access to home care was reduced in several Member States (FR, LU, NL, SI), while 
in others home care services were limited to strictly necessary visits (e.g. BE, CY, FR, NL). In 
Austria  problems  in  home  care  arose  especially  regarding  live-in  care  at  home,  who  come 
mostly from central and Eastern Europe. Travel bans prevented carers from travelling between 
their place of work and  their home in  a usually  biweekly cycle. Conversely,  long-term care 
facilities continued to provide care in most Member States147. However, in most EU countries 
residential  care  providers  appeared  to  be  largely  unprepared  for  the  epidemiological  threat: 
insufficient sanitary procedures related to isolation of potentially infected people, shortages of 
personal protective equipment particularly in the social sector, staff shortages and insufficient 
testing 148.  In  cases  of  COVID-19  outbreaks,  the  most  common  response  of  long-term  care 
facilities  was  to  minimise  contact  from  outside  as  much  as  possible  and  reduce  in-person 
interactions inside149. In several Member States (BG, EE, HR, LU, PL), the placement of new 
residents in residential care was temporarily restricted.  

As an attempt to  offset  the reduced availability and accessibility of care services during the 
pandemic150, caregiving via  telecommunication was  strengthened. A number of countries 
have enhanced digital care provision (CY, ES, FR, NL, PL, RO). Nevertheless, informal care 
is likely to have compensated for a significant share of the care that was previously provided 
by professionals. In addition, anecdotal evidence suggests that people in need of long-term care 
sometimes chose to reduce or not to receive care in order to minimise their risk of contracting 

145 Ibid.  
146 Unless specified differently, this paragraph is based on: European Commission and Social Protection Committee, 2021, 
Long-term care report: trends, challenges and opportunities in an ageing society, Volume I, Publications Office of the 
European Union, Luxembourg. 
147 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
148 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and 
opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 
149 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
150 This paragraph is based on: European Commission and Social Protection Committee, 2021, Long-term care report: trends, 
challenges and opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 

35 

 
 
                                                 
COVID-19.  During  the  first  months  of  the  crisis,  unmet  long-term  care  needs  may  have 
increased. 

Reduction  in  the  availability  of  formal  care  services  due  to  the  pandemic  and  social 
distancing  have  possibly  enhanced  the  dependence  on  informal  carers,  implying  an 
additional psychological and financial strain on them. A survey of Eurocarers shows that the 
pandemic led to more and new informal carers, as more than 10% of respondents started to 
provide care as  a result of the pandemic. COVID-19 negatively impacted several  aspects  of 
many  carers’  lives,  including  social  network/participation  (78.7%);  quality  of  life  (76.8%); 
mental health/psychological state of mind (66.5%); access to health/social services for the care 
recipient  (59.8%);  and  care  recipient’s  health  status  (54%)151.  Informal  care  appeared  to  be 
taking a heavier toll on women, in comparison to men, in terms of increased intensity of the 
informal long-term care provided, decreased reliance on formal care services, or difficulties in 
reconciling work and care duties, to name just a few152. In addition, evidence suggests that the 
share of people aged 50 or over who became unemployed, were laid off, or had to close their 
business because of COVID-19 by August 2020 was higher for informal carers than for non-
informal carers in almost all EU countries153. 

Furthermore, the COVID-19 pandemic had a negative impact on the quality of care and the 
quality  of  life  of  people  receiving  care.  In  order  to  prevent  the  COVID-19  virus  from 
spreading through care homes, external visits were banned, residents were often isolated from 
one another, and visits from carers were limited to attending to their basic needs154. Only later, 
it was possible to alleviate some of the isolation and protection measures with an increase in 
testing and later in vaccination capacity across the EU. Special meeting areas were designed 
(DE), contacts with visitors were carried out using telephones or video tools (CY, BG, DE, FR, 
HR,  HU,  LU,  SK)  or,  when  visits  were  allowed,  their  rules  were  revised  to  make  sure  that 
visitors did not display COVID-19-related symptoms (DK, HR). Creative solutions were also 
deployed to help residents cope with isolation, such as ‘corridor-games’, music broadcasting, 
and entertainment events (FR, LU).  

The  COVID-19  pandemic  has  also  worsened  the  working  conditions  of  long-term  care 
workers155. Long-term care workers have been more exposed to the virus and related potential 
health risks, compared to other professions. Evidence from  some Member States has shown 
that long-term care workers have taken more days of sick leave during the pandemic than during 
comparable periods before (DE, LU, SI). Not only the physical, but also the mental health of 
long-term care workers was of concern during the pandemic. As a result of the difficult working 
conditions during the pandemic, labour shortages in the sector increased. Between 2020 and 

151 Eurocarers, 2021, Impact of the Covid-19 outbreak on informal carers across Europe.  
152 EIGE, 2022, Gender inequalities in long-term care – draft statistical brief, forthcoming. 
153 Eurocarers, 2021, How informal caregivers’ life and care situations changed during the corona-pandemic in Germany,  
154 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and 
opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 
155 Sources for this section include: European Commission and Social Protection Committee, 2021, Long-term care report: 
trends, challenges and opportunities in an ageing society, Volume I, Publications Office of the European Union, 
Luxembourg. And Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses 
and challenges. OECD Health Working Papers, No. 131, OECD Publishing, Paris. 

36 

 
 
                                                 
2021, highly likely due to the pandemic, the published online job advertisements for long-term 
care  occupations  grew  by  39%.  According  to  a  recent  survey  of  the  Federation  of  Social 
Employers among employers’ organisations and social service providers from 20 EU countries, 
a large majority of respondents faced staff shortages, which for most worsened over the course 
of 2021, as a  result of the pandemic. The sub-sector most concerned  was services for older 
people156. 

To  address  the  issue  of  staff  shortages  urgently  during  the  COVID-19  crisis,  a  number  of 
countries implemented some temporary changes in rules, regulations or laws. These included: 
relaxation  of  education  requirements157 (CZ,  DE,  LT,  NL,  HU);  short-term  contracts158 with 
foreign workers (LU); bonus payments159 for long-term care workers (CZ, DE, PL, RO, SK) or 
live-in carers (AT); bans on firing160 for long-term care workers (ES); accelerated accreditation 
of  foreign  diplomas 161 (DE,  EL,  LU,  PT);  mobilisation  of  workers  from  other  sectors 162, 
including  the  healthcare  sector  (BE,  DE,  FR,  HR,  PL);  and  mobilising  volunteers,  medical 
students, and retirees (CZ, DE, IE, LU, PL, RO). 

Beyond  the  immediate  effects  of  the  COVID-19  crisis  on  long-term  care  systems,  it  is  also 
important  to  consider  the  potential  impact  on  the  preferences  for  a  specific  long-term  care 
setting after the pandemic163. Some first evidence comes from Canada, which was hit by the 
pandemic in a similar fashion as EU Member States. The study has established that as a result 
of the pandemic residential care has become a less attractive long-term care option, as there 
has been a shift towards stronger preference for home care. This is likely to influence people’s 
saving behaviour as well as the type of policies they would support (e.g. citizens more likely to 
support home care subsidies financed by taxation). Moreover, a study164 commissioned by the 
European Parliament points out that research consistently reveals a preference for home-based 
care among older people, in addition to evidence that home-based care is less costly and has the 
potential to offer better quality care, compared to traditional institutionalised care.  

156 Federation of European Social Employers, 2022, Survey results illustrate extent of current staff shortages in social 
services. 
157 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris. 
158 Ibid.  
159 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and 
opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 
160 Ibid.  
161 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
162 Ibid.  
163 Achou, B., De Donder,P., Glenzer, F., Lee,M. and Leroux,M.-L., 2021, Nursing Home Aversion Post-Pandemic: 
Implications for Savings and Long-Term Care Policy, Munich Society for the Promotion of Economic Research – CESifo.  
164 Barry, U. and Jennings, C., 2021, Gender equality: Economic value of care from the perspective of the applicable EU 
funds. Study for the FEMM committee of the European Parliament.  

37 

 
 
                                                 
4.  CURRENT UNION SUPPORT AND THE CASE FOR 

REINFORCED ACTION AT EU LEVEL  

While the design and organisation of long-term care is primarily a competence of the Member 
States (Article 153 TFEU), long-term care touches on several policy areas with relevance for 
the European Union legal acquis and initiatives (e.g. social inclusion, social protection, social 
security coordination, free movement of workers, working conditions, skills, healthcare, gender 
equality, fiscal sustainability, etc.).  

The  European  Pillar  of  Social  Rights  proclaimed  in  2017  set  out  in  its  Principle  18  that 
‘everyone  has  the  right  to  affordable  long-term  care  services  of  good  quality,  in  particular 
home  care  and  community-based  services’. 165  The  Pillar  principles  also  cover  the  carers’ 
perspective by highlighting a number of principles related to working conditions as well as the 
right to leave. As part of the European Pillar of Social Rights action plan that followed in 2021, 
the European Commission proposed to turn principle 18 on long-term care into concrete action 
via an initiative.  

The  European  Commission  has  been  supporting  the  activities  of  the  Member  States  at 
various  levels  by  policy  guidance,  such  as  the  Social  Investment  Package166.  Further,  it  has 
undertaken  analytical  work in  this area,  monitored long-term  care-related developments  and 
supported mutual learning and exchange of best practices in close cooperation with the Member 
States, civil society, and other stakeholders. This is achieved mainly through the Social Open 
Method of Coordination and the European Semester. Existing acquis are also touching upon 
different dimensions of long-term care policies. Funding for policy reforms and investments, 
social  innovations  and  research  are  equally  part  of  the  EU  support  mobilised  for  long-term 
care.167  

4.1.  EU initiatives relevant to long-term care  

To date, several EU legislative acts or initiatives touch upon different aspects of long-term care, 
but  these initiatives  or legislative actions have a horizontal dimension, and therefore do not 
have a specific focus on the long-term care sector.  

The European Commission’s proposal from 2016 for the revision of Regulation 883/2004 
on social security coordination aims to bring legal clarity and transparency regarding access 
to  long-term  care  benefits  when  residing  in  another  Member  State.  In  the  context  of 
demographic  ageing  and  the  promotion  of  greater  independence  and  mobility  for  disabled 
people, more and more mobile citizens need long-term care benefits. The proposal introduces 
specific  coordination  rules  for  long-term  care  organised  on  the  same  logic  as  the  current 
sickness benefits rules.  

165 Commission staff working document (SWD/2017/0201 final), Establishing a European Pillar of Social Rights.  
166 Commission staff working document (SWD/2013/41 final), Social Investment Package, Long-term care in ageing 
societies - Challenges and policy options.  
167 Leichsenring, K. and ICF, 2019, Mutual Learning Workshop on Taking Stock of EU action in the area of long-term care, 
Thematic Paper and Output Report, European Commission. 

38 

 
 
                                                 
In December 2021168, a second provisional agreement was reached between the co-legislators169 
to integrate long-term care benefits into the chapter on sickness benefits and on the definition 
of long-term care benefits170. If final agreement is reached, the revised regulation will clarify 
what long-term care benefits are and where mobile citizens can claim them, (e.g. under which 
conditions  mobile  citizens  are  entitled  to  export  long-term  care  benefits  when  they  move 
abroad). This means that people's rights are better protected in cross border situations.  

The importance of an accessible and balanced mix of  long-term care  services for people 
with disabilities is highlighted by the Strategy for the Rights of Persons with Disabilities 
2021-2030171. It contains an ambitious set of actions and flagship initiatives in various domains 
to empower people with disabilities so they can enjoy their rights and participate fully in society 
and economy. These issues include amongst others accessibility (being able to move and reside 
freely but also to participate in the democratic process), having a decent quality of life and to 
live  independently  (as  it  focuses  notably  on  the  deinstitutionalisation  process)  and  equal 
participation (e.g. equal access to all long-term care services) for people with disabilities. In 
particular,  the  strategy  announced  guidance  on  independent  living  and  inclusion  in  the 
community, as well as a specific framework for Social Services of Excellence for people with 
disabilities.  

Furthermore, the European accessibility act172 aims to  improve the functioning of the single 
market  for  accessible  products  and  services.  It  covers  products  and  services  that  have  been 
identified as being most important for persons with disabilities while being most likely to have 
diverging accessibility requirements across EU countries. Furthermore, the Web Accessibility 
Directive173 already requires websites and mobile applications of the public sector bodies to be 
accessible, including information, online contact and applications forms, to users, in particular 
to persons with disabilities. This proposal calls on Member States to ensure that long-term care 
information, services and facilities are accessible to persons with disabilities. 

Most of the EU initiatives address the situation of long-term care workers, in terms of their 
skills,  working  conditions,  including  pay  and  occupational  health  and  safety,  and  social 
protection. Regarding the skills needs of the formal long-term care workforce, the European 
skills agenda will also contribute to upskilling and reskilling in the long-term care sector. The 
Communication on a European skills agenda for sustainable competitiveness, social fairness 

168 The second provisional agreement was not endorsed by the COREPER, thus negotiations remain open on a limited 
number of issues not related to long-term care (which is considered a close chapter). 
169 Provisional agreement among Council of Ministers, European Parliament and European Commission, Document 7698/19 
ADD1 REV1 of 25 March 2019. 
170 A benefit in-kind or in cash the purpose of which is to address the care need of a person who, on account of impairment, 
requires considerable assistance from another person or people to carry out essential activities of daily living for an extended 
period of time in order to support his/her personal autonomy; this includes benefits granted for the same purpose to the 
person providing such assistance. 
171 Commission Communication (COM/2021/101 final), Union of Equality: Strategy for the Rights of Persons with 
Disabilities 2021-2030. 
172 Directive (EU) 2019/882 of the European Parliament and of the Council of 17 April 2019 on the accessibility 
requirements for products and services.  
173 Directive (EU) 2016/2102 of the European Parliament and of the Council of 26 October 2016 on the accessibility of the 
websites and mobile applications of public sector bodies. 

39 

 
 
                                                 
and resilience of July 2020174 highlights that ‘Demographic change will require Europe to draw 
on all of its talents and diversity. At the same time, it will also generate new job opportunities 
in the silver and care economies. These transitions show the need for an unparalleled shift in 
skill sets to reap their full potential.’ The objective of the Pact for Skills (action 1) is to mobilise 
all relevant actors to assist people in developing the right skill set175, which can contribute to 
the upskilling and reskilling in the long-term care sector. In addition, a proposal for a Council 
Recommendation  on  a  European  approach  to  micro-credentials  for  lifelong  learning  and 
employability176 can support upskilling and reskilling opportunities also in the context of care 
work. Micro-credentials are the outcome (e.g. certificate or award) of a short training course 
and  can  be  awarded  following  targeted  training  that  is  developed  in  response  to  the  fast-
changing needs of the care sector.  

Recent legislative measures at EU level  relate to working conditions and minimum wage, 
and as such are also relevant for formal carers across the EU. The Directive on Transparent 
and Predictable Working Conditions177 was agreed in 2019 and aims to improve working 
conditions by promoting more transparent and predictable employment. This includes amongst 
others the information workers must receive at the start of their employment relationship, the 
length of their probationary period, the right to additional employment, planning of the work 
schedule,  anti-abuse  legislation  for  on-demand  work  and  cost-free  mandatory  training.  The 
Directive applies to every worker in the European Union who has an employment contract or 
employment relationship as defined by the law, collective agreements or practice in force in 
each Member State, with consideration to the case-law of the Court of Justice of the European 
Union.178 According  to  Recital  8,  domestic  workers  and  voucher-based  workers,  which  also 
form a substantive part of the care workforce could also fall within the scope of the Directive 
if they fulfil the criteria mentioned above. In addition, this Directive can also help improve the 
transparency  of  working  conditions  for  long-term  care  workers  providing  services  abroad, 
which again are quite well represented in the care sector. Indeed, Member States are required 
to  ensure  that  a  posted  worker  (covered  by  Directive  96/71/EC) 179  is  notified  of  the 
remuneration to which the worker is entitled in accordance with the applicable law of the host 
Member State and where applicable, any allowances specific to posting and any arrangements 
for reimbursing expenditure on travel, board and lodging. 180 Not only long-term care workers, 

174 Commission Communication (COM/2020/274 final), European Skills Agenda for sustainable competitiveness, social 
fairness and resilience.  
175 The Pact for Skills is accompanied by a Charter outlining a shared vision from industry, social partners, vocational 
education and training (VET) providers, national, regional and local authorities as regards quality training.  
176 Commission (COM/2021/770 final), Proposal for a Council Recommendation on a European approach to micro-
credentials for lifelong learning and employability. 
177 Directive (EU) 2019/1152 of the European Parliament and of the Council of 20 June 2019 on transparent and predictable 
working conditions in the European Union.  
178 E.g. Judgment of the Court of Justice of 3 July 1986, Deborah Lawrie-Blum v Land Baden-Württemberg, C-66/85, 
ECLI:EU:C:1986:284.  
179 Directive 96/71/EC of the European Parliament and of the Council of 16 December 1996 concerning the posting of 
workers in the framework of the provision of services.  
180 See Article 7 of the Directive. However, self-employed carers providing services in another Member State are not subject 
to the Posting of Workers Directive. 

40 

 
 
                                                 
but also informal carers can benefit from this directive, as it allows better planning of the caring 
obligations for people in employment and thus when support from formal home care is needed. 

The Working Time Directive181 requires EU Member States to guarantee a limit to weekly 
working hours (48h), which may be calculated over a reference period, a rest break, a minimum 
daily rest period of 11 consecutive hours and a minimum weekly rest period of 24 uninterrupted 
hours and paid annual leave. In addition, it lays down extra protection in case of night work. 
However, the Directive allows for a possible derogation of these rights in order to ensure the 
continuity  of  services  within  a  list  of  specific  sectors  and  activities,  notably  for  ‘services 
relating to the reception, treatment and/or care provided by hospitals or similar establishments, 
including  the  activities  of  doctors  in  training,  residential  institutions  and  prisons’  (Articles 
17(3)(c)(i) and 22(1)).182 Importantly, as other EU labour law Directives,  the Working Time 
Directive is only applicable to workers, excluding the (genuinely) self-employed from its scope. 

The proposal of the European Commission for a Minimum Wage Directive183 in 2020 and 
the proposal for a directive on pay transparency184 in 2021 touch on the issue of workers’ 
pay. The proposal for a Minimum Wage Directive aims to establish a framework at EU level to 
ensure both that minimum wages are set at an adequate level and that workers have effective 
access to minimum wage protection, in the form of a statutory minimum wage or of minimum 
wages set by collective agreements. The approval of this directive could therefore provide an 
important  step  forward  in  ensuring  adequate  wages  in  the  formal  long-term  care  sector  and 
increasing therefore also attractiveness of jobs in the sector. Finally, in low-wage economies 
better  working  conditions,  including  higher  minimum  wages  may  reduce  outward  labour 
mobility of long-term care workers (i.e. brain drain). The proposal on pay transparency should 
ensure that women and men in the EU get equal pay for equal work. The initiative aims to tackle 
the persisting inadequate enforcement of the fundamental right to equal pay and ensure that this 
right  is  upheld  across  the  EU,  by  establishing  standards  for  pay  transparency  to  empower 
workers to claim their right to equal pay.  

In 2021, the Commission adopted the EU strategic framework on health and safety at work 
(OSH) 2021-2027 185,186.This sets out three key objectives needed to improve workers’ health 
and safety over the coming years: 1) anticipating and managing change in the new world of 

181 Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of 
the organisation of working time.  
182 Furthermore, reference can be made to judgments of the CJEU in cases C-175/16 Hälvä and C-147/17 Sindicatul Familia 
Constanca, which addressed respectively the situation of carers in a residential setting and of foster parents, as well as by 
analogy C-428/09 Isère which concerned staff at a residential recreational centre for children. 
183 Commission (COM/2020/682 final), Proposal for a Directive of the European Parliament and of the Council on adequate 
minimum wages in the European Union.  
184 Commission (COM/2021/93 final), Proposal for a Directive of the European Parliament and of the Council to strengthen 
the application of the principle of equal pay for equal work or work of equal value between men and women through pay 
transparency and enforcement mechanisms. 
185 Commission Communication (COM/2021/323 final), EU strategic framework on health and safety at work 2021-2027: 
Occupational safety and health in a changing world of work. 
186 The EU OSH legislative framework consists of a framework directive and 24 specific directives developed over time. The 
“Framework Directive” 89/391/EEC on the introduction of measures to encourage improvements in the safety and health of 
workers at work is the basis for common principles and minimum requirements across the EU. 

41 

 
 
                                                 
work;  2)  improving  prevention  of  work-related  diseases  and  accidents  and  3)  increasing 
preparedness for possible future health threats.187 One of the follow-up actions to the strategy 
will  be  an  occupational  safety  and  health  (OSH)  overview  focusing  on  the  health  and  care 
sector, in cooperation with the European Agency for Safety and Health at Work (EU-OSHA) 
by  the  beginning  of  2024.  Moreover,  the  Commission  calls  on  Member  States  to  actively 
address hazards in the healthcare sector and to develop guidance for the healthcare on worker 
protection. These initiatives may contribute to better working conditions for workers employed 
in the long-term care sector. 

With the Council Recommendation on access to social protection in 2019, Member States 
committed  to  extend  the  coverage  of  social  protection  systems  to  non-standard  forms  of 
employment, including long-term care workers who often work part-time or in non-standard 
forms  of  employment.  The  Recommendation  applies  to  the  following  branches  of  social 
protection, insofar as they are provided in the Member States: unemployment benefits; sickness 
and healthcare benefits; maternity and equivalent paternity benefits; invalidity benefits; old-age 
benefits  and  survivors’  benefits;  benefits  in  respect  of  accidents  at  work  and  occupational 
diseases.  Moreover,  there  can  be  a  risk  that  the  emergence  of  digital  platforms  enforces 
precarious  working  conditions.  To  address  these,  the  European  Commission  published  in 
December 2021 a proposal for a directive on improving working conditions in platform 
work188.  The  proposal  includes  new  rules  to  correctly  determine  the  employment  status  of 
people  working  through  digital  labour  platforms  and  new  rights  for  both  workers  and  self-
employed people regarding algorithmic management.  

Recent  EU  initiatives  introduced  more  flexibility  but  also  more  predictability  of  the  work 
schedule to support people in combining care responsibilities and employment. The Directive 
on work-life balance, entered into force in August 2019, aims to promote the participation of 
women  in  the  labour  market,  and  the  take-up  of  family-related  leave  and  flexible  working 
arrangements for caring purposes. According to the Directive, workers providing personal care 
or support to a relative should be entitled to five days of leave per year. Besides, it extends the 
right to request flexible working arrangements to carers and working parents of children up to 
eight  years old.189 The rise in care needs should be considered by Member States when they 
develop their care policies, including with regard to carers’ leave (recital 27). Member States 
are  encouraged  to  make  the  right  to  carers’  leave  available  to  additional  relatives,  such  as 
grandparents  and siblings (recital  27)190. Member States have three  years to adopt  the laws, 
regulations and administrative provisions necessary to comply with the Directive.  

187 Expert panel on effective ways of investing in health. Furthermore, for workers in the health or care sectors, the 
“RESPOND” project aims to address adverse mental health effects due to the COVID-19 pandemic. 
188 Commission (COM/2021/762 final), Proposal for a Directive of the European Parliament and of the Council on improving 
working conditions in platform work. 
189 Defined by Article 6 of the Directive.  
190 See also the Directive for the definition of some relevant concepts: Art. 3 (c): ‘carers’ leave’ means leave from work for 
workers in order to provide personal care or support to a relative, or to a person who lives in the same household as the 
worker, and who is in need of significant care or support for a serious medical reason, as defined by each Member State; 
Art. 3 (d): ‘carer’ means a worker providing personal care or support to a relative, or to a person who lives in the same 

42 

 
 
                                                 
4.2.  EU analytical work 

In addition to the above initiatives that contribute to framework conditions for long-term care, 
the European Commission has aimed to strengthen the evidence base over the last years. This 
effort includes not only studies, but also increasing the quality and availability of statistical data 
for long-term care that is collected by Eurostat.  

A recent study explored the incidence and costs of informal long-term care in the EU191 and 
resulted in first time estimates for the number of people providing informal long-term care, and 
an  in  depth  analysis  of  their  characteristics.  It  also  estimated  the  costs  associated  with  the 
provision  of  informal  long-term  care  for  the  individual  and  the  society  as  a  whole. 
Eurofound192 conducted a study on the employment and working conditions in the long-
term care sector, looking also at the nature of employment and role of collective bargaining 
in the sector. It also discusses policies to make the sector more attractive, combat undeclared 
work and improve the situation of a particularly vulnerable group of long-term care workers: 
live-in carers. 

A  study  on  the  long-term  care  supply  and  market  in  EU  Member  States 193 provides  a 
mapping of the supply structure for long-term services and examines a sample of 16 Member 
States  with  a  focus  on  provider  structures.  Furthermore,  the  European  Social  Protection 
Network conducted research on the quality of long-term care194, the role of new technologies 
in modernising long-term care systems195 and long-term care and social protection models196.  

The Commission has also worked with the OECD on measuring the effectiveness of social 
protection for long-term care in old age197. Using a set of ‘typical cases’ of long-term care 
need to ensure comparability this work shows cross-country and regional variations in the total 
costs of long-term care services, the degree of public coverage, the out-of-pocket costs that care 
recipients face, and the associated poverty risks. The cooperation entered a new phase in 2022, 
not  only  producing  population  level  estimates  of  the  typical  cases,  but  also  analysing  the 
effectiveness of social protection more broadly.  

This rich analytical work has been instrumental for building up a strong evidence base for the 
recent  publication  of  the  2021  Joint  Report  on  Long-Term  Care  by  the  Social  Protection 

household as the worker, and who is in need of significant care or support for a serious medical reason, as defined by each 
Member State. 
191 Van der Ende, M. et al., 2021, Study on exploring the incidence and costs of informal long-term care in the EU.  
192 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg.  
193 KPMG, 2021, Study on the long-term care supply and market in EU Member States.  
194 Zigante, V. and King, D., 2019, Quality Assurance Practices in Long-term Care in Europe, Research Note for the Social 
Situation Monitor. 
195 Zigante, V., 2021, The role of new technologies in modernising long-term care systems: a scoping review. Research Note 
for the Social Situation Monitor.  
196 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union.  
197 Cravo Oliveira Hashiguchi, T. and Llena-Nozal, A., 2021, The Effectiveness of Social Protection for Long-term Care in 
Old Age: Is social protection reducing the risk of poverty associated with care needs?, OECD Health Working Papers No 
117, OECD Publishing, Paris. 

43 

 
 
                                                 
Committee (SPC) and the Commission (DG EMPL)198. It has put a spotlight on the common 
challenges related to the provision of long-term care and set out key messages199 on the way 
forward, endorsed by the Employment, Social Policy, Health, and Consumer Affairs Council 
(EPSCO) on 14 June 2021. The 2021 long-term care report follows the first joint long-term 
care  Report  in  2014 200 ,  which  looked  in  more  detail  at  strategies  of  prevention, 
rehabilitation/re-enablement, and age-friendly environments in the Member States. 

Moreover, the Economic Policy Committee and the Commission (DG ECFIN) jointly published 
the 2021 Ageing Report201, which amongst others collects and analyses data on public long-
term care expenditure and cash and in-kind long-term care benefits. It states that ‘the clear need 
for  a  broadening  of  formalised  coverage  of  the  European  population  with  long-term  care 
services will have to be balanced with the need to ensure the sustainability of public finances’ 
(p 162).  

4.3.  The social Open Method of Coordination 

The  social  open  method  of  coordination  (OMC)  is  an  important  channel  of  dialogue  and 
cooperation of the European Commission with the Member States in the area of long-term care. 
This coordination is implemented via the Social Protection Committee (SPC), an advisory 
policy committee to  the Ministers in  the Employment and Social Affairs Council (EPSCO), 
established in accordance with Article 160 of the TFEU and acting as a forum for multilateral 
social policy coordination, dialogue and cooperation at EU level. 

Member States agreed common objectives for long-term care in terms of access, quality, 
and  sustainability202 which  form  the  background  of  collaboration  on  long-term  care  in  the 
SPC. As part of its tasks to monitor the social situation in the EU and the development of social 
protection  policies  the  SPC  produces  annual  reports 203 .  In  its  2021  Report,  the  SPC 
highlighted that investment in the social, long-term care and health sectors and in human capital 
will  need  to  be  maintained  or  expanded  where  necessary  and  that  Member  States  need  to 
significantly step up their efforts to address the structural challenges in relation to  long-term 
care.204 As part of its  annual Social Protection Performance Monitor (SPPM)205, the SPC 
highlighted the exposure of older people to the health risks of the COVID-19 virus, but also the 

198 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and 
opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 
199 Council (9144/21), Endorsement – Key conclusions on 2021 long-term care report of the Social Protection Committee and 
the European Commission.  
200 European Commission and Social Protection Committee, 2014, Adequate social protection for long-term care needs in an 
ageing society, Publications Office of the European Union, Luxembourg.  
201 European Commission and Economic Policy Committee, 2021, The 2021 Ageing Report – Economic and budgetary 
projections for the EU Member States (2019-2070), Publications Office of the European Union, Luxembourg.  
202 Commission Communication (COM/2008/418 final), A renewed commitment to social Europe: Reinforcing the Open 
Method of Coordination for Social Protection and Social Inclusion. 
203 SPC, 2021, Annual Report.  
204 In particular, this entails ensuring the availability of high-quality, affordable and accessible long-term care services to all 
those in need; addressing the workforce challenges and supporting long-term carers; and enhancing the cost-effectiveness of 
long-term care in times of rising demand and a shrinking workforce, including through tapping into the potential of 
digitalisation and focussing on prevention. 
205 SPC, 2021, Social Protection Performance Monitor (SPPM). 

44 

 
 
                                                 
burden  that  was  placed  on  women  as  formal  and  informal  carers  and  the  need  to  reinforce 
cooperation between social services and healthcare systems. 

A monitoring framework in the field of long-term care has been under development since 
2018,  through  the  joint  efforts  of  the  Indicators  subgroup  of  the  SPC  and  the  European 
Commission.206 The group thereby supports the collection of comparative data as part of the 
open  method  of  coordination  long-term  care  work  stream  regarding  access,  quality  and 
sustainability  and  works  closely  with  Eurostat  to  develop  and  harmonise  European  data 
collections.  

Thematic reviews and mutual learning activities on long-term care are regularly organised 
in SPC with the support of the European Commission207. Topics addressed included quality of 
long-term care, financing of long-term care, the work-life balance of informal carers, addressing 
workforce shortages in the long-term care sector, or deinstitutionalisation.  

4.4.  The European Semester 

At  the  core  of  the  EU’s  socio-economic  governance  structure  is  the  European  Semester  of 
policy  coordination,  through  which  the  Commission  and  the  Council  set  priorities,  review 
national performance and reform programmes, and issue Country-Specific Recommendations 
(CSRs) to Member States.  

The Joint Employment Report208 provides an annual overview of the key developments, and 
the  Union’s  and  Member  States'  performances  regarding  the  implementation  of  the 
Employment  Guidelines,  including  the  principles  of  the  Pillar  of  Social  Rights.  The  Social 
Scoreboard monitors Member States' performance in relation to the European Pillar of Social 
Rights. As part of the European Pillar of Social Rights action plan209, the European Commission 
proposed a revision of the Social Scoreboard that also includes secondary indicators relating to 
long-term care210. 

In the area of long-term care, most CSRs have focused on access of the people in need of care, 
but it was also sometimes highlighted from a complementary perspective, that of carers and 
their  labour  market  participation.  Some  CSRs  were  multifaceted  balancing  social  and  fiscal 
considerations, and several were sustainability-driven. In 2019, there were 8 long-term care-
related CSRs focusing on sustainability (AT, BE), on access and female labour participation 
(IT,  PL,  SK),  and  on  access,  affordability,  quality  and  cost-effectiveness  (EE,  FI,  SI).  In 
response to the COVID-19 pandemic, in 2020 the CSRs were streamlined and emphasised long-
term  care  systems’  resilience,  with  relevant  aspects  for  long-term  care  regarding  fiscal 
sustainability  and  female  labour  market  participation  were  reflected  in  the  recitals.  Three 
Member States (FI, PT, SI) had a long-term care-related CSR. In 2021, the Commission did not 
propose non-fiscal Country Specific Recommendations, while in 2022 five Member States (AT, 
BE, EE, PL, SI) received a Country Specific Recommendation related to long-term care. These 

206 Monitoring and benchmarking frameworks.  
207 Peer reviews.  
208 Commission (COM(2021) 743 final), Joint Employment Report 2022. Adopted by EPSCO on 14 March 2022. 
209 Commission (COM/2021/102 final), The European Pillar of Social Rights Action Plan.  
210 Agreement on the secondary indicators is however still pending with the ISG and SPC. 

45 

 
 
                                                 
touched upon issues such as improving the affordability and quality of long-term care, ensuring 
the adequacy and fiscal sustainability of long-term care systems, or improving access to long-
term care as a way to enhance women’s labour market participation. 

Exceptional  measures  were  adopted  to  support  the  recovery  process  during  the  COVID-19 
pandemic and enhance the social and economic resilience through the Recovery and Resilience 
Facility (RRF). This led to a need to temporarily adapt the Semester to ensure synergies with 
RRF cycle. The Member States were invited to reflect their national agendas for reforms and 
investments in their recovery and resilience plans (RRPs) consistently with the challenges and 
priorities identified in the context of the European Semester. The Commission accompanied the 
proposals for the Council implementing acts with analytical documents assessing the substance 
of the recovery and resilience plans, which replaced the European Semester country reports in 
2021.  Given  the  comprehensive  and  forward-looking  policy  nature  of  the  recovery  and 
resilience plans, the Commission did not propose non-fiscal country-specific recommendations 
in 2021.  

Reform  implementation  is  monitored  by  the  Social  Protection  Committee  and  Employment 
Committee through multilateral implementation reviews, respectively multilateral surveillance 
of reforms, focused on the previous years’ country-specific recommendations in their areas of 
competence.  The  SPC  2022  thematic  discussion  on  long-term  care  confirmed  that  social 
protection coverage for long-term care needs varies considerably across the Member States and 
even when available, it is in some cases insufficient to ensure that people in need of care are 
not pushed into poverty. As concerns workforce challenges, some Member States are taking 
measures to reinforce formal care services and provide support to informal carers. The role of 
person-centred care and integrated delivery of services focused on personal needs in ensuring 
continuity  of  care  and  supporting  independent  living  in  all  care  settings  was  stressed.  The 
discussion showed that there is a need to draw up and/or expand quality standards to respond 
to structural weaknesses revealed by the COVID-19 pandemic, while reflecting the increasing 
diversity of care services and care settings and care users’ preferences.  

4.5.  Funding opportunities at EU level 

The  EU-level  funding  opportunities  to  support  investments  in  long-term  care  include  the 
structural  funding  programmes  such  as  European  Regional  Development  Fund  (ERDF),  the 
European Social Fund plus (ESF+), the Employment and Social Innovation strand (EaSI), the 
European  Agricultural  Fund  for  Rural  Development  (EAFRD)  and  the  Just  Transition  Fund 
(JTF). The Recovery and Resilience Facility (RRF) finances reforms and investments aimed at 
supporting recovery  from  the COVID-19 pandemic. Technical  support is  available from  the 
Technical Support Instrument (TSI) for reform design and implementation. Finally, research 
projects  can  be  financed  via  the  Horizon  Europe  or  Digital  Europe  programmes,  while 
Erasmus+  programme  can  support  sectoral  skills  cooperation  and  development  for  training 
curricula and programmes for carers. 

4.5.1.  Structural funds 

In the programming period 2014-2020, the ESF has supported several actions related to long-
term care ranging from the reskilling and upskilling of the workforce, expanding access and 

46 

 
 
coverage,  supporting  integrated  care  services  and  independent  living,  to  active  and  healthy 
ageing. 

Expenditure related to type 4 – access to services which include long-term care stands at 19 
% of expenditure declared by beneficiaries to Managing Authorities for TO9 operations: 

Figure 11: ESF Investment priorities and operations (2014-2020) 

Programming for the period 2021-2027 Member States is ongoing, and access to the European 
Regional Development Fund (ERDF) and the European Social Fund plus (ESF+) is conditional 
upon national or regional strategic policy framework for health and long-term care. ESF+, with 
a  total  budget  of  EUR 99.3  billion,  supports  the following  specific  objectives  in  the  area  of 
long-term care with regards to people with support needs: 

-  promoting  a  gender-balanced  labour  market  participation,  equal  working  conditions, 
and a better work-life balance including through access to affordable childcare, and care 
for dependent persons; 

-  promoting the adaptation of workers, enterprises and entrepreneurs to  change, active 
and healthy ageing and a healthy and well adapted working environment that addresses 
health risks. 

- 

enhancing  equal  and  timely  access  to  quality,  sustainable  and  affordable  services, 
including services that promote the access to housing and person-centred care including 
healthcare; modernising social protection systems, including promoting access to social 
protection,  with  a  particular  focus  on  children  and  disadvantaged  groups;  improving 
accessibility  including  for  persons  with  disabilities,  effectiveness  and  resilience  of 
healthcare systems and long-term care services; 

The  ESF+  also  promotes  the  transition  from  residential  and  institutional  care  to  family  and 
community-based care, in particular for those who face multiple discrimination and should not 
support any action that contributes to segregation or to social exclusion.  

47 

 
 
 
4.5.2.  The European Agricultural Fund for Rural Development 

The European Agricultural Fund for Rural Development (EAFRD) supports European policy 
on rural development with a total budget of EUR 95.5 billion for the period 2021-2027. Also 
based on the relevant evidences and facts described in the Long-term Vision for Rural Areas1 
the Regulation (EU) 2021/2115 on the Common Agricultural Policy Strategic Plans gives the 
possibility for Member States to support rural childcare and long-term care under the Specific 
Objective 8 (in coordination with and complementing to other EU funds). Rural areas and rural 
population all around the EU can face challenges related to access to care services which has a 
negative  impact  on  the  economic  and  living  conditions.  Also,  depopulation  and  ageing  are 
negative  phenomena  in  many  rural  areas  of  the  EU  and  often  influenced  by  the  lack  of 
affordable  and  accessible  basic  services,  which  is  why  EU  rural  development  policy  is 
addressing to improve the current situation. 

4.5.3.  The Just Transition Fund  

The Just  Transition  Fund (JTF), equipped with  EUR 17.5 billion (in 2018 prices;  EUR 19.2 
billion in current prices), is one of the key tools to support regions in the transition towards 
climate neutrality by 2050. It aims to alleviate the socio-economic costs triggered by climate 
transition,  by  supporting  the  economic  diversification  and  reconversion  of  the  territories 
concerned.  This  entails  supporting  productive  investments  in  small  and  medium-sized 
enterprises, the creation of new firms, research and innovation, environmental rehabilitation, 
clean  energy,  up-  and  reskilling  of  workers,  job-search  assistance  and  active  inclusion  of 
jobseekers programmes, as well as the transformation of existing carbon-intensive installations 
when these investments lead to substantial emission cuts and job protection. It is expected to 
mobilise close to EUR 30 billion in investments within the 2021-2027 budget cycle.  

While the main aim of the programme is to support investments to mitigate the impact of the 
climate transition , where duly justified, territorial just transition plans may contain activities in 
the  areas  of  education  and  social  inclusion  including,  investments  in  infrastructure  for  the 
purposes of training centres, child- and long-term-care facilities as indicated in territorial just 
transition plans. 

4.5.4.  EASI social innovation projects on long-term care 

The Employment and Social Innovation (EaSI) programme promotes a high level of quality 
and sustainable employment, guaranteeing adequate and decent social protection, combating 
social  exclusion  and  poverty  and  improving  working  conditions.  It  became  strand  of  the 
European Social Fund Plus (ESF+) for the period 2021-2027. 

A 2019 EASI  call  for social innovation  projects  in the area of  long-term  care funded  seven 
projects (total budget: EUR 9 million), which aim to design and test innovative ways to address 
long-term care challenges. They include designing integrated care models, new ways to provide 
long-term  care  in  rural  sparsely  populated  areas,  new  funding  models  for  long-term  care, 
strengthening individual autonomy and introducing participatory decision-making in long-term 
care policy formation. Some projects have a regional focus while others have a pan-European 
dimension and cover a number of countries (France, Italy, Portugal, Greece, Germany, Poland, 

48 

 
 
Austria,  Spain,  North  Macedonia,  Belgium,  Montenegro,  Republic  of  Serbia,  etc.).  Their 
implementation is ongoing (running between 2020-2024), and if successful, the new models 
can later be up-scaled using EU structural funding. 

4.5.5.  Technical Support Instrument  

The Technical Support Instrument (TSI) provides technical support to EU Member States  on 
reform  design  and  implementation.  The  TSI  follows  an  annual  cycle  with  a  total  budget  of 
EUR 864.4 million for the period 2021-2027 (in current prices), thus around EUR 120 million 
annually.  

The programme already  supports a number of projects aimed at improving the affordability, 
quality and availability of long-term care benefits and services.  

Provision of integrated care services in Estonia 

The  overall  aim  of  this  project  was  to  contribute  to  a  more  integrated  and  person-centred 
provision of social, medical and vocational support services to people with disabilities and 
elderly with high support needs in Estonia. To this extent, the project provided a strategy to the 
Estonian government, which should contribute to: (i) improvements in the interoperability of 
registries and administrative datasets; (ii) the development of measures and indicators through 
which  to  support  quality  improvement  and  assess  performance;  (iii)  the  introduction  of 
performance-based financing and payment elements to incentivise integrated service provision; 
and (iv) a closer cooperation between services administered at central and at local level, as 
well as between local stakeholders. 

The  Communication  on  a  European  care  strategy  announces  a  flagship  ‘Towards  person-
centred integrated care’. Such support aims at facilitating reforms in line with the proposal 
for  a  Council  Recommendation  on  access  to  affordable  high-quality  long-term  care.  The 
flagship will help Member States, upon demand, to design and implement reforms aimed at 
strengthening  the  coordination  between  health,  social  care  and  long-term  care  and  the 
integration  of  the  different  levels  of  care  provision,  by  putting  the  person  at  the  centre  of 
services to ensure better access and better quality of care at every stage of life. 

4.5.6.  The Recovery and Resilience Facility 

The outbreak of COVID-19 has changed the economic outlook for the  years to  come in the 
European Union. Investments and reforms are needed more than ever to ensure convergence 
and a sustainable economic recovery. The Recovery and Resilience Facility, with EUR 732.8 
billion in grants and loans211, provides Member States with significant opportunities to fund 
reforms and investments in social resilience, including in long-term care. 

A large number of Member States212 mobilised the RRF for the long-term care sector. 

Examples  of  reforms  under  the  RRPs  include  strengthening  long-term  care  system  and 
promoting a change in the model of support and long-term care, increasing human resources 

211 In current prices, see here.  
212 18 Member States: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czechia, Estonia, France, Greece, Italy, Latvia, 
Lithuania, , Poland, Portugal, Romania, Slovakia, Slovenia, Spain and Sweden. 

49 

 
 
                                                 
and infrastructure capacity for the provision of long-term care services, training, reskilling and 
upskilling  of  long-term  care  professionals.  Additional  reforms  are  also  expected  to  improve 
long-term care provision by modernising or expanding social services, including community-
based  services,  and  by  supporting  long-term  fiscal  sustainability  of  long-term  care  systems. 
Many  plans  also  include  measures  to  support  high-quality  long-term  care  services  through 
targeted investments in public utility housing and housing for vulnerable persons and related 
services as well as in community-based care and outpatient facilities and services. Quality and 
access of long-term  care services  will also be supported through energy-efficient  renovation 
and  modernisation  of  long-term  care  institutions,  including  the  improvement  of  digital 
infrastructure. 

Lithuania - Reform ‘Provision of long-term care services’ 

The objective of the reform is to improve the accessibility of integrated social and healthcare 
services by developing and implementing a sustainable  long-term care model. An action 
plan for training, reskilling and upskilling of long-term care professionals shall be developed 
and  a  plan  for  ensuring  the  necessary  infrastructure  for  the  provision  of  long-term  care 
services at the level of each municipality and region shall ensure an optimal use of existing 
infrastructure  for  health  and  social  protection  and  resources  of  municipal  and  non-
governmental  organisations.  For  each  region,  the  analysis  of  resources  for  institutional, 
community-based and home-based long-term care shall be made and a new model for the 
provision of long-term care shall become operational. This reform is accompanied by two 
sub-measures: (1) Adoption of the long-term care model (sub-measure 1); (2) Increase of 
human  resources  and  infrastructure  capacity  for  the  provision  of  long-term  care  services 
(sub-measure 2).  

Examples of investments under the RRPs cover equipping social services with the means to 
enable home care (e.g. setting up rapid response units), setting up community-based care and 
outpatient  facilities,  equipping  long-term  care  facilities  with  digital  infrastructure  such  as 
internet connections, computers and software as well as with equipment to better identify needs 
and improving quality, implementing energy efficient renovation and modernisation of long-
term  care  structures  such  as  elderly  homes  (nursing  homes),  day  care  and  community  care 
centres, and hospital infrastructure. 

Austria - Investment in the implementation of community nurses  

The objective of the establishment of community nursing in Austria is to make a significant 
contribution to  local, low-threshold  and needs-based care; community nurses are central 
contact people who coordinate various services (such as therapies and social services) and 
play a central role in the field of prevention. The investment consists in the establishment of 
a  network  of  community  nurses  close  to  their  patients.  Community  nurses  are  qualified 
nurses with at least two years of professional experience. Community nurses with a further 
relevant qualification (such as courses on community nursing, family health nursing, public 
health nursing) shall preferably be employed. In the course of the project, 150 community 
nurses shall be posted nationwide as part of the pilot project within the framework of fixed-

50 

 
 
term employment contracts. The implementation of the investment shall be completed by 31 
December 2024. 

4.5.7.  Horizon Europe 

Horizon Europe is the EU’s key funding programme for research and innovation with a budget 
of EUR 95.5 billion.213 It facilitates collaboration and strengthens the impact of research and 
innovation  in  developing,  supporting  and  implementing  EU  policies  while  tackling  global 
challenges. It supports creating and better dispersing of excellent knowledge and technologies. 

Several  components  of  Horizon  Europe  can  support  long-term  care,  including  the  health 
component214. The Work Programme 2023-2024 contains a research project on ‘Integrated care 
solutions for better quality, person-centred long-term care and territorial inequalities in their 
provision’ with a budget of EUR 9 million. 

4.5.8.  Digital Europe 

The Digital Europe Programme focuses on bringing digital technology to businesses, citizens 
and  public  administrations.  It  provides  supports  projects  in  five  key  capacity  areas:  in 
supercomputing,  artificial  intelligence, cybersecurity, advanced digital  skills,  and ensuring a 
wide  use  of  digital  technologies  across  the  economy  and  society,  including  through  Digital 
Innovation Hubs.  

With a planned overall budget of EUR 7.5 billion (in current prices), it aims to accelerate the 
economic  recovery  and  shape  the  digital  transformation  of  Europe’s  society  and  economy, 
bringing benefits to everyone, but in particular to small and medium-sized enterprises. 

As digital technologies play an important and growing role in the transformation of health and 
care delivery, health promotion, disease prevention, assisted living technologies and monitoring 
devices, various initiatives under Digital Europe Programme could promote Long-Term care. 
These include in particular the ‘Artificial Intelligence Testing and Experimentation Facility in 
Health’ and the ‘Uptake of Digital solutions in Health and Care’ Calls, but also other topics 
supporting the cybersecurity in health, as well as the exchange of health data and of Electronic 
Health Records, as one of the ambitions set in the Digital Decade Communication is to have 
100% of citizens having access to medical records by 2030. In addition, the network of Digital 
Innovation Hubs215 co-funded by DIGITAL will help innovators, also in the health domain, to 
scale-up their solutions across European regions.  

4.6.  Why and how the EU should act now 

Long-term care systems are designed nationally and long-term care services are delivered in 
local communities, but challenges are shared among the countries and the consequences of not 
acting to improve them spill over across borders. Long-term care is increasingly relevant for 
the single market, as care providers and recipients take advantage of the freedom to move and 

213 European Commission, 2021, Horizon Europe, budget. Publications Office of the European Union, Luxembourg.  
214 Ibid. 
215 Digital Innovation Hubs. 

51 

 
 
                                                 
to  establish  and  provide  and  receive  services,  including  digitally  enabled  ones.  Access, 
affordability, quality challenges as well as workforce shortages and gender inequalities have a 
negative impact on social cohesion, labour market participation and economic growth. Effective 
long-term care systems are crucial for improving living conditions and ensuring proper social 
protection, as enshrined in Article 151 of the Treaty on the Functioning of the European Union 
(TFEU).  

The scale of the problem demands a focused and comprehensive approach at EU level. Current 
Union  efforts  to  support  Member  States  in  addressing  long-term  care  challenges  –  notably 
exchanges of best practice, mutual learning, and joint analysis and reporting – have exhausted 
their  potential  to  address  a  substantial  and  growing  concern.  Furthermore,  the  existing  EU 
initiatives which are indirectly touching various aspects of long-term care provide a scattered 
picture of the EU policy framework on long-term care.  

The European care strategy provides an EU-level response to and recognition of the societal 
and  economic  importance  of  long-term  care.  On  one  hand,  it  proposes  concrete  supportive 
actions at EU level, and, on the other, it provides Member States with comprehensive policy 
guidance on addressing the multifaceted challenges in this area. The measures outlined in the 
initiatives respect national competences and do not prevent EU countries from maintaining or 
introducing more ambitious measures that are compatible with the Treaties.  

5.  POLICY OPTIONS FOR ADDRESSING THE CHALLENGES 

OF LONG-TERM CARE 

This chapter sets out different policy scenarios and practical examples of how  to strengthen 
affordability, availability, and quality of long-term care and how to address the challenges faced 
by  formal  and  informal  carers.  It  concludes  by  underlining  the  importance  of  sound  policy 
governance in long-term care and of adequate and sustainable funding for long-term care. 

It builds on the rich array of policy practices currently in place at EU, national, regional and 
local  levels.  It  factors  in  the  input  received  during  the  targeted  stakeholder  consultation 
underpinning the initiative. It also runs some policy simulations to illustrate the potential costs 
and benefits associated with action to improve social protection, increase the availability of care 
and to invest in the long-term care workforce. The calculations are only indicative due to the 
scarcity and limited comparability of data.  

5.1.  Social protection for long-term care 

The  proposal  for  a  Council  Recommendation  on  long-term  care  invites  Member  States  to 
improve the adequacy of social protection for long-term care, in particular by ensuring that 
long-term care is: 

 

timely, allowing people in need of long-term care to receive the necessary care as soon 
as, and for as long as, needed; 

  comprehensive, covering all long-term care needs, arising from mental and/or physical 
decline  in  functional  ability,  assessed  on  the  basis  of  clear  and  objective  eligibility 
criteria; 

52 

 
 
  affordable, enabling people in need of long-term care to maintain a decent standard of 

living and protecting them from poverty due to long-term care needs. 

5.1.1.  Providing adequate social protection for long-term care  

The adequacy of social protection depends not only on the rules granting social protection, but 
also on providing it in a timely manner. Therefore it is important to ensure the existence and 
geographical proximity of the authorities responsible for care in Member States, and that they 
have the capacity to handle requests for support (e.g. to conduct needs assessments). Especially 
when social protection is provided via benefits in-kind, public care services should be available 
shortly after the request, in the area where the person in need lives.  

Shock plan to reduce waiting times in Spain216 

A  shock  plan  approved  in  January  2021  brought  in  reforms  designed  to  simplify 
administrative procedures, speed up the processing of applications, reduce waiting lists for 
dependents  that  are  not  receiving  the  services  to  which  they  are  entitled  and  reduce 
differences  in  levels  of  care  across  the  country.  The  immediate  actions  also  included 
strengthening  the  quality  of  professional  services,  improving  working  conditions  and 
increasing the coverage of different types of financial benefits. 

The Spanish authorities identified that long waiting times are a multi-causal phenomenon, 
caused  partly  by  the  complexity  of  the  administrative  process,  process  fragmentation, 
interoperability and insufficient staffing. To address these challenges, the reforms integrate 
administrative and technical procedures and integrate computer systems, while also taking 
steps to improve data quality. The reforms also include boosting the workforce for both the 
management and the needs assessment. Lastly, Spain plans to invest more in technical and 
material resources, and to expand the effective availability of services and benefits.  

Though  it  is  still  a  work  in  progress,  the  reform  has  already  brought  down  the  average 
waiting  time  between  the  date  a  person  submits  an  application  and  when  they  actually 
receive the benefit by 36 days in the first year, from a very high starting point of 457 days in 
2020.  

Adequate  social  protection  to  cover  long-term  care  is  based  on  a  comprehensive  needs 
assessment with clear and objective eligibility criteria. Member States can define long-term 
care needs in a narrower or broader sense and this has a significant impact on the level of social 
protection benefits, as the criteria are usually used by authorities to differentiate among levels 
of long-term care needs.  

In general, health professionals (GPs, gerontologists, or nurses) and social workers make this 
assessment.  The  needs  assessment  and  its  regulation  can  be  centralised  or  devolved  to 
regional/local levels, depending on whether they have an integrated long-term care system and 
on the level of government in charge of organising long-term care public provision. In Nordic 

216 IMSERSO, 2022, Long-term care reforms in Spain. Presentation at the Social Protection Committee.  

53 

 
 
                                                 
countries, for example, the criteria and assessment are highly devolved to municipalities and 
their long-term care professional teams.  

To encourage and help people in need of care to apply for social protection, it is also important 
that the criteria used to assess needs and the application procedures are clear and objective. 

Capacity building for the assessment process of long-term care recipients in Slovenia217  

The Slovenian authorities have developed a tool to assess long-term care needs via a pre-
pilot project building on a German long-term care assessment tool. Through two subsequent 
pilot  projects218 financed  by  the  European  Union  through  the  European  Social  Fund,  the 
assessment tool suggested by the pre-pilot project was upgraded and tested by over 5 000 
people.219 The project then added a single entry point, new services for users (including e-
care services) and monitoring functions.  

The Long-Term Care Act, adopted in December 2021, specifies that this assessment scale is 
now the uniform tool used to assess an insured person's entitlement to long-term care rights, 
amongst other provisions. The assessment of long-term care eligibility takes into account the 
applicant’s:  

1. ability to move in the environment where the insured person lives; 

2. cognitive and communication skills; 

3. behaviour and mental health; 

4. ability to be self-sufficient (in terms of self-care) in the environment where the insured 
person lives; 

5. ability to cope with disease and illness, the treatment-related requirements and burdens; 

6. daily routine and social contacts; 

7. ability to perform activities outside the home environment; and 

8. ability to perform household chores in the environment where the insured person lives. 

The reform also established the Health Insurance Institute of Slovenia as the single entry 
point  for  long-term  care.  This  Institute  carries  out  professional  and  administrative  tasks, 
including the needs assessment. Before the new long-term care Act, services that could be 
classified  as  long-term  care  were  provided  through  multiple  social  protection  systems 
(healthcare  system,  pension  system,  social  care  system,  disability  care  system…)  with 
different entry points and different assessment procedures. 

The  long-term  care  assessment  will  now  be  provided  at  the  individual’s  home,  after  they 
submit  the  application  for  an  assessment  of  long-term  care  eligibility.  If  the  applicant  is 
eligible for care, reaching the entry threshold, they will be put into one of five categories, 

217 Slovenian Ministry of Health, Information provided by the Department of Long-term Care on 29 May 2022.  
218 (1) Implementation of pilot projects supporting the implementation of the long-term care systemic law and (2) Redesign of 
existing networks and entry of new providers to provide community services and programs for the elderly. 
219 The evaluation summary of the pilot project Implementation of pilot projects supporting the implementation of the long-
term care systemic law, including the assessment scale, is available here.  

54 

 
 
                                                 
indicating the basis for benefits (long-term care at home, long-term care at an institution, 
benefits in cash, carer of a family member, or eligible for services to maintain and strengthen 
their independence and e-care). All long-term care beneficiaries will be regularly assessed 
after five years.  

Over the last 20 years, Member States have implemented or mainstreamed policies that aim to 
both broaden long-term care service provision to more groups (e.g. people with dementia), and 
deepen the social protection given (e.g. raising the level of cash benefits).  

Long-term care coverage for dementia 

In  2017,  Germany 220  extended  long-term  care  benefits  to  around  500 000  more  people 
suffering from dementia (Second Long-Term Care Act Strengthening Act - PSG II). Dementia 
is regarded as one of the most expensive brain disorders that typically requires permanent 
monitoring and intensive caregiving. The government’s response has been to redefine the 
care-level grades through the use of a new assessment tool. Compared to before, the tool no 
longer calculates the time needed for nursing care but assesses the degree of self-reliance 
restrictions.  The  assessment  takes  into  account  all  kinds  of  self-reliance  restrictions: 
disabilities  both  in  physical  as  in  mental  health  and  in  cognition.  The  three  care  levels 
(Pflegestufen) are replaced by five new care degrees (Pflegegrade).  

This reform has been accompanied by a substantial increase in cash and in-kind benefits by 
more  than  EUR 2.5  billion.  It  was  preceded  in  2015  by  the  first  Long-Term  Care 
Strengthening Act (PSG I), which expanded benefits to all 2.7 million beneficiaries. Germany 
has increased  long-term care benefits  for  people living  at  home by  EUR 1.4 billion every 
year, and for people in residential care by EUR 1 billion for every year.  

Providing adequate social protection for long-term care makes services affordable, in particular 
for the least well-off. As discussed in chapter 3, if long-term care is unaffordable, care needs 
go  unmet,  which  may  later  on  translate  into  greater  and  more  costly  care  needs  and  more 
pressure on the health system. This can undermine other essential spending and puts an undue 
burden on informal caregivers.  

Social protection221 coverage for long-term care varies greatly. There are three main dimensions 
to  these  differences,  which  determine  the  affordability  of  long-term  care  for  the  overall 
population in need: who is covered (the people in need of long-term care who are covered 
by social protection for long-term care), what is covered (the range of needs and the types 
of services covered, usually based on the care needs assessment (breadth)), and how much is 
covered (depth of financial protection, reflecting cost-sharing arrangements, often referred to 
as adequacy).  

Most countries that provide social protection for long-term care needs apply some form of cost-
sharing arrangement. They either provide cash benefits that do not cover the full cost of care, 
or require the care recipients and their families to co-pay part of the costs of long-term care 

220 Germany's Long Term Care Strengthening Acts 
221 Muñoz De Bustillo Llorente, R., Fernandez Macias, E. and Gonzalez Vazquez, I., 2020, Universality in social protection: 
an inquiry about its meaning and measurement, Publications Office of the European Union, Luxembourg, p. 21-22. 

55 

 
 
                                                 
services  provided  as  in-kind  benefits.  Without  social  protection,  the  estimated  total  costs  of 
long-term care often exceed the disposable income of people in need of long-term care.  

As  illustrated  in  section  3.2,  even  when  social  protection  is  available,  in  some  cases  social 
protection for long-term care needs is still insufficient. On average nearly half of older people 
with long-term care needs would be below the poverty threshold after meeting the out-of-pocket 
costs of home care. Thus, it is important that social protection covers a sufficient share of the 
costs of care. In some cases, cost-sharing can be deferred, with the co-payments made on the 
death of the long-term care recipient when their assets are sold. Regular indexation of long-
term care cash benefits can also help ensure that they remain adequate over time. 

In January 2020, Austria brought in yearly indexation of long-term care cash benefits. This 
is a major change, as, in the past, long-term care cash benefits were indexed on an ad hoc 
basis, and thus their real value tended to fall substantially over the medium term.  In July 
2019,  Czechia  brought  in  a  4%  increase  in  the  personal  care  allowance  for  the  most 
dependent groups of beneficiaries (apart from people in residential care facilities). 

Given  that  historically,  long-term  care  lies  at  the  intersection  between  universal  healthcare 
services  and  sometimes  discretionary social care services, it has been  long seen  as  a  family 
responsibility222. However, in recent  years, several  Member States  have increased the social 
protection  available  to  cover  long-term  care  by  reducing  the  legal  obligation  on  families  to 
provide or cover the costs of care.  

In  Austria,  in  2007,  the  federal  provinces  stopped  recourse  to  the  assets  of  people  in 
residential long-term care, or those of their relatives, heirs or gift-recipients, to cover the 
costs  of  care.  Previously,  those  in  residential  long-term  care  often  lost  all  their  assets. 
Similarly, since 2019, Germany exempts children (with an annual gross income of less than 
EUR 100 000) of people in need of care from the obligation to cover care costs not covered 
by the care beneficiary, regardless of the care setting. Since 2017, co-payments for people 
receiving  residential  care  no  longer  depend  on  the  level  of  care  needed.  Everyone  in  a 
nursing home who needs long-term care and has been assessed as needing higher levels of 
care pays the same care-related co-payment (though the amount differs between residential 
homes)223. 

Member States are reforming their social protection systems to adjust them to the requirements 
of  an  ageing  population.  This  includes  establishing  a  sustainable  financing  base  often  in 
combination with an increase in financial protection and quality of long-term care. As research 
by Pavolini224 shows, Member States with a high level of social protection for long-term care 
usually have a dedicated social protection branch for long-term care.  

222 Leitner, S.,2003, Varieties of familialism: The caring function of the family in comparative. 
Perspective, European Societies 5(4): 353-375. 
223 European Commission and Social Protection Committee, 2021, Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 
224 Pavolini, E., 2021, Long-term care social protection models in the EU, European Social Policy Network (ESPN), 
Luxembourg: Publications Office of the European Union.  

56 

 
 
                                                 
In  order  to  improve  the  provision  of  care  for  older  people  and  people  with  disabilities, 
France aims to set up a fifth social protection branch in its general social security system 
covering  the  risk  of  loss  of  autonomy.  Current  branches  cover  the  risks  of  sickness, 
retirement,  family,  work-related  accidents  and  occupational  disease.  The  Social  Security 
Financing  Law  of  2021  defines  the  first  measures  for  organising  the  governance  and 
financing  of  this  new  branch,  with  EUR 1billion  co-financed  via  the  RRP.  The  main 
guidelines  of  a  deep-seated  reform  were  presented  in  the  Libault  report  of  2019,  which 
includes the recommendation to invest almost EUR 10 billion in long-term care by 2030.  

Slovenia adopted a long-term care Act in December 2021 introducing compulsory long-term 
care insurance. The compulsory health insurance (HIIS) covers everyone aged 18 and over 
in Slovenia. Another act will set the other conditions for long-term care insurance, such as 
contribution rates and a contribution base. Until its adoption (estimated to be in June 2025), 
3.8% of  HIIS funds and 2.2% of  funds collected by the Pension and Disability Insurance 
Institute will be used to finance long-term care, in addition to transfers from the state budget. 
The  new  act  defines  the  rights  and  assessment  mechanism  for  categories  of  care  and  it 
emphasises community care and brings in e-care and some other new services.  

The  COVID-19  pandemic  is  also  an  opportunity  to  further  re-think  the  paradigm  of  social 
protection in long-term care and to adjust it to an evolving social contract regarding care. As 
people in need of care and their families are often unable to pay for the high cost of long-term 
care,  nor  to  adequately  provide  informal  care,  public  long-term  care  provision  is  crucial.  It 
should build on a renewed social contract and sense of intergenerational solidarity. 

5.1.2.  Illustrating the impact of improving social protection for long-term care 

The European Commission has worked together with the OECD to simulate a number of 
policy  scenarios  that  estimate  the  potential  impact  of  expanding  or  deepening  the  social 
protection coverage for long-term care across the EU225. They illustrate how increasing social 
protection can reduce the share of people at risk of poverty after using formal long-term care 
services.  

The baseline scenario estimates the impact of public social protection for long-term care in old 
age under current circumstances (based on latest available information and data as of March 
2022), and under  certain  key  assumptions.  First, the  EU-27 average uptake of  any formal 
long-term care services by people in need of care is estimated to be 27%226. According to 

225 No models of social protection for long-term care in old age are available for Bulgaria, Cyprus and Romania, the 
information lacking was imputed for those three Member States. The models for Denmark, Greece, Poland and Portugal have 
not yet been validated with Member State representatives. OECD, forthcoming, 2022, Measuring social protection for long-
term care in old age, OECD Health Working Papers, OECD Publishing, Paris. 
226 Calculated as an average between the European Health Interview Survey (EHIS), the Survey of Health, Ageing and 
Retirement in Europe (SHARE) and the Irish Longitudinal Study on Ageing (TILDA). Determining current availability and 
uptake of public social protection for long-term care in old age in all Member States is challenging, given limited detailed 
data on the existence and geographical location of public social protection offices in Member States, and their capacity to 
handle requests for support (e.g. conduct needs assessments). Even then, assuming full availability of public social protection 
for long-term care, effective use also depends on the availability of providers, whose availability and geographical 
distribution is also difficult to establish across all Member States. Lastly, even if public social protection offices and 

57 

 
 
                                                 
these estimates, across the EU-27, around 7.2 % or 6.3 million people 65+ receive formal care, 
1.7 million of whom have severe needs and receive residential care227. Second, in the baseline 
scenario, the breadth and depth of social protection are derived from the latest OECD-developed 
models of social protection for each Member State for people with long-term care needs. Under 
the baseline scenario, if all older people use formal long-term care to fully cover their long-
term care needs, about 37% of them would be at risk of poverty (compared to 22.74% of older 
people with no long-term care needs). 

However, not all older people take up social protection for long-term care. This may be due to 
their limited administrative capacity, limited capacity to cover out-of-pocket costs, the limited 
availability of services, or by choice not to use public formal long-term care services or benefits. 
The estimated level of uptake of formal care differs significantly across the EU, from 8% in 
Romania to 46% in France228.  

In the two simulated policy scenarios, two hypothetical levels of uptake of social protection 
for long-term care229 are considered: 40% and 60% of people in need of long-term care. 
In the 40% take-up scenario, the number of people over 65 years of age using social protection 
for  long-term  care  would  increase  to  9.4  million  and  in  the  60%  take-up  scenario,  it  would 
increase to 14 million230. In Belgium, Cyprus, Denmark, France, Germany and the Netherlands, 
the estimated uptake of public social protection at baseline is over 40%. No Member State has 
a take-up ratio at baseline higher than 60% (the highest is France at 46%). The assumption is 
that the probability of uptake of older people with long-term care needs is higher for people 
with more severe needs and lower income.  

In policy scenario 1, the breadth (types of services covered) and depth of financial protection 
(cost-sharing arrangements) remain at current levels, with hypothetical levels of uptake of 40%, 
60% (coverage). Figure 12 shows the average out-of-pocket costs of long-term care, as a share 
of disposable income, averaged across respondents receiving home care for low, moderate and 
severe needs and institutional care for severe needs. The EU-27 average out-of-pocket costs of 
long-term care, as a share of disposable income, are 59% at 40% uptake and 47% at 60% uptake. 
In these scenarios, the risk of poverty would decrease only slightly by 2 percentage points (pp) 
(40% uptake) and by 6.8pp (60% uptake) for people using formal long-term care compared to 
the baseline (uptake of social protection by 27% of people with  long-term care needs). This 
shows  that  simply  increasing  the  take-up  of  public  social  protection  for  long-term  care 
without addressing gaps in financial coverage is not enough to reduce the at-risk-of-poverty 
rate significantly at EU-27 level.  

providers are available, older people with long-term care needs may choose not to use the public sector, in which case they 
will not take up public formal long-term care services. 
227 It is estimated that they use on average 7.6 hours of care a week. 
228 The assumption is that people with higher needs take up long-term care first. As the uptake level increases, the distribution 
of needs among people receiving social protection will also change; there will be more people with less severe needs. 
229 The underlying assumption is that these older people are able to do so, i.e. public social protection is available and 
accessible to them. 
230 All people in need would receive on average social protection for 10.7 hours and 12.9 hours of care a week respectively. 

58 

 
 
                                                 
Figure 12: Simulated out-of-pocket costs of care, as a share of disposable income after public 
support, averaged across respondents who take up formal care services under policy scenario 1 

Baseline

40% uptake

60% uptake

Disposable income of care recipient

350%

300%

250%

200%

150%

100%

50%

0%

Note: EU-27 is the unweighted average. Estimates shown are averages of three approaches to estimating long-term care needs 
among older people. * Member States for which no models of social protection for long-term care in old age were available 
and for which information on total costs and cost coverage is estimated (Bulgaria, Cyprus and Romania) and Member States 
for which models of social protection for  long-term care in old age have not yet been validated by country representatives 
(Denmark, Greece, Poland and Portugal). Outliers are removed using the interquartile range method to calculate the mean 
OOP as a % of disposable income. 

Source: OECD analysis based on the OECD long-term care social protection questionnaire, SHARE survey (Wave 7, 2017) 
and the TILDA survey for Ireland (Wave 3, 2015). 

Policy scenario 2 estimates the impact of public social protection for long-term care in old age 
when all Member States converge upwards to reach the EU-27 average depth of financial 
protection and extend the financial coverage to fully eliminate the poverty risks associated 
with  out-of-pocket  expenditure  for  formal  long-term  care  services  (Figure  13).  In  this 
scenario, paying for long-term care does not change an older person’s poverty risk. To illustrate, 
an older person that was in relative income poverty before receiving care would continue to be 
in relative income poverty, but under this scenario, people that were not previously income poor 
would  be  prevented  from  being  at  risk  of  poverty  due  to  the  intervention  of  public  social 
protection.  The  average  depth  of  financial  protection  is  the  unweighted  average  of  public 
financial coverage as a share of the total costs of care. In this scenario, Member States with an 
above-average depth of financial coverage would maintain that level of coverage, and Member 
States with a below-average depth of coverage would increase it to reach the average depth of 
coverage231.  

231 Bulgaria, Croatia, Cyprus, Czechia, Estonia, France, Greece, Hungary, Latvia, Portugal, Slovenia and Spain have lower 
than the EU-27 average financial coverage for home care for low, moderate and severe needs. These countries will converge 
upward to the EU-27 average of 67% of the total costs of home care being covered by public social protection systems. 
Belgium, Bulgaria, Croatia, Cyprus, Czechia, Estonia, France, Hungary, Portugal, Romania, the Slovak Republic and 

59 

 
 
 
                                                 
In  this  scenario,  the  EU-27  average  out-of-pocket  costs  of  long-term  care,  as  a  share  of 
disposable  income,  are  38%  at  40%  uptake  and  31%  at  60%  uptake,  leading  to  a  bigger 
reduction in average out-of-pocket costs of long-term care compared to policy scenario 1. This 
would reduce the risk of poverty by 13.9pp at 40% uptake and by 22.4pp at 60% uptake among 
older  people  with  long-term  care  needs,  compared  to  the  baseline  scenario.  This  scenario 
eliminates  the  poverty  risk  associated  with  out-of-pocket  costs  of  formal  long-term  care 
services  for  people  with  long-term  care  needs  who  receive  social  protection.  It  would  also 
decrease the out-of-pocket costs of long-term care as a share of disposable income, across the 
EU-27. 

Figure 13: Simulated out-of-pocket costs of care, as a share of disposable income after public 
support, averaged across respondents who take up formal care services under policy scenario 2 

Note: EU-27 is the unweighted average. Estimates shown are averages of three approaches to estimate long-term care needs 
among older people. * Member States for which no models of social protection for long-term care in old age were available 
and for which information on total costs and cost coverage is imputed (Bulgaria, Cyprus and Romania) and Member States 
for which models of social protection for  long-term care in old age have not yet been validated by country representatives 
(Denmark, Greece, Poland and Portugal). Outliers are removed using the interquartile range method to calculate the mean 
OOP as a % of disposable income. 

Source: OECD analysis based on the OECD long-term care social protection questionnaire, SHARE survey (Wave 7, 2017) 
and TILDA survey for Ireland (Wave 3, 2015). 

Table 1 provides an overview of the outcomes at baseline and under different policy scenarios, 
averaged across the EU-27. Though policy scenario 1 does lead to major reductions in the at-
risk-of-poverty rate  for  all older people in  some Member States (e.g. Romania and Poland), 
simply increasing the take-up of public social protection for long-term care without addressing 

Slovenia have lower than the EU-27 average financial coverage for institutional care for severe needs and they would 
converge to the average of 70% of the total costs of institutional care being covered. 

60 

 
 
 
                                                 
gaps in financial coverage is not enough to reduce at-risk-of-poverty rates significantly at EU-
27 level.  

Under policy scenario 2, the at-risk-of-poverty rate would fall the most, especially at higher 
levels  of  take-up  of  public  social  protection  for  long-term  care.  However,  because  of  the 
assumption that older people estimated to have long-term care needs who do not take up public 
social protection pay all costs of care out-of-pocket, the at-risk-of-poverty rates are difficult to 
compare  directly  with  the  at-risk-of-poverty  rates  among  older  populations  (using  Eurostat 
figures). 

As expected, a higher uptake of public social protection for long-term care also leads to higher 
total government spending on financial coverage for long-term care in old age, relative to total 
government spending in the baseline scenario. The differences across Member States can be 
significant, depending on current social protection arrangements. Total spending of all EU-27 
countries for social protection for  long-term care was estimated  at  EUR 229 billion in  2019 
(unweighted average of 0.9% of GDP).232 Under scenario 1, total spending would increase by 
EUR 103 billion to 1.5% of GDP, while it would increase by 147 billion to 1.8% of GDP under 
scenario 2 by 2030 (with 60% uptake).  

Table 1: Overview of EU-27 average outcomes, at baseline and under different policy scenarios 

Policy scenarios and 
uptake levels among 
older people (65+) in 
need of LTC 

Baseline 

Policy scenario 1 

Policy scenario 2 

40% 

60% 

40% 

60% 

Share of older 
people (65+) 
receiving care 

Average OOP 
costs as share 
of income 

Median OOP 
costs as share 
of income 

Average hours 
of SP for care 
per older 
person (65+) 
in need 

Spending 
increase over 
baseline 

Percentage 
point changes 
AROPE 
among LTC 
users 

7.6 

10.7 

12.9 

10.7 

12.9 

7.7% 

12.5% 

18.7% 

12.5% 

18.7% 

70.9% 

58.7% 

47.5% 

38.2% 

30.7% 

74.3% 

55.2% 

44.4% 

33.9% 

28.1% 

- 

-2.0 

-6.8 

-13.9 

-22.4 

- 

35% 

65% 

71% 

104% 

Note: EU-27 is the unweighted average. OOP – out-of-pocket. AROP – at-risk-of-poverty. Estimates shown are averages of 
three approaches to estimate long-term care needs among older people. Outliers are removed using the interquartile range 
method to calculate the mean OOP as a % of disposable income. 

Source: OECD analysis based on the OECD long-term care Social Protection questionnaire, SHARE survey (Wave 7, 2017) 
and TILDA survey for Ireland (Wave 3, 2015). 

The different country examples and policy scenarios in this section show how Member States 
extend the timeliness and generosity of social protection for long-term care, both in terms of 
expanding coverage to broader groups and increasing the level of benefits. This illustrates the 
impact  that  extending coverage  would have on  reducing poverty risks associated with  long-
term care. The calculations are first estimates underpinned by a number of assumptions (using 
modelling where data were lacking for some countries). These cost estimates also do not take 
into account the potential costs associated with expanding the administrative system to manage 
the increased take-up of social protection. Well-designed policies to protect older people from 
the  total  costs  of  long-term  care  can  have  a  major  impact  on  out-of-pocket  costs  and  the 

232 Please note that estimated spending on social protection differs from the total public expenditure on long-term care in the 
2021 Ageing Report, as it does not include spending categories such as administrative costs, infrastructure investments, 
spending on medical or rehabilitative care, and spending on community care, for example. In 2019, total public expenditure 
on long-term care was 1.7% of GDP (2021 Ageing Report).  

61 

 
 
 
                                                 
associated poverty risks for older people. Policy making on long-term care would benefit from 
sound monitoring of the affordability of long-term care and the impact of social protection for 
long-term care in old age, looking at the adequacy of benefits and eligibility rules, as well as 
the take-up of benefits.  

5.2.  Availability of long-term care 

The proposal for a Council Recommendation on long-term care encourages Member States to 
increase the offer of long-term care services, while providing a balanced mix of long-term care 
options and in all care settings to cater for different long-term care needs and supporting the 
freedom of choice of people in need of care. This can be achieved in particular by developing 
and/or improving home care and community-based care. In addition, attention should be paid 
to closing territorial gaps in availability of and access to long-term care, in particular in rural 
and  depopulating  areas,  and  to  rolling-out  accessible  innovative  technology  and  digital 
solutions.  Member  States  should  also  ensure  that  long-term  care  services  and  facilities  are 
accessible to persons with specific needs and disabilities, respecting equal rights. 

5.2.1.  Expanding long-term care services  

A  balanced  mix  of  high-quality  long-term  care  options  in  home,  community-based  and 
residential care, adjusted for the different levels of long-term care needs, is necessary to meet 
the rising demand for long-term care.  At the same time, it is important that  all care settings 
comply with high quality standards and care is delivered in the most cost-effective setting. For 
people  with  low  and  moderate  care  needs,  the  most  cost-effective  setting  can  be  home  and 
community-based care. Importantly, expanding home and community-based care reflects the 
preferences  of  people  to  continue  to  live  at  home  for  as  long  as  possible  and  supports  the 
freedom of choice of people in need of care in line with the principle of independent living.  

The UN Convention on the Rights of Persons with Disabilities233 and the common European 
Guidelines on the transition from institutional to community-based care234 already support the 
deinstitutionalisation process across the EU. According to the guidelines, deinstitutionalisation 
requires a long-term strategy with sufficient investment to develop alternative home care and 
community-based services. Institutions are not necessarily residential, but defined as such when 
their residents are isolated from the broader community and no longer have sufficient control 
over their lives.  

At the same time as residential care is transformed to support independent living, it is important 
to make available additional home and community-based care services. Measures to develop 
long-term care services in the community235 should not only include home care, day care and 
respite care, but also technical aids and assistive technologies (e.g. wheelchairs, social alarms, 

233 UN, 2006, Convention on the Rights of Persons with Disabilities. 
234 Ad Hoc Expert Group, 2009, Report of the Ad Hoc Expert Group on the Transition from Institutional to Community-
based Care, convened by the European Commission. 
235 European Expert Group on the transition from institutional to community-based care, 2021, EU Funds checklist to 
promote independent living and deinstitutionalisation, p. 8. 

62 

 
 
                                                 
hearing and visuals aids, communication aids etc.), supported living and housing adaptations 
and general accessibility of the environment, products/devices, services, and information. 

France 236,  as  part  of  its  Ageing  Reform,  is  rolling  out  a  number  of  measures  to  both 
modernise residential care and expand home care. 

One of the aims is to transform the care institutions into living and caring places, by: 

 

increasing  the  number  of  caregivers  and  the  number  of  people  working  with 
residents: coordinating physicians, night nurses; 

  providing more support for neurodegenerative diseases: psychologists, psychomotor 
therapists  and  closer  health  and  medical-social 

therapists,  occupational 
cooperation: mobile teams, palliative care, direct hospitalisation; 

  redefining medical and care functions in institutions;  

  renovating  facilities  and  adapting  the  living  and  working  environment,  including 

rolling out digital technology. 

In  parallel,  France  is  focusing  on  reforming  home  care  services,  adapting  housing  and 
expanding  the  supply  of  housing,  in  particular  inclusive  housing  and  independent  living 
facilities. It will also expand respite care solutions for caregivers via day care, temporary 
accommodation, relaying at home etc. 

Leveraging public and private investment, both at EU and national level,  could  improve the 
availability of long-term care, including in rural areas237. It can target private actors (both for-
profit  and  non-profit),  civil  society  organisations,  the  social  economy,  local  authorities  and 
private households.  

Public and private investment to increase the availability of long-term care 

Cultivating public-private partnerships (PPPs) might be one of the options to facilitate joint 
public and private investments in long-term care. One goal could be to involve private-sector 
partners in innovation for better and cost-effective service delivery. Another option is to 
provide subsidies for care recipients to purchase assistive care devices and make structural 
adjustments to their homes and environments (i.e. ‘age-friendly housing’ and ‘age-friendly 
environments’). The innovative use of technology often fits in with ageing in place strategies. 
Assistive technology, telemedicine, and remote health and safety monitoring have a positive 
impact on the perceived health status and security, and the overall quality of life of older 
adults. These investments also boost the quality of long-term care (e.g. better infrastructure 
or digitalisation of services) and working conditions.  

236 Puiseux, A., 2022, the Ageing Reform. Presentation for the Mutual Information System on Social Protection. 
237 In A long-term Vision for the EU’s Rural Areas – towards stronger, connected, resilient and prosperous rural areas by 
2040, the Commission refers to the need for rural areas ‘to become places equipped with accessible and affordable public and 
private services, providing tailored solutions (such as long-term care)’.  

63 

 
 
                                                 
Often as an alternative to residential care238, new long-term care models are emerging, such as 
shared housing or intergenerational housing. In these models, people with different care needs 
live in a shared private home or residential development and share outside spaces, domestic 
support, care and nursing.  

Local  authorities  in  Ljubljana  in  Slovenia  collaborated  with  private-sector  partners  to 
provide over 400 sheltered apartments reserved for older people who were still able to live 
independently and were not interested in living in nursing homes. This reduced the pressure 
on  nursing  homes  and  gave  older  people  a  higher  quality  of  life,  adapted  to  their  care 
needs.239  

Also in Germany, the model of shared housing (‘ambulant betreute Wohngemeinschaften’) 
has gained prominence since first emerging in 1995. A limited number of six to eight people 
in need of care rent private rooms in ordinary apartments, while sharing a common space, 
domestic support, and access to nursing care. The aim of this model is to provide a small-
scale, home-like facility with ample leeway for individual activities and autonomy, alongside 
group-based activities, and is particularly well suited to the needs of people with dementia 
240. Typically, a case manager responsible for all residents is on the premises and organises 
ambulatory  professional  care  services  through  long-term  care  insurance,  while  relatives, 
friends and community volunteers are involved in social aspects. The state supports shared 
housing by providing specific financial grants to create residential groups and barrier-free 
homes, and by paying an additional monthly supplement of around EUR 200 per resident.241 

The availability of services should be strengthened in particular in rural and depopulating areas, 
also  addressing  territorial  gaps  in  access  to  long-term  care  within  countries.  People  in  rural 
areas  are not  only older  on average, but  typically have  more frequent  long-term care needs. 
With people moving to find work, their children may live far away from their parents and thus 
are  not  able  to  care  for  them.  One  key  aspect  is  also  the  need  to  attract  a  long-term  care 
workforce to rural areas. 

RuralCare242 is a EU funded social innovation project (see section 4.5.4) in social services 
that aims to design, test and evaluate a new model of integrated long-term care services in 
the rural region of Castile and León in Spain. The new model involves adapting care services 
to the individual needs of a person living in their home in a rural area to make care more 
accessible, affordable, sustainable and of better quality. 

238 Frisina Doetter, L., Barbabella, F., Guillen, M., Le Bihan, B., Marczak, J., Rodrigues, R., Rothgang, H., Santolino, M., 
Sopadzhiyan, A., Sowa-Kofta, A. and Wittenberg, R., 2019, Improving outcomes for people with long-term care needs 
through personalization, in: Enhancing the sustainability of long-term care. Eurohealth, WHO, pp. 6-9.  
239 Konjar, M., Niksic, M., Grom, J.P., Mujkic, S., and Fikfak, A., 2018, Ensuring living condition for ageing population by 
public-private partnership (PPP), E3S Web of Conferences, p. 13.  
240 Moise, P., Schwarzinger, M., Um, M.Y., 2004, Dementia Care in 9 OECD Countries: A Comparative Analysis; OECD 
Publishing: Paris. 
241 Frisina, Doetter, L., 2021, Rethinking home-based settings for long-term care: the novel approach of shared living 
arrangements in Germany. 
242 RuralCare.  

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The project carries out a proactive segmentation of households at risk, factoring in not only 
the individual situation but also their environment. Households at risk should be transformed 
into  safe  households,  allowing  people  requiring  long-term  care  to  remain  at  home.  The 
portfolio of services is customised and may include home adaptations, technological support, 
social community support and professional care. To achieve these, a multilevel partnership 
for care provision is put in place, including public and private actors and coordination of 
social and health services at local, regional and national levels, and involving the users. 

Older people, including those living isolated or in rural areas, are also affected by loneliness. 
Targeted and effective measures to combat social isolation and loneliness among older adults 
in long-term care can improve their mental health and quality of life.  

Addressing social isolation and loneliness243 

The Sällbo Housing Programme is a multicultural and multigenerational living space in a 
small  port  city  in  southern  Sweden.  The  goal  of  the  project  is  to  combat  loneliness  and 
promote social cohesion by giving residents incentives and space for social interaction. More 
than half of the residents are over 70, and the rest between 18 and 25 years old. All residents 
have  to  sign  a  contract  promising  to  spend  at  least  two  hours  a  week  socialising  with 
neighbours. 

Madrid’s 2021-2023 action plan against loneliness is a strategy implemented at city level 
with the goal of tackling loneliness among the older population. The strategy has four pillars. 
First is data collection on loneliness and social isolation among older people at city level 
(Madrid más cerca de ti). Second is to prevent loneliness and identify individuals at risk of 
loneliness (Madrid contigo). The third pillar is based on the development of a mobile app 
(Madrid  en  red)  to  help  connect  lonely  people  to  their  families  and  a  loneliness  helpline 
(Madrid te escucha). The last pillar seeks to develop a broad set of collaborations across 
different actors with the shared goal of reducing loneliness among older adults (Madrid te 
acompaña).  

Schlomann et al. (2020)244 also investigated the potential of ICT applications on feelings of 
loneliness, anomie, and autonomy among people in the oldest age category (aged between 
80 and 103) in Westphalia, Germany. The quantitative data analysis found that individuals 
using web-connected ICT reported lower levels of loneliness and anomie, and higher levels 
of autonomy. These differences remained significant when checking for indicators of social 
inclusion and individual characteristics. 

5.2.2.  Illustrating the impact of expanding the availability of home care 

A  simulated  policy  scenario  based  on  the  European  Health  Interview  Survey  (EHIS)  data 
illustrates the impact of increasing the share of older people in need of long-term care who 

243 Casabianca, E. and Kovacic, M., 2022, Loneliness among older adults - A European perspective, JRC Policy brief. 
244 Schlomann, A., Seifert, A., Zank, S., Woopen, C., & Rietz, C., 2020, Use of information and communication technology 
(ICT) devices among the oldest-old: loneliness, anomie and autonomy, Innovative Aging 4(2).  

65 

 
 
                                                 
use formal home care to 60% by 2030. Under the baseline for this scenario, 29.4% of older 
people are in need of long-term care245, and 13.9% of all older people 65 + use care services 
(9.1 million home care (of which 6.6 million are considered to be need of long-term care) and 
3.4 million institutional care). Thus, 38% of older people in need of long-term care use care 
services in 2019, and they receive 12 hours of home care per week on average. In this scenario, 
home care is expanded until 60% of people in need of long-term care receive care by 2030, 
maintaining the average care intensity of 12 hours of home care a week constant. In 2030, 15 
million  older  people  with  long-term  care  needs  will  receive  home  care  under  this  scenario, 
increasing by 7 million relative to the baseline in 2030 (8 million), equivalent to an increase of 
89%.  

Projecting to 2030246, the long-term care workforce would increase from about 2.1 million full-
time equivalent (FTE) workers to 3.2 million FTE workers. The additional staff cost would be 
around EUR 30 billion (at 2030 wage levels) or 0.19% of GDP (unweighted average) extra in 
2030. The total cost of the long-term care workforce (at 2030 wage levels) would be around 
EUR 114 billion for home care and EUR 206 billion for institutional care247 in 2030. At 2019 
wage levels, the additional staff cost in 2030 for home care would be EUR 27 billion, with total 
costs  for  the  workforce  reaching  EUR  101  billion  for  home  care  and  EUR  182  billion  for 
institutional care.  

This simulated increase in the availability of long-term care can be combined with a scenario 
where long-term care workers’ salaries are increased to the average salary level in the healthcare 
sector  (see  section  5.4).  With  labour  cost  convergence,  the  total  cost  of  home  care  in  this 
scenario would increase from EUR 114 billion (at 2030 wage levels) in 2030 to EUR 172 billion 
(at 2030 wage levels) in 2030. 

5.2.3.  Increasing access to long-term care via digitalisation  

More national and EU-level support is becoming available for technology development in 
care, often linked to healthcare but increasingly with long-term care248. The challenge is to 
progress  from  the  piloting  stage  to  large-scale  production  of  assistive  technologies  and  to 
encourage their widespread use.  

The  aim  of  the  State  Competence  Centre  Digital  Care  Baden-Württemberg 249 
(PflegeDigital@BW) is to shape digitalization in long-term care and to be a contact point 
for  all  stakeholders.  Initiated  by  and  in  cooperation  with  the  Ministry  of  Social  Affairs, 
Health  and  Integration  Baden-Württemberg, 
the  centre  develops,  analyses  and 
communicates digitally supported solutions for long-term care together with partners from 

245 Defined as having a severe difficulty with ADLs or IADLs, see chapter 2.  
246 Wages have been projected by applying hourly labour productivity growth from the 2021 Ageing Report. GDP is projected 
by applying potential GDP growth rates from the 2021 Ageing Report. 
247 Calculated using ‘number of FTE workers X average labour costs in relevant sector’, as per Eurostat. 
248 The EU has provided substantial funding to stimulate research initiatives, development and marketing of innovative 
technologies for ageing well, including the Active and Assisted Living Programme (AAL JP) and the European Innovation 
Partnership on Active and Healthy Ageing (EIP AHA). These initiatives have funded projects on access to information for 
care providers and sensors for security in the home (Gehem & Sánchez Díaz, 2013). 
249 Landeskompetenzzentrum Pflege & Digitalisierung BW. 

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the field, from academia, wider society, industry and government. The centre receives public 
funding of EUR 12 million. 

It is based on four fields of action for digitalisation in long-term care: 

  empowerment – enhancing inclusion and independence of people that are in need of 

care and assistance 

  new care – providing digital support for care-related activities 

  boosting  care  –  facilitating  digital  assistance  for  improved  organisation  and 

management in care 

  smart  consultation  – enhancing  digital support for  providing care and assistance-

related information and consultation services 

Among  its  many  projects,  the  centre  offers  for  example  a  digital  campus  (Campus 
PflegeDigital) – a digitally fully equipped residential home that is used for teaching long-
term care technologies to staff in a hands-on way. Besides, it offers a bus (Transfermobil) 
that is equipped with state-of the art technology used in long-term care, than can be booked 
by long-term care facilities to test the different technologies on-site and to receive consulting.  

A literature review into the potential of digital technologies in long-term care highlighted three 
main functions of technology at different stages of long-term care: (i) to improve information 
for users and carers to understand what is available and to prepare initial interactions with care 
professionals; (ii) to facilitate easy access to services through various remote facilities such as 
telecare; and (iii) ongoing support mechanism enabling older people to remain in their home, 
i.e. ageing in place. 

First, technology can offer cheap and effective ways of making information about the services 
available through online platforms, including information from other users and their families 
shared on social media. Second, at the stage when a person needs care, often when a patient is 
discharged from hospital or through a primary care referral, technology has been shown to be 
useful in integrating care measures. Third, technology has a great potential to enable access to 
services  that  facilitate  ‘ageing  in  place’.  Telecare,  smart  home  technologies  and  remote 
monitoring can help older people carry out everyday activities and improve physical safety and 
social communication. Older people reported that smart homes improved their sense of security, 
the quality of their daily life and activities and provided them with information about the care 
available.250 

250 Zigante, V., 2021, The role of new technologies in modernising long-term care systems: a scoping review. Research Note 
for the Social Situation Monitor.  

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Table 2: The potential of digital technologies in improving access to long-term care 

Theme 

Examples of technologies 

Expected benefits 

Information and 
communication 

Information platforms, online reviews, 
social media 

Facilitating understanding of what is 
available and suitable. Better matching 
and targeting of services 

Facilitate access to 
services 

Telecare/telehealth Remote patient 
monitoring Hospital 
discharge/integration Community 
support 

loneliness,  fast  access 

Reducing 
to 
services as part of hospital discharge or 
when  a  new  need  has  arisen,  or  the 
person’s health has deteriorated. 

Ageing in place 

‘Smart’ home technology, remote 
monitoring, telecare/telehealth 

Enabling independence, reducing social 
isolation, preventing deterioration and 
hospitalisation 

Source: Zigante, V., 2021. 

Digital  innovation  in  care  cooperatives  is  driven  by  responding  to  community  needs. 
CGM251,  the  main  national  consortium  of  social  cooperatives  in  Italy,  has  promoted  the 
digital revolution in the care sector, offering social services through the digital platform 
WelfareX.  The  platform  provides  services  directly  to  public  institutions:  it  works  directly 
with  88  municipalities,  receiving  about  40  000  applications  from  single  users,  managing 
more than 152 000 vouchers and about EUR 6 million worth of services. A spinoff company 
CGM Welfare is specialised in providing assistance and training to local clusters that want 
to  establish  a  local  digital  platform  for  welfare  and  care  services.  Through  the  local 
platforms,  private citizens  can purchase services,  including  care and residential  services, 
directly  from  social  cooperatives.  The  platforms  grew  rapidly  during  the  COVID-19 
pandemic. 

Wang  et  al.  (2019)252 investigated  the  potential  of  Technology-Enabled  Long-Term  Care 
Services and Supports (T-eLTCSS) in home settings. They state ‘T-eLTCSS refers to services 
provided  for  independent  living  via  health  information  technology,  telemedicine,  assistive 
technology, online resources, apps and social media. T-eLTCSS in home settings consists of 
several major functional systems, including physiological monitoring, functional monitoring, 
safety monitoring and assistance, security monitoring and assistance, emergency detection and 
response,  social  interaction  monitoring  and  assistance,  cognitive  assistance,  and  sensory 
assistance’. In the care of older people, T-eLTCSS is being used in a variety of ways, ranging 
from using wearable devices (e.g. integrated in bracelets) to ambient devices, wireless devices 
and floor sensors. Moreover, smart detection devices e.g. smart water leak monitors, could alert 
older  adults  to  potentially  dangerous  situations  or  detect  potential  hazards  in  their  homes. 
Consequently,  T-eLTCSS  can  help  older  adults  with  disabilities,  chronic  diseases  or 
people needing long-term care to live in their homes with minimal assistance from their 
caregivers.  

251 CECOP, 2022, Cooperatives care! Advantages of the cooperative model for meeting multiple care-related needs and 
challenges in the EU. 
252 Wang, L., Gu, D. and Wu, B., 2019, Technology-enabled long-term care services and supports (T-eLTCSS) in Home 
Settings, Encyclopedia of Gerontology and Population Aging. 

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Digitalisation  can  help  improve  functional  independence  and  long-term  care  efficiency,  for 
example, by helping older people ‘age in place’. This could reduce more expensive residential 
stays (in hospitals or residential care homes). Different types of technologies could facilitate 
this in different ways: telecare and telehealth could enable exchanges between professionals, 
care users, and informal carers; remote monitoring by qualified staff could provide added safety 
and prevent unnecessary deterioration and hospitalisation; and ‘smart home’ technology could 
offer comfort, access to care and help ensure users' safety at home. ‘Smart home’ and other 
digital solutions could also help reduce feelings of loneliness and isolation, which may benefit 
users’  mental  health.253 Robotics  can  contribute  and  extend  the  period  of  living  at  home  for 
older  people.  Robots  have  become  increasingly  able  to  interact  with  people  in  their 
environment, reducing feelings of loneliness and isolation, providing help with simple tasks, 
giving  instructions,  supporting  medication  compliance,  or  calling  emergency  services  when 
needed.  

The  aim  of  the  MOBISERV254 project  is  to  design  and  evaluate  a  system  and  service  to 
support  independent  living  of  seniors  by  means  of  a  proactive  personal  companion  robot 
integrated with smart textiles, innovative sensors, and a smart home environment. The system 
monitors physical activity and health indicators by means of wearable fabrics. It monitors 
nutrition habits by smart home sensors and offers an extensive secure portal for informal and 
professional carers to use, set up, and fine-tune the support system. MOBISERV provides 
older adults with: (i) nutrition assistance and dehydration prevention by eating and drinking 
reminders and encouragements; (ii) a personal health coach encouraging physical activity 
and  specific  exercises,  and  supporting  telemedicine  services;  (iii)  well-being  services  for 
cognitive stimulation and social inclusion, responding to the user’s emotions; (iv) games for 
entertainment; (v) a mobile remote control for the home environment; (vi) fall detection with 
direct communication to a care centre; and (vii) video communication to friends and family. 

The literature255 shows two aspects of quality where technology may have a positive impact. 
Firstly, digital tools can help improve the quality of services provided, for example by reducing 
errors, ensuring timely visits, freeing up carers’ time to spend more time socialising with the 
users,  making  services  more  personalised  and  increasing  users’  independence.  Secondly, 
technology can also support quality assurance efforts through monitoring of service provision. 
Tasks  such  as  timing  and  duration  of  visits  and  logging  medication  can  all  be  done 
electronically and monitored for quality assurance purposes.  

The table below lists some examples of technologies and their potential benefits in the quality 
and quality assurance of long-term care.  

253 Zigante, V., 2021, The role of new technologies in modernising long-term care systems: a scoping review. Research Note 
for the Social Situation Monitor.  
254 An Integrated Intelligent Home Environment For The Provision Of Health, Nutrition And Mobility Services To The 
Elderly | MOBISERV Project | Fact Sheet | FP7 | CORDIS | European Commission (europa.eu) 
255 Zigante, V., 2021, The role of new technologies in modernising long-term care systems: a scoping review. Research Note 
for the Social Situation Monitor.  

69 

 
 
                                                 
Table 3: The potential of digital technologies in improving the quality of long-term care 

Theme 

Examples of technologies 

Expected benefits 

Structural and 
process quality 

Remote monitoring, telecare/telehealth  More efficient and safer provision of 
care. Also more personalised through 
improved space (i.e. structure) and 
work processes that allow 
individualised plans. 

Users’ outcomes 
(outcome quality) 

Information platforms, social media  

Telecare/telehealth, Remote patient 
monitoring, Hospital 
discharge/integration  

Connectedness, reduced loneliness and 
mental health issues.  

Safety, hospital admissions, disease 
management, prevention 

‘Smart’ home technology 

Independence and person-centred care 

ICT, social media 

Electronic monitoring 

Social connectedness 

Safer care, prevention 

Quality assurance 
and safeguarding 

Source: Zigante, V., 2021. 

Digital technologies and innovations have also proven useful in facilitating the integration 
between  long-term  care  and  healthcare. 256 For  example,  CareWell 257 worked  on  delivering 
integrated  healthcare  to  frail,  older  patients  in  a  pilot  setting  through  comprehensive 
multidisciplinary integrated care programmes where the role of ICTs can foster coordination 
and patient-centred delivery care. Carewell focused on complex, multi-morbid elderly patients 
who are most in need of health and social care resources and of more complex interventions 
due  to  their  frailty  and  comorbidities.  These  interventions  included  health  and  social  care 
coordination, monitoring, self-management of the patient and informal caregiver. 

More  recently,  during  the  pandemic,  a  digital  platform  was  developed  in  Portugal  to  help 
residential facilities monitor the health of residents by monitoring symptoms associated with 
COVID-19. In Italy, lung ultrasonography was used in nursing homes to measure the presence 
of  lung  damage  in  people  with  a  history  of  COVID-19  symptoms258.  In  Germany,  Lower-
Saxony launched an initiative to develop digital health and social services by supplying tablets 
and  the  platform  used  for  medical  consultations  as  well  as  giving  the  necessary  medical 
software free of charge to the general practitioners involved.  

5.2.4.  Strengthening the accessibility of long-term care 

In order to support the accessibility of home care and help people remain independent for as 
long as possible while receiving care, age-friendly environments have to be created. This age-

256 This paragraph is based on: Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy 
responses and challenges. OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
257 Home (carewell-project.eu) 
258 Dini, F.L.,Bergamini,C., Allegrini, A., Scopelliti,M., Secco,G., Miccoli,M., Boni,S., Brigada, R.,and Perlini,S., 2020, 
Bedside Wireless Lung Ultrasound for the Evaluation of COVID-19 Lung Injury in Senior Nursing Home Residents. 
Monaldi Archives for Chest Disease 90 (3). 

70 

 
 
                                                 
friendly environment already starts at home, so that it is suitable for the changing needs of older 
people.  

Several Member States have brought in specific programmes/grants for modifying homes (i.e. 
housing adaptation)259 in order to adapt unsuitable homes so that older people can continue to 
live independently and receive home care as long as possible. According to the WHO, important 
measures  for  achieving  this  are  ‘publicly  subsidised  provision  and  easy  access  to  home 
maintenance and modification services to make homes more accessible and support ageing in 
dignity and autonomy’. Such locally implemented measures were evaluated positively by the 
older people who greatly valued such services.260 Several Member States also have a system of 
personal  assistance  in  place  to  allow  people  with  disabilities  to  live  independently  and  be 
included in society.  

Sweden has set up a comprehensive support system to allow people with disabilities to live 
independently. Based on the Health and Medical Services Act (1982), assistive devices for 
daily  living,  for  care  and  treatment,  and  also  personal  assistive  devices  for  school  and 
education are provided by the regions and municipalities. Based on the Law on Grants for 
Housing Adaptation (1992), municipalities also approve grants to adapt housing to enable 
people with functional impairments to continue to live in their own homes. Sweden also has 
a quite generous system of personal assistance (the Act concerning Support and Service for 
Persons with Certain Functional Impairments, 1993) to help people with activities in daily 
life (cooking, shopping, participating in leisure activities or work, parenting, etc.).261 

5.3.  Quality of long-term care  

The proposal for a Council Recommendation invites Member States to ensure that high-quality 
criteria  and  standards  are  established  for  all  long-term  care  settings,  tailored  to  their 
characteristics,  and  strictly applied to  all long-term  care providers irrespective of their legal 
status. To this effect, Member States are recommended to ensure a quality framework for long-
term care which is guided by the quality principles set out in the Annex of the proposal for a 
Council Recommendation and includes an appropriate quality assurance mechanism.  

5.3.1.  Long-term care quality framework 

A  quality  framework  helps  ensure  that  service  providers  take  a  consistent  and  integrated 
approach to the quality of services. It also helps encourage and support all stakeholders involved 
in  addressing  gaps  and  in  identifying  systemic  issues,  best  practices  and  opportunities  for 
continuous improvement. It sets out a common understanding of: (i) the quality of long-term 
care; (ii) the quality standards that services should meet; (iii) methodological guidelines and 

259 This can be defined as those ‘alterations of permanent physical features in the home and the immediate outdoor 
environment that aim at reducing the demands of the physical environment in the home and its close surroundings’ (Chiatti, 
C. and Iwarsson, S., 2014, Evaluation of housing adaptation interventions: integrating the economic perspective into 
occupational therapy practice, Scandinavian Journal of Occupational Therapy, 21(5), pp. 323-333). 
260 WHO, 2017, Age-friendly environments in Europe: A handbook of domains for policy action, WHO Publications, 
Copenhagen, p. 160.  
261 DOTCOM: The Disability Online Tool of the Commission 

71 

 
 
                                                 
indicators  to  monitor  and  evaluate  the  quality  of  services;  and  (iv)  regulatory  enforcement 
mechanisms.  

At  EU  level,  the  voluntary  European  Quality  Framework  for  Social  Services 262  provides 
guidance on how to define, provide, assess and improve social services, including long-term 
care. Most EU Member States do not have a comprehensive quality framework specific to long-
term care263. A few (e.g. DE, LU, PT) have dedicated legal rules on the quality of long-term 
care, which apply to all types of facilities and providers. Usually, these frameworks follow the 
traditional approach, which looks more at the structural aspects of care provision, and they often 
have a heavy administrative burden. However, there are innovative attempts to base a quality 
framework on the quality of life of the person in need of care and to move from a bureaucratic 
to a partnership-based model. The COVID-19 pandemic also created a need for more guidance, 
as illustrated by the fact that at least half264 of the EU countries that did not have specific long-
term care measures in place before the pandemic issued public guidelines on infection control 
in long-term care facilities (AT, FR, IE, IT, LU, PL, SI).  

Examples of national quality frameworks for long-term care 

In Portugal, long-term care services are covered by the national network for continued and integrated 
care (RNCCI). The long-term care quality framework, legally formalised, is mandatory for all long-
term care services - convalescent care, post-acute rehabilitation services, medium- and long-term care, 
home  care  and  palliative  care.  There is  no  distinction  between  sectors  (health or  social care),  care 
settings (residential or community care) or the type of service provider (public, for-profit or private). 
Quality is mainly ensured by: (i) setting minimum standards; (ii) using indicators to monitor processes 
and outcomes; (iii) listening to patient complaints; (iv) carrying out surveys of users, family members, 
informal carers and professionals; and (v) conducting internal audits and inspections.  

A novel quality framework for residential care265 

The National Quality Council of the Netherlands has developed an innovative quality of care framework 
(see Figure 14), which focuses on the quality of life of the person and on learning and improving, rather 
than on accreditation, regulation and inspection. It aims to reduce the administrative burden with a 
smaller set of centrally-defined indicators (quality, safety and related aspects to enable person-centred 
care and support) and flexible reporting formats. Professionals are empowered to use this supportive 
environment to create trust rather than bureaucracy in quality assurance. 

262 Social Protection Committee, A voluntary European quality framework for social services, 2010, SPC/2010/10/8 final. 
263 Cès, S. and Coster, S., 2019, Mapping long-term care quality assurance practices in the EU, European Social Policy 
Network. 
264 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
265 Nies, H., 2018, Quality in long-term care and large-scale implementation – The introduction of new policy instruments in 
the Netherlands.  

72 

 
 
 
                                                 
Figure 14: Dimensions of quality of life (The Netherlands) 

Source: Nies, H., 2018. 

In the absence of a comprehensive quality framework dedicated to long-term care, it is difficult 
to  ensure  a  consistent  approach  to  long-term  care  quality  across  different  regions  and  care 
settings. This  is  especially challenging where quality assurance is  mainly regulated at  local, 
regional or municipal level  (e.g. AT, BE, DK, SE) or when both  care provision and quality 
assurance  are  decentralised  (e.g.  EE,  SE,  DK).  Beyond  the  geographical  challenges  to 
consistent  quality  assurance,  the  lack  of  an  integrated  approach  often  leads  to  quality  being 
considered from two different angles – social and healthcare – even in the same facilities. In a 
number of Member States (BE, CZ, EE, FR, HU, LT, PL, SI, SE and SK)266 separate quality 
frameworks have developed for these two sectors, with separate regulations, including quality 
principles, guidelines, requirements and standards. Having parallel processes, however, creates 
room for inefficiencies and inconsistencies. 

5.3.2.  Long-term care quality principles 

The basis for a quality framework is a common understanding of what quality is, which can be 
expressed  as  quality  principles.  Quality  principles  can  guide  the  development  of  a  quality 
framework for long-term care that applies to all long-term care providers irrespective of their 
legal status and are applicable in all care settings. Such principles are set out in the voluntary 
European Quality Framework for Social Services267 and have been adapted to long-term care 
by the WedO project268..Some of the principles are discussed in other parts of this document, 
namely availability and accessibility in section 5.2, affordability in section 5.1, workforce in 
section 5.4 and facilities in section 5.2 and 5.4. The remaining principles are briefly presented 
in this section. 

266 Cès, S. and Coster, S., 2019, Mapping long-term care quality assurance practices in the EU, European Social Policy 
Network. 
267 Social Protection Committee, A voluntary European quality framework for social services, 2010, SPC/2010/10/8 final. 
268 Principles and guidelines for the wellbeing and dignity of older people in need of care and assistance.  

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Respect 

According to this principle, long-term care providers respect the human rights and dignity of 
people in need of care, their families and carers, as outlined in the relevant national, European 
and  international  human  rights  instruments.  This  includes  the  equal  right  of  all  persons,  in 
particular those with disabilities, to live independently in the community, with choices equal to 
others. It also includes compliance with general safety standards to ensure that long-term care 
services are provided in a safe environment that promotes the physical and mental well-being 
of the people receiving care and of their carers. This also includes the prevention of abuse and 
neglect. Prevention could be achieved by: (i) having in place clear rules for how long-term care 
providers operate, which are based on ethical guidelines that ensure the dignity and well-being 
of the people receiving care and their carers; (ii) by having a clear and simple procedure for 
complaints and for signalling potential cases of abuse or neglect by long-term care providers; 
(iii) by making sure that long-term care workers are informed, trained and prepared to raise 
awareness of, detect and fight abuse, harassment and neglect of people receiving care; and (iv) 
by having means for legal redress if breaches occur.  

Prevention 

According  to  this  principle,  long-term  care  aims  to  restore  as  far  as  possible  or  prevent 
deterioration  in  the  physical  and/or  mental  health  of  people  in  need  of  long-term  care  and 
strengthen their capacity to live independently. This builds on measures to promote healthy and 
active  living  and  ensure  age  friendly  environments  and  includes  measures  to  prevent  falls, 
rehabilitation and strengthening autonomy, for example, through home adaptation and use 
of assistive devices.  

Health promotion and prevention should play an important role as part of healthcare already 
before people develop long-term care needs. 80% of the healthcare budgets are spent on non-
communicable diseases, such as cancer, diabetes and cardiovascular diseases. More ambitious 
actions on health promotion and disease prevention are needed to ensure that people remain in 
good mental and physical health for as long as possible, a strong work force is ensured and the 
healthcare systems remain sustainable and resilient.  

Person-centredness 

According to this principle, long-term care services are provided without any discrimination 
and address the specific and changing needs of each individual in need of care. The services 
provided fully respect the personal integrity of people in need of care, taking into account their 
gender, as well as their different physical, intellectual, cultural, ethnic, religious, linguistic and 
social diversity, and, when appropriate, those of their families or their immediate social circle. 
The  person  in  need  of  long-term  care  is  the  centre  of  attention  and  is  the  basis  for  service 
planning, care management, worker development and quality monitoring. This means that the 
person in need of care and/or their family or carers are involved in the assessment of their care 
needs  and  in  planning  their  care  provision.  This  assessment  and  planning  focuses  on  the 
person’s  abilities,  needs,  preferences,  and  on  the  goals  of  care,  including  choosing  the  care 
setting and modalities consistent with their personal needs and lifestyle choices, which might 
change over time. 

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Personal participation in care planning 

In Finland, care recipients participate in assessing their needs and drawing up their care 
plans.  The  person’s  participation  is  ensured,  even  in  situations  where  they  have  lost  the 
capacity to participate, by making a written statement in advance of their wishes as regards 
medical  treatment  if  they  become  legally  incapacitated.  Traditionally,  such  decisions 
concern the end of life and define the conditions under which any treatments that keep the 
person alive on a short-term basis can be stopped. However, as the person may be dependent 
on long-term care for a number of years, they can state in advance the kind of things that are 
important  to  them  in  everyday  life.  This  is  especially  valuable  for  patients  with  memory 
disorders. 

Comprehensiveness and continuity (integration) 

According to this principle, long-term care is designed and delivered in an integrated manner 
with  all  other  relevant  services  (e.g.  healthcare)  and  with  effective  coordination  between 
national, regional and local levels when required and for as long as needed. This means that the 
person in need of care can access an uninterrupted range of reliable and flexible services, from 
early intervention, care and support, to palliative care, depending on the complexity of their 
needs and how these evolve over time. This involves the timely and effective coordination of 
different stakeholders, including people in need of long-term care themselves and their families. 
This could be achieved by reducing the administrative procedures to access care, including via 
case and care managers, multidisciplinary teams or partnerships between care providers. 
These professionals can facilitate transitions between different care services and settings as the 
person’s needs evolve (e.g. ensuring a proper transfer of information when a person is admitted 
to hospital or returns home).  

Strategy for the provision of integrated care services 

The  aim  of  this  project  was  to  contribute  to  more  integrated  and  person-centred  social, 
medical and vocational support services to people with disabilities and older people with 
extensive needs in Estonia. It provided a strategy to the Estonian government to contribute 
to: (i) improvements in the interoperability of registries and administrative datasets; (ii) the 
development  of  measures  and  indicators  to  support  quality  improvement  and  assess 
performance; (iii) the introduction of performance-based financing and payment elements to 
incentivise  integrated  service  provision;  and  (iv)  a  closer  cooperation  between  services 
administered at central and local level, as well as between local stakeholders. 

After  the  outbreak  of  the  COVID-19  pandemic,  some  countries269 (EE,  FI,  LT,  LU,  PT,  SI) 
introduced new measures to foster multidisciplinary teams, with the aim of integrating more 
primary care in long-term care facilities, while others (BE, EL, EE, FR, HU, NL) introduced 
new guidelines on the integration of long-term care and care in hospitals. Italy and Luxembourg 
obliged nursing homes to have a permanent medical presence to follow-up ill residents.  

269 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  

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Focus on outcomes 

According to this principle, long-term care services are focused primarily on the benefits for 
the people receiving care, while taking into account, wherever appropriate, the benefits for 
their families, informal carers and the community. The best possible services are delivered on 
the basis of quality management and the principles of continuous improvement involving all 
relevant stakeholders. 

Transparency  

According to this principle, information and advice on long-term care is provided in full and in 
an accessible and easy to understand way to people in need of care, their families or carers. 
This should include information on: (i) social protection coverage for long-term care; (ii) the 
eligibility conditions and procedures to follow; (iii) the long-term care services available and 
who  provides  them;  and  (iv)  quality  standards  and  quality  assurance  arrangements.  This 
information should be reliable, up-to-date and available upon request  without a complicated 
administrative procedure. It should be available through communication tools such as helplines, 
leaflets, and websites that are accessible to everyone.  

Long-term care providers are encouraged to provide clear and comprehensive information and 
advice to users and potential users about the services they offer, their cost to the user, how to 
access or cancel the service(s), and on the process for taking decisions on care. Information on 
the activities of providers should be made public, including reports of quality assessments (both 
internal and external), in accordance with the national legislation on the protection of personal 
data. People receiving  long-term care are informed in  good time about  any change that will 
affect the service they receive and are provided with full, accessible and easy to understand 
information about alternative solutions, if they so require. 

5.3.3.  Long-term care quality assurance  

An  integral  part  of  a  good  quality  framework  is  a  clear  and  comprehensive  mechanism  for 
quality management and assurance, with appropriate funding and legally underpinned criteria 
and standards for the accreditation and control (i.e. auditing system) of all types of organisations 
providing long-term care services and facilities. Few Member States have in place a dedicated 
agency that is legally responsible for quality assurance in long-term care services and facilities. 
More  often,  responsibilities  for  quality  assurance  are  shared  by  different  organisations  (see 
Annex 2). For example, in Denmark, the law on social services stipulates that all municipalities 
that are responsible for long-term care must annually adopt and publicise their quality standards 
on health and social services for adults. The municipalities are also required to monitor their 
provision  of  long-term  care.  Also,  since  2018,  the  Danish  Patient  Safety  Authority  has 
monitored care for older people, both in nursing homes and at home. Unlike the municipalities, 
the Danish Patient Safety Authority is an independent body as it does not provide  long-term 
care itself.270 

270 Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., Schepers, 
W., 2022, Analytical support under VC/2020/066. 

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Quality  in  long-term  care  has  traditionally  been  ensured  by  making  inspections  to  monitor 
compliance with  minimum  standards  and, if necessary, via penalties to  enforce compliance. 
However, there is a common trend to move away from mere bureaucratic inspection towards a 
collaborative approach that focuses on continuous improvement processes in combination with 
the involvement of relevant stakeholders, including the people receiving care, staff and informal 
carers (see box on DE).  

Since 2019, Germany has applied a partnership approach to the external monitoring of the 
quality of residential care, whereby care providers have a bigger role in quality assurance 
and external monitoring focuses on identifying the support that providers need to improve 
their  results.  External  quality  monitoring  takes  place  on  a  regular  basis  or  following  an 
incident or a complaint. Regular monitoring is announced one day in advance and focuses 
on nine residents, who participate voluntarily. Examiners are trained carers with additional 
training  in  quality  assurance.  Other  professionals  are  invited  to  participate  if  there  is  a 
specific  reason  for  this.  External  examiners  first  meet  residents  individually,  then  review 
information on the provider, discuss their evaluation and decide in which areas the provider 
could benefit from a consultation. Lastly, they talk to the provider about their strengths and 
the weaknesses to be addressed. 

Continuous improvement of quality can also be organised via third-party certification, as is 
the case in some countries. 

Austria  has  a  dedicated  agency  (NQZ  Austria)  to  manage  the  application  process  for  the 
national quality certificate (NQZ) and the relevant audits, including the training of auditors. 
Eligible  care  homes  (those  that  have  already  implemented  one  of  the  accredited  quality 
management  systems  -  E-Qalin,  ISO,  QAP  or  EFQM)  may  have  been  able  to  apply  for  the 
certificate voluntarily since 2012271. The NQZ focuses on process and outcome indicators and 
is granted after an assessment period of 8 months. The quality assessment includes 24 ‘quality 
and result areas’ that are assessed from 5 perspectives: 

- residents (e.g. self-determination, participation);  
- staff (e.g. cooperation, participation and communication); 
- management (e.g. leadership and personnel management); 
- social context and external relations (e.g. families and suppliers); 
-‘learning organisation’ (e.g. continuous improvement).  

The assessment is based on both the ‘plan - do - check - act’ quality cycle and results-oriented 
indicators proposed by each care home. The certification process consists of a pre-test (review 
of documentation), a certification visit to the premises by two trained auditors, who draft the 
certification report with recommendations and, eventually, the award of certification, which is 
valid for three years.  

PREZO272 is  a quality management model  developed in the Netherlands  by the non-profit 
organisation Stichting Perspekt. It helps to assess and improve the performance of long-term 

271 NQZ-Austria  
272 PREZO stands for ‘PREstaties in de ZOrg’, which could be translated as ‘performance in care’, https://perspekt.nu/prezo 
and https://www.prezowoonzorg.be/  

77 

 
 
                                                 
care professionals and organisations by focusing on the quality of life of people with care needs 
and their perception of the care and support they receive. By avoiding protocols and guidelines, 
the model looks at the actual results of care: ‘Do residents feel at home? Do they feel heard? 
Do they feel that they are enabled to make their own choices?’ The tool assesses performance 
in a dialogue between staff and residents (clients) in six domains, including companionship, 
vitality,  comfort  and  enjoyment;  three  pillars  (continuity  of  care,  care  planning  and 
communication/information);  and  eight  enabling  conditions  on  general  organisation, 
continuous  improvement  and  staffing  issues  (skills).  PREZO  provides  software  for  the 
documentation and training of staff and management on continuous improvement, and for an 
external audit. The PREZO quality mark is valid for three years. If performance in some areas 
is  not  yet  satisfactory,  recommendations  for  improvement  and  an  additional  audit  will  be 
proposed. Apart from the Netherlands, this model has also been adapted for use in Flanders 
(Belgium) and is already being used by more than 140 facilities in Belgium. 

5.3.4.  Drivers of quality improvement 

Member States differ considerably in their starting positions on quality assurance in long-term 
care and those with less-developed quality assurance systems would need more time to improve 
them. Table 4 lists some drivers of quality improvement that could be useful to consider when 
designing related policy interventions. 

Table 4: Potential drivers of quality improvement 

Regulatory 

Top-down 

Legal avenues 

Public reporting vs. disclosed 
information (inspection only) 
  Defined structural indicators 
  Defined process indicators 
  Defined outcome indicators 

Choice of governance level: national, 
regional, local 

Financial incentives linked to 
implementation of quality management 

Linking price and quality indicators 

Linking public procurement and quality 
indicators 

Economic 

Intrinsic/organisational 

Quality management (legally 
prescribed vs organisational 
requirement) 

Staff levels vs needs-adapted staff 
(skills & grade mix) 

Quality management as marketing tool  

Balancing quality and price 

Information/ 

knowledge based 
instruments 

Registers regarding various quality 
indicators (clinical, e.g. pressure sores, 
dehydration) 

Quality management and continuous 
improvement process (outcome-and 
user-oriented) 

Good practice in assessing quality of 
life outcomes  

Support by research agencies 

Enabling management and staff 

Steering by defined indicators 

Continuous improvement by linking 
structures and processes to result-
oriented indicators 

Source: Barslund, M., et al., 2021. 

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5.3.5.  Quality of informal care 

Quality assurance in informal care is hampered by the fact that informal care takes place in 
private households, in family settings and thus in a situation of privacy. In some cases informal 
carers are not only providers of care, but also recipients of public support (via support services 
in-kind and in cash), which could be an entry point for selective supervision and assistance. 
However, it is challenging to systematically monitor and ensure the quality of informal care 
directly.  Indirect  measures  such  as  the  prescription  of  regular  counselling  by  professionals 
(DE), selective visits to beneficiaries of cash allowances (AT), case management (NL, partly 
DE, AT, FR, PT) and training offered to informal carers (e.g. BE, ES, IT, AT, NL) are relatively 
frequent in many countries and may help to improve the situation in selected cases.  

5.4.  Long-term care workforce and informal carers 

The  proposal  for  a  Council  Recommendation  outlines  that  Member  States,  in  collaboration, 
where relevant, with social partners, long-term care providers and other stakeholders, should 
address skills needs and worker shortages in long-term care. The skills of the long-term care 
workforce can be strengthened by  designing and improving initial and continuous education 
and training and by building career pathways in the care sector. More long-term care workers 
can be attracted for example by establishing pathways to a regular employment status and by 
exploring legal migration pathways. In order to attract enough workers into the sector, also fair 
working  conditions  in  long-term  care  have  to  be  ensured.  This  can  be  done  by  promoting 
national  social  dialogue  and  collective  bargaining,  including  to  support  the  development  of 
attractive wages in the sector. For informal care, it is important to establish clear procedures 
to identify informal carers and support them in their caregiving activities.  

5.4.1.  Attracting a skilled long-term care workforce 

Member States need to attract a sufficient number of adequately-skilled long-term care workers 
to  meet  the increasing demands for high-quality  formal  long-term  care that  results from  the 
ageing of the population. However, many Member States face labour shortages in the long-term 
care  sector.  A  wide  range  of  measures  is  needed  to  make  the  long-term  care  sector  more 
attractive to workers, including skills policies, better working conditions and higher wages.  

In the Netherlands, the ‘Labour market agenda 2023: working for older people’ (Aan het 
werk  voor  ouderen),  launched  in  2017,  and  the  general  action  programme  ‘Working  in 
healthcare’ (Werken in de zorg), launched in 2018, aim to support that there will be enough 
well-educated care professionals. These comprehensive strategies set out 11 action points on 
care for older people, which mainly focus on: (i) improving the attractiveness of the sector, 
e.g. by campaigns to improve its image; (ii) improving working conditions, e.g. quality of 
work,  job  security;  (iii)  better  education,  e.g.  qualifications  and  (re)training;  and  (iv) 
working in a different way, e.g. (inter) sectoral cooperation, innovation, matching demand 
and supply. Regions and municipalities play a key role in carrying out these initiatives273. 

273 European Commission and Social Protection Committee, 2021, Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 

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A policy focus on skills ensures that long-term care workers are equipped with the necessary 
skills and competence to provide high-quality long-term care. Measures to enhance the skills 
of current and future long-term care workers can include better initial and continuous education 
and training. Upskilling, reskilling, skills validation, the use of micro-credentials and individual 
learning accounts, and information and guidance services can support career pathways into an 
long-term  care  profession.  Higher  professional  standards,  and  offering  an  attractive 
professional status and career prospects to care workers, can also help to make the long-term 
care profession more attractive.  

Under  a  policy  scenario 274  aimed  at  improving  continuous  training  in  the  sector,  it  was 
estimated that the cost of 7 days of training a year for each long-term care worker (measured in 
full-time equivalents or FTE) would amount to EUR 482.5 million annually in the EU-27. In 
addition, there may be costs to replace the long-term care workers who cannot perform their 
tasks during these 7 days. These costs may be borne by long-term care providers or by the state. 
However,  7  days  of  training  per  year  is  standard  in  many  sectors,  and  some  providers  may 
already be providing this. These training costs may therefore be an overestimation of the actual 
amount.  

In  Austria275,  different  measures  have  been  taken  over  the  last  decade  to  increase  the 
availability of carers at different levels of qualification. In 2016, the educational system for 
carers and nurses was reformed, with the goal of offering different levels of qualification to 
attract  more new applicants.  The federal  provinces,  partly in  cooperation with the public 
employment service, offer different types of financial subsidies while people are in education 
for relevant professions. Another measure is the substantial expansion of advice services to 
validate or recognise qualifications acquired in other countries, which are also available for 
people in the caring professions. 

Sweden  provides  an  example  of  training  for  people  already  working  in  the  sector.  The 
largest private care provider (Ambea) provides skills development, training and coaching in 
social services and long-term care for older people and people with disabilities. One of these 
upskilling  courses  is  the  Dementia  Academy,  which  offers  a  three-day  training  to  teach 
appropriate skills to those working with older people suffering from dementia276. 

Given that wages in the long-term care sector are comparatively low, improvements in pay 
that reflect the challenging tasks and working arrangements, as well as the value of long-term 
care to society, are likely to help attract and retain long-term care workers. Social dialogue and 
collective  agreements  for  the  long-term  care  sector  play  a  significant  role  in  this,  so  it  is 
essential to improve the capacity of social partners at national level.  

274 Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., Schepers, 
W., 2022, Analytical support under VC/2020/066.  
275 European Commission and Social Protection Committee, 2021, Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 
276 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 

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Wages in the healthcare sector are higher than in the long-term care sector in many Member 
States,  thus  the  long-term  care  sector  is  often  less  attractive  for  care  workers.  In  a  policy 
scenario  where  the  long-term  care  workforce  grows  in  line  with  the  increase  in  the  65+ 
population and labour costs in the long-term care sector converge with those in the healthcare 
sector, the cost of wages in the long-term care sector would increase by 41% by 2030. Under 
the same scenario, total annual labour costs would increase from 1.65% of the EU-27’s GDP in 
2019 to 2.22% of GDP in 2030277. Improved wages in the long-term care sector promote fair 
working conditions, help to prevent unfairly low wage levels in Member States and help reduce 
wage inequality and in-work poverty. They may also help reduce outward labour mobility in 
low-wage economies, which exacerbates shortages in the sector. 

Since 2014, the government in Czechia278 has been increasing salaries in the social services 
sector to improve its attractiveness. In July 2017, the government increased the salaries of 
social workers and other workers in social services by 23%. There were further increases in 
salaries  in  the  public  sector,  social  services  and  long-term  care  including  by  10%  in 
November 2017 and by 10.8% in 2018. Latest data for 2019 indicate that the average wage 
of personal care workers represented 78% of the average wage in the residential care sector 
and  72%  in  home-based  care.  This  is  considered  a  partial  improvement  and  to  have 
contributed  to  stabilising  the  long-term  care  workforce  at  100  000  people. However, 
difficulties in recruiting long-term care workers persist. 

In  Austria,  collective  agreements  are  regularly  negotiated  at  company  level  between 
management and a work council, and annually at national level during negotiations between 
industry social partners (employers and trade unions). In 2019, the negotiation led to a 3.2% 
increase in wages for the whole workforce and also to paid leave agreements279. In spring 
2020, the private-sector unions entered the annual collective bargaining round in the social 
economy sector  with  only one demand, to  reduce working  hours  from  38 to  35 hours  per 
week and waive a wage increase. A three-year agreement between the social partners was 
reached in April 2020. The social partners agreed to wage increases for 2020 and 2021, and 
to reduce working time to 37 hours from 1 January 2022. This agreement is considered a 
milestone by the unions280.  

As a result of the COVID-19 crisis, some EU countries (CZ, FR, DE) increased wages281 or 
gave  long-term  care  workers  additional  days  of  annual  leave 282  (LU).  These  have  been 
introduced as permanent measures, set to remain even after the pandemic. 

277 Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., Schepers, 
W., 2022, Analytical support under VC/2020/066.  
278 European Commission and Social Protection Committee, 2021 Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 
279 Ibid. 
280 Allinger, B. and Adam, G., 2022, Impact of the Covid-19 pandemic on the social services sector and the role of social 
dialogue, FORESEE project (VS/2021/0054). 
281 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
282 Ibid.  

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Better staffing levels help to improve the working conditions for long-term care workers, as 
they reduce stress levels, as well as the need to work at short notice. Better staff ratios are also 
essential to improve the quality of care as they allow carer workers to dedicate more time to 
each person receiving care. 

Finland283 passed a law on the nurse-client ratio in long-term care, which came into force 
in October 2020. The law sets the number of personnel in 24/7 services at around 4 400 by 
2023, which would increase the ratio of nurses per client from 0.5, i.e. 5 nurses per 10 client, 
to at least 0.7. 

The occupational health and safety of long-term care workers is a challenge, as the job often 
includes heavy lifting and handling infectious substances. Furthermore, atypical working times, 
shift work and exposure to harmful or challenging social behaviour and can lead to an increased 
risk of accidents at  work, cardiovascular disease  and depression.  As outlined in  section 3.6, 
long-term care workers have also been more exposed to the COVID-19 virus, compared to other 
workers284.  Measures to  improve the health and safety of  long-term care  workers, including 
training and information campaigns on how to avoid health risks at work, can improve their 
working  conditions  and  help  them  to  stay  in  their  jobs  until  retirement  age.  Reducing 
psychological  risks  is  also  important,  given  that  long-term  care  workers  often  face  harmful 
social behaviour and are at risk of experiencing mental health issues, including burnouts. The 
problem of harmful social behaviour can be countered by appropriate supervision, discussion 
with colleagues and supervisors, and comprehensive aggression-management systems.  

As a result of the pandemic, numerous Member States recognised the risk of infection of 
long-term  care  workers  in  the  workplace  and  COVID-19  was  defined  by  many  as  an 
occupational disease or, in a few cases, as an accident at work (AT, BE, CZ, DK, EE, FI, FR, 
DE, HU, IT, LT, LV, LU, PL, PT, SK, ES). Recognition involved a case-by-case investigation 
to establish a clear connection between the virus and workplace exposure. Once the medical 
and  administrative  requirements  were  met,  workers  could  benefit  from  compensation  to 
cover at least part of their lost salary. Compensation rules varied widely across the EU.  

Because of the unprecedented nature of COVID-19 outbreaks in long-term care facilities, a 
number  of  countries  offered  support  for  mental  well-being  to  long-term  care  workers, 
including access to a free phone line during the acute phases of the epidemic (BE, CZ, EE, 
FI, FR, DE, EL, HU, LT, LV, LU, NL, PT), or specialist consultations as part of psychological 
support systems (BE, CZ, EE, FI, DE, LT, NL, PT). Advocacy groups and stakeholders such 
as nurses’ associations provided resources to support long-term care providers and workers. 

Effective regulation (including ratification by all Member States of the ILO Convention 189 
on domestic workers) and its proper enforcement can help to professionalise the live-in care 
model  and  give  workers  greater  protection  where  needed.  Undeclared  work,  which  is 

283 European Commission and Social Protection Committee, 2021 Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 
284 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  

82 

 
 
                                                 
particularly  common  among  live-in  carers,  could  be  tackled  by:  (i)  providing  incentives  to 
declare work (e.g. via voucher schemes or non-bureaucratic registration procedures); (ii) proper 
regulation and monitoring of employment situations, including via digital platforms; and (iii) 
improved labour inspections, including in private households.  

To  counter  undeclared  work,  Belgium  has  introduced  a  voucher  system  for  domestic 
services. The services included are cleaning, ironing, washing, mending, food preparation, 
transporting  people with reduced  mobility and food  shopping. This  does not  include care 
services specifically, but the high take-up of vouchers by older people suggests that these 
services provide help with IADLs (and less so with ADLs). In 2020, one voucher cost EUR 9 
per hour, reduced to EUR 7.20 after tax benefits. Workers paid with the vouchers are covered 
by social insurance. In 2016, 22% of Belgian households used the service voucher system 
and it is likely that the rate has increased since then. More than one quarter of voucher users 
stated that they used the services because they could not do the tasks themselves (i.e. older 
people and people with health problems) 285.  

While improving the working conditions and wages remains the most efficient way to attract 
enough workers into the long-term care sector, proactive recruitment policies to increase the 
pool  of  potential  long-term  care  workers  can  also  be  explored.  Such  policies  include  the 
recruitment of non-EU nationals, pathways to legal employment for undeclared care workers, 
the retraining of workers in other sectors who are at risk of redundancy and the recognition and 
validation of skills and qualifications of informal carers.  

Many  people  from  non-EU  countries  are  already  working  in  the  long-term  care  sector. 
However, they often work illegally, or under precarious conditions or their work is undeclared. 
The migration of workers in the global care chain  also leads to  a ‘care drain’ in their home 
countries, with a negative impact on the families that these carers, who are mostly women, leave 
behind.  

Pathways to regularise the employment status of undeclared workers and non-EU nationals 
could provide opportunities for currently undeclared and migrant workers to officially work in 
the  care  sector,  while  helping  to  address  gaps  in  the  labour  market.  Such  measures  include 
integration programmes  to  encourage  migrants  already  living  in  the  EU to  work in  the  care 
sector and official agreements with non-EU countries to recruit care professionals. Proactive 
recruitment  may  also  include  arrangements  under  which  long-term  care  providers  recruit 
workers at risk of redundancy in other sectors and retrain them to work in the care sector. This 
could become especially relevant in the context of greening European economies, as workers 
in carbon-intensive sectors, who are being made redundant in their original professions, could 
start a new career in the growing long-term care sector.  

In 2019, Germany set up an agency for skilled labour in health and care occupations, DeFa 
(Deutsche Fachkräfteagentur für Gesundheits- und Pflegeberufe). This agency serves as a 

285 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 

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contact point for health and care providers that want to recruit skilled staff from abroad, and 
helps with visa applications, the recognition of professional qualifications and work permits 
(for  a  cost  of  EUR 350  per  case).  It  also  organises  the  selection  processes  and  offers 
language courses286. In Germany, 65% of all recognitions of qualifications obtained abroad 
concerned medical professions, in particular nursing occupations. The Federal Government 
has  intensified  its  attempts  to  recruit  long-term  care  professionals  abroad,  mainly  from 
Central and Eastern European and Asian countries. In 2019, agreements on the recruitment 
of  long-term  care  professionals  have  been  reached 287 with  Mexico,  the  Philippines  and 
Kosovo288. In Kosovo, individual (nursing) schools design their curricula in such a way that 
they are equivalent to the degrees in Germany. In Mexico, a company-integrated adaptation 
course  for  the  recognition  of  Mexican  degrees  is  being  developed,  which  has  been 
coordinated  with  the  recognition  authorities.  The  German  Society  for  International 
Cooperation (GIZ) is also setting up additional courses in nursing studies at universities in 
Mexico, leading to equivalence with German degrees. 

In  Sweden,  training  programmes  for  assistant  nurses  include  vocational  and  language 
training designed so that immigrants and refugees can begin working in the care sector (for 
example, the YFI programme in Stockholm). A fast-track training course makes it easier to 
rapidly integrate migrants into the job market289. 

In  the  Netherlands  during  the  COVID-19  crisis,  when  the  airline  sector  had  to  lay  off 
workers,  the  airline  KLM  and  the  care  organisation  Actiz  cooperated  to  enable  airline 
personnel that were made redundant (mostly flight attendants) to switch to a career in long-
term care rather than become unemployed. Airline personnel received a job guarantee, free 
professional  nursing  education  and  a  similar  salary  to  what  they  earned  in  their  airline 
job290.  

Many measures to attract workers into the long-term care sector have a cost and therefore more 
investment is needed. However, investment in the sector pays off in the long run, due to its 
significant employment potential (as outlined also in chapter 3).  

In Germany291, following the law to increase care staff, (Pflegepersonal-Stärkungsgesetz) 
which came  into  effect  on 1 January 2019, up to  13 000 additional posts were created in 
residential long-term care facilities, which will be financed by the Statutory Health Insurance 

286 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 
287 European Commission and Social Protection Committee, 2021, Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 
288 This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on 
the Kosovo declaration of independence. 
289 Eurofound, 2020, Long-term care workforce: Employment and working conditions, Publications Office of the European 
Union, Luxembourg. 
290 Ibid.  
291 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and 
opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 

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fund.  Moreover,  healthcare  funds  have  been  obliged  to  fund  health  promotion  for  care 
workers at the workplace. 

In  Sweden,  SEK  10  billion  (EUR 0.92  billion)  were  allocated  in  2016  to  create  job 
opportunities.  Municipalities  have  a  great  deal  of  independence  over  how  to  spend  this 
budget. In 2015-2018, the government allocated SEK 7 billion (EUR 0.64 billion) to increase 
staff in the long-term care sector, which is estimated to have created around 19 000 jobs. 
Municipalities received  additional  funding  of  SEK 2.5 billion (EUR 0.23  billion)  in  2020, 
before the COVID-19 pandemic, to reduce the risk of lay-offs in the welfare sector292. 

5.4.2.  Tapping into the potential of digitalisation 

Although robots and new technologies cannot replace long-term care workers, automation and 
digitalisation have the potential to enhance labour productivity in the sector, therefore requiring 
support for training in digital skills. Technology can take over certain tasks of long-term care 
workers and thus relieve them in their daily work, including helping with case management, 
lifting patients, managing electronic documentation, and remote monitoring of people receiving 
care at home293. Travel may be reduced through telecare and remote communication with users 
in their homes.  

Table 5: The potential of digitalisation to support the workforce 

Theme 

Examples of technologies 

Expected benefits 

Training (I/F)  

Learning technology  

Recruitment (F)  

Algorithm, matching  

Retention, job satisfaction  

Retention, job satisfaction  

Work processes 
(I/F)  

Formal carers: Robotics, patient monitoring, 
electronic records  

Replacing/supporting care workers, 
job satisfaction  

Workforce 
monitoring (F) 

Adoption and 
implementation 
(I/F) 

Informal carers: Robotics, communication 
with care services, virtual consultation  

Reduce caregiver burden 

Video monitoring, electronic monitoring 
(including GPS) 

Improving safety 

Skills, attitudes, stakeholders/partnerships 

Sustainable interventions 

Family decision making, knowledge and 
awareness 

Reducing family and informal carer 
stress 

Source: Zigante, V., 2021. 

In  2012,  an  interdisciplinary  international  team  of  14  institutions  launched  the  Carer+ 
project, which is targeted towards care workers in Europe. The project aimed to identify and 
improve the digital and information technology skills of workers who care for older people 
at home, anticipating a new and vital role for care workers. The project set up a competence 
framework, a curriculum and training tools in theory and practice, training for trainers and 

292 Ibid. 
293 Zigante, V., 2021, The role of new technologies in modernising long-term care systems: a scoping review. Research Note 
for the Social Situation Monitor.  

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policy exchange visits, as well as an open online learning  space and community for  care 
workers294. 

5.4.3.  Measures to support informal carers 

While improving the provision of formal care remains the main answer to reducing pressure on 
informal carers, measures are needed to support those who decide to care for family members 
or  friends,  thus  mitigating  the  negative  consequences  of  care  responsibilities.  As  many 
countries  lack  information  about  their  informal  carers,  research  on  the  characteristics  of 
informal carers and their situation can help to target measures to their needs. Clear procedures 
to identify informal carers and clear regulation of the rights associated with informal care can 
help to understand the scale and impact of informal care and to define and guarantee the rights 
of informal carers.  

With the support of the technical support instrument of the EU, Croatia undertook thorough 
research  and  reflection  on  the  provision  of  informal  long-term  care  in  the  country.  The 
research encompassed the demographic, health, social, economic and other characteristics 
of  older  people  and  the  people  who  care  for  them.  The  results  fed  into  policy 
recommendations to introduce new in-kind/cash social benefits for informal long-term care). 
Based  on  the  analysis,  a  proposal  for  the  revision  of  the  status  of  informal  carers  was 
developed.  It  is  expected  that  the  Croatian  ministry  will  use  the  study  for  more  strategic 
reflections on long-term care policy in Croatia. 

Portugal implemented a comprehensive law on informal care in 2019, which established a 
formal status and a number of rights for informal carers, including the right to: (i) have their 
fundamental role acknowledged; (ii) receive training and follow-up; (iii) receive information 
from  health  and  social  security  professionals;  (iv)  be  provided  with  information  on 
counselling for informal carers; (v) receive psychological support from the health services; 
(vi)  benefit  from  respite  periods;  (vii)  receive  an  allowance;  (viii)  reconcile  caring  with 
professional life; and (ix) be consulted about public policies aimed at informal carers295. 

In  Belgium,  a  law  adopted  in  2011  and  amended  in  2019  grants  official  recognition  to 
informal carers. This recognition allows all informal carers to identify themselves to their 
health  insurance  organisation,  which  contributes  to  awareness-raising,  helps  prevent 
problems and provides an overview of the extent of informal care in the country. In addition, 
since 1 September 2020, under certain conditions on the level and duration of care provided, 
informal carers have been granted a right to a respite period of one month (full-time, or part-
time over a longer period), which can be taken six times over the duration of the period of 
care, and which is compensated by up to EUR 1 400 for one month if taken full-time 296. 

Many informal carers have to  reduce or stop  paid  employment  completely  due to  their care 
responsibilities. Care allowances can partly compensate for this loss of income and serve as a 

294 European Commission, 2014, Presentation of the Carer+ project: "From Carer to CarerPlus: developing digital 
competences in the care worker sector" | Shaping Europe’s digital future (europa.eu) (09 July 2014) 
295 Ibid. 
296 Aidant-proches, Foire aux questions Foire aux questions - Aidants Proches Wallonie. (accessed on 11 April 2022) 

86 

 
 
                                                 
form of recognition for informal carers. Pension credits can recognise the periods of informal 
caregiving to provide an income in old age. These financial compensations can therefore help 
reduce current and old-age poverty among informal carers, and reduce gender gaps in wages 
and pensions. Flexible working conditions and care leaves can allow informal carers to remain 
in the labour market for as long as possible.  

Several EU Member States introduced specific measures to support informal carers during the 
pandemic. These included: (i) special care leave297 (AT, BE, LU); (ii) a caregiver’s allowance298 
to replace lost wages for an extended period of up to 20 working days (instead of 10 days), 
given to a person who provided or organised care in situations caused by the pandemic (DE); 
(iii) psychological support299 (AT, SI); (iv) hotlines to receive advice and support300 (FR, CZ); 
and (v) financial compensation for family carers taking leave to  care  for an ill  older person 
(FR).  

In  a  policy  scenario  where  informal  carers  between  35  and  64  years  old,  who  provide  care 
intensively (more than 41.25 hours per week), would receive a care allowance and a pension 
credit, 3.1 million carers in the EU-27 could benefit from such support. The care allowance in 
this scenario would be set at a level equal to the minimum wage in each Member State, and the 
pension credit would be set at 10% of the minimum wage. Overall, the total annual cost in the 
EU-27 of providing this financial compensation to informal intensive caregivers would amount 
to EUR 47.4 billion (or 0.35% of GDP in the EU-27). The impact of financial compensation 
would be highest  in  Greece  (0.65%  of GDP),  Denmark (0.52%),  Italy (0.46%), and Croatia 
(0.45%)301.  Estimates302 show  that  total  expenditure  on  care  allowances  in  2019  in  the  EU 
amounted  to  0.19%  of  GDP.  Therefore,  under  the  scenario  discussed  above,  the  total 
expenditure on care allowances, including a pension credit, for those aged between 35 and 64 
years old who provide intensive care is estimated to be 0.16 percentage points of GDP higher 
than the current estimate. 

In Ireland, a Carer’s Allowance is available to full-time family carers who care more than 
35 hours per week for someone who has been medically certified as in need of full-time care. 
The Carer’s Allowance also secures automatic access to other financial support including: 
(i) a GP visit card, which gives free access to GP care; (ii) an annual Carer Support Grant 
of EUR 1 850 paid to the carer, in respect of each person they care for; (iii) free travel on 
all public transport; and (iv) a Household Benefits Package (if the carer lives with the person 
receiving care) which gives discounts on monthly utility bills and exempts the carer from 
having to pay for a TV Licence. The Carer’s Allowance is means tested303. 

297 European Commission and Social Protection Committee, 2021, Long-term care report: trends, challenges and 
opportunities in an ageing society, Volume I, Publications Office of the European Union, Luxembourg. 
298 Ibid. 
299 Ibid.  
300 Rocard, E., P. Sillitti and A. Llena-Nozal, 2021, COVID-19 in long-term care: Impact, policy responses and challenges. 
OECD Health Working Papers, No. 131, OECD Publishing, Paris.  
301 Barslund, M., Pacolet, J., Leichsenring, K., De Wispelaere, F., Waeyaert, W., Harald Hauben, H, De Smedt, L., Schepers, 
W., 2022, Analytical support under VC/2020/066.  
302 Van der Ende, M. et al., 2021, Study on exploring the incidence and costs of informal long-term care in the EU. 
303 Eurocarers, 2022. Example submitted via the call for evidence. 

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Since 2019, a pilot project in the Burgenland, the smallest region of Austria, aims to offer 
informal carers the opportunity to put their caregiving on a formal footing. Informal carers 
can  sign  a  service  contract  with  a  state-owned  care  service  (Pflegeservice  Burgenland 
GmbH). Provided they meet the criteria (including a family tie with the person they care for, 
an  acceptable  care  environment  at  home  etc.)  they  can  earn  a  salary  at  the  level  of  the 
minimum wage, on a pro-rata basis according to the number of hours of care the person 
needs, plus national insurance contributions and holiday entitlement. In return, they must 
attend a ten-week course (one and a half days a week) to acquire basic knowledge of first 
aid and care, and receive guidance and support on their caring activities. Many of the carers 
who participated remain in contact after the course, sharing advice and experiences304. 

Germany grants pension credits to informal carers who provide at least 10 hours of care a 
week (on at least two days per week) to a person whose need for care is at least at need level 
2. The carer must not work more than 30 hours in paid employment305.  

In France, a caregiver’s leave (congé de proche aidant) is designed for those caring for a 
relative  who  is  coping  with  a  loss  of  autonomy.  Caregivers  can  ask  their  employer  to 
temporarily  interrupt  their  work, while  keeping  their  position  and  rights  in  the  company. 
This leave can last up to three months (except if there is a collective agreement) and can be 
renewed. An allowance of EUR 52 per day for a single person, and EUR 43 for people living 
in a couple306 became payable from 30 September 2020. The benefit also opens up pension 
rights.  

Informal carers need access to training and counselling to help them provide good quality care. 
So it is important for them to have opportunities to exchange information and provide integrated 
care  with  formal  healthcare  and  long-term  care  workers.  Psychological  support  can  help  to 
prevent and tackle mental health issues among informal carers. Meeting other informal carers 
offers possibilities to exchange and share experiences with other people in similar situations.  

Informal carers should be able to take a break from their care responsibilities. Being able to 
take some time off and having access to respite care that temporarily replaces them, such as 
temporary residential care or day care centres, allows informal carers to have some time for 
themselves and to improve their well-being.  

Among other support measures, the Finnish Informal Care Act gives informal carers the 
right to at least two days of statutory respite care services per month. However, only one 
third of those who are eligible use the leave available to them. Many informal carers think 
that the options available are not good enough or not suitable for the person receiving care. 
Reflections are ongoing on how to tackle the lack of take-up and measures have been brought 
in to improve the respite care options. For instance, some municipalities have introduced 
pools of substitute carers, who can step in during the care leave. Family foster care can be 

304 Pflegeservice Burgenland, Gute Betreuung in vier Schritten. (accessed on 11 April 2022) 
305 Pflege.de, Rente für die Pflege von Angehörigen. (accessed on 11 April 2022) 
306 European Commission and Social Protection Committee, 2021, Long-term care report, Vol. 2 Country profiles, 
Publications Office of the European Union, Luxembourg. 

88 

 
 
                                                 
provided in the home of the care recipient or of the family foster carer. This form of respite 
care is arranged, supported and supervised by the municipality. An agreement between the 
municipality and the family foster carers outlines rights and responsibilities. Family foster 
care offers personalised care and takes into account the needs of the care recipient307.  

France  is  currently  experimenting  with  ‘baluchonnage’,  an  innovative  solution  from 
Quebec,  whereby  a  care  professional  replaces  the  informal  carer  for  several  consecutive 
days (24 hours a day) to allow the carer to enjoy a break. At the end of the period of care, 
the care professional makes a series of suggestions aimed at improving support to the carer 
in the longer term. There are several benefits to this innovative approach: (i) support for 
vulnerable people who need care; (ii) support and recognition of the carer; (iii) better quality 
of  life  of  the  carer  and  the  person  cared  for;  and  (iv)  improved  home-based  care.  Some 
pension funds and mutuals support the individual costs of the intervention308. 

5.5.  Long-term care governance and funding 

The  proposal  for  a  Council  Recommendation  on  long-term  care  recommends  that  Member 
States  ensure  sound  policy  governance  in  long-term  care,  including  through  a  coordination 
mechanism  to  design  and  deploy  actions  and  investments  and  to  mobilise  and  make  cost-
effective use of adequate and sustainable funding. 

5.5.1.  Sound policy governance in long-term care 

Effective coordination at national, regional and local levels, active involvement of all relevant 
stakeholders in preparing, implementing, monitoring and evaluating long-term care policies and 
stronger coherence between long-term care and other relevant policies (including healthcare, 
employment, education and training, broader social protection and social inclusion and gender 
equality, and disability) can help reduce fragmentation between systems and thus achieve better 
outcomes while reducing costs.  

France309 is carrying out a comprehensive reform to improve the governance of the long-
term care system. A new home autonomy service will act as a single contact point for people 
with long-term care needs, bringing together the players in home assistance and home care 
and coordinating the provision of care. This will bring clarity for the people in need and 
their caregivers, who until now had to coordinate the different assistance and care providers. 
Territorial resource centres will ensure the link between professionals in the sector, and will 
develop an offer of reinforced support at home. Conditions for success of these centres are 
a  common  tool  such  as  a  ‘shared  file’  to  monitor  the  progress  of  individuals, 
interdisciplinary training and  sufficient  funding  also  for the training  of  staff.  The pricing 
system will be reformed to better reflect care and dependency needs and to allow for a real 
integration of home assistance and home care by creating the right incentives. 

307 Eurocarers, Towards care-friendly societies, Eurocarers country profiles. (accessed on 11 April 2022) 
308 BalunchonFrance, Mise en place du Baluchonnage: répit de longue durée pour les aidants. (accessed on 11 April 2022) 
309 Puiseux, A., 2022, The Ageing Reform. Presentation for the Mutual Information System on Social Protection. 

89 

 
 
                                                 
Prevention can postpone or reduce the need for  long-term care and thus relieve pressure on 
resources. Even before it arises, Member States can act to mitigate the need for long-term care 
through  policies  to  extend  healthy  life  years,  and  by  creating  social  and  environmental 
conditions that allow adults to maintain functional independence throughout their old age. The 
WHO  defines  healthy  ageing  as  ‘the  process  of  developing  and  maintaining  the  functional 
ability that enables well-being in older age’. The United Nations has designated 2021–2030 the 
Decade  of  Healthy  Ageing310.  People  who  are  fit  when  they  become  old  and  who  remain 
physically  and  mentally  active  not  only  have  a  better  chance  of  avoiding  or  postponing 
frailties,311 but they are also often better at managing functional decline when it occurs.312 As 
part of a life-course approach, intervention should start before a need for long-term care arises. 
In particular, primary prevention should start at as young an age as possible, in early childhood 
education and care.  

Sound  policy  governance  is  guided  by  evidence,  underpinned  by  relevant  and  timely  data 
(including  feedback  from  people  receiving  care  and  other  stakeholders),  evaluation,  the 
collection of evidence, and the sharing of lessons learned and successful practices. 

Integrated care seeks to achieve person-centred, effective and safe care for all age groups 
across the whole spectrum of health and social care: from disease prevention, to treatment, 
to management of chronic conditions (including at home), to long-term care. Patients with 
multiple  morbidities,  complex  care  needs  and  mental  health  conditions  require  a  care 
delivery system that connects and coordinates a wide range of care service providers and 
skills. Policymakers have to ensure a systematic approach that integrates health promotion, 
primary  care,  hospital  care,  mental  health  services,  long-term  care,  and  social  care. 
Through  three  key  projects  funded  by  the  third  health  programme,  the  Commission  is 
assisting national and regional authorities to build  the capacity and know-how to deploy 
integrated care. The Vigour313 and Scirocco-Exchange314 projects leverage the experience 
of  integrated care  ‘pioneers’ and transfer  knowledge to  the  ‘next  adopters’ of  integrated 
care. A third project, the Jadecare joint action315, works on the transfer of good practices 
from ‘pioneers’ to ‘next adopters’, with pilot projects on integrated care carried out by more 
than 20 ‘new adopters’ (care authorities).  

Furthermore, forecasting long-term care needs can help plan the resources needed, effective 
outreach  can  help  improve  the  take-up  of  available  support  and  the  use  of  long-term  care 
services, while contingency planning can help prepare long-term care systems for unforeseen 
circumstances and emergencies. 

310 WHO, 2021, Ageing and health.  
311 The EU co-funded ‘Advantage` project summarises the current state of the art of the different components of frailty and 
its management, both at a personal and population level, and increases knowledge in the field of frailty to build a common 
understanding to be used by participating Member States.  
312 The EU-funded ‘FrailSafe’ project aims to delay frailty by developing a set of measures and tools, together with 
recommendations to reduce its onset.  
313 VIGOUR  
314 SCIROCCO  
315 JADECARE  

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A shift  towards  services  to  better manage chronic conditions,  including  at  home, to  offer 
more social care and to respond to end of life needs requires a healthcare workforce with 
the right professionals and skills.  Health workforce planning can help  health and social 
systems keep up with changing health needs and take advantage of innovative solutions. It 
should support comprehensive strategies on working conditions, compensation, recruitment, 
retention  and  the  attractiveness  of  health  professions,  especially  those  which  tend  to  be 
undervalued.  The  Commission  is  supporting  Member  States  in  better  health  workforce 
planning through the joint action ‘HEROES –Health workforce to meet health challenges’316 
which is being set up in 2022 on the initiative of 18 Member States under the EU4Health 
programme. It will last 3 years and contribute to health workforce planning by supporting 
the  capacities  of  Member  States  in  developing  and  using  specific  tools  to  define  the  best 
combination of professions and the best skill-mix. 

5.5.2.  Investing in long-term care 

The  proposal  for  a  Council  Recommendation  outlines  reform  pathways  to  improve  social 
protection, availability, and quality of long-term care services, and address the challenges faced 
by  formal  and  informal  carers.  To  support  these  reforms,  the  proposal  recommends  that 
Member States mobilise and make the most cost-effective use of adequate and sustainable 
funding for long-term care, including by making use of Union funds and instruments. 

Public support for the care sector is a social investment, which entails health promotion, 
prevention,  support  for  healthy  and  active  ageing,  using  modern  technologies  to  improve 
productivity in care delivery, tapping into the job creation potential of the sector and improving 
gender  equality.  This  brings  multiple  returns,  for  individuals,  society  and  the  economy. 
More people in need of long-term care would be able to use high-quality formal care and be 
less at risk of poverty due to paying for care services. Their right to independent living and a 
generally good quality of life would be strengthened. Secondly, the burden of intensive caring 
on informal carers/family members, mostly borne by women, would be reduced and they could 
benefit  from  greater  participation  in  the  labour  market,  earnings  and  pension  credits. 
Furthermore, there would be a positive impact on their health, work-life balance and general 
well-being.  Thirdly,  the  long-term  care  workforce  would  benefit  from  better  working 
conditions,  pay,  training  and  job  satisfaction.  Fourthly,  long-term  care  service  provision  is 
expected to expand, implying new opportunities for service providers and care workers.  

The growth potential of the silver care economy arises from the growing demand for care 
services.  Research  suggests  that  investment  in  the  labour-intensive  care  sector  would  create 
positive  employment  effects,  as  1.6%  of  GDP  net  investment  could  generate  a  rise  of  8.5 
percentage points increase in women’s employment rate across the EU-28. In comparison, an 
investment of 5.3% of GDP would be needed to achieve a similar employment effect in the 
construction sector317.  

316 HEROES –Health Workforce to meet health challenges  
317 De Henau, J. and Himmelweit, S., 2021, A care-led recovery from covid-19: Investing in high-quality care to stimulate 
and rebalance the economy. Feminist Economics, 27(1-2), pp.453-469. 

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Similarly, the International Labour Organization estimates that an annual investment of 0.8% 
of GDP in early childhood education and care and an investment of 1.9% of GDP in long-term 
care would create an additional 13.6 million jobs in the EU by 2030318. 

Given its job creation potential, the care sector can attract workers from sectors impacted by 
the green transition. Active and healthy ageing and the effective prevention of the need for 
long-term care also depend on the physical and social environment where people live. An age-
friendly  environment  is  a  green  environment,  supporting  better  health  and  providing  more 
opportunities for social interaction across the generations. In addition to contributing to gender 
equality, addressing care needs also leads to job creation, which strengthens local communities. 
Investing in care can contribute further to social fairness by providing jobs for workers affected 
by the digital and green transitions. 

While investing in long-term care pays off, implementing reforms will still require a careful 
balancing between the adequacy of long-term care and ensuring the overall sustainability 
of public finances. One cannot be reached at the expense of the other. In particular, Member 
States that are starting from low levels of public expenditure on  long-term care will need to 
invest  in  the  sector  to  not  only  strengthen  social  protection  for  long-term  care,  but  also  to 
increase  the  availability  of  long-term  care,  improve  its  quality  and  sustain  its  workforce. 
However, this expenditure would not only benefit people in need of long-term care and their 
carers, but it can also harness the social dividends of investing in the care economy and thus 
provide a significant return on investment. A recent study from Austria319 concluded that for 
every euro spent on long-term care services in Austria, the aggregated value added is EUR 1.70 
and it generates more than EUR 0.70 in taxes and social security contributions (due to the high 
share of labour costs in care).  

In order to sustain long-term care financing also in light of increasing demand for care, it is 
important to increase the efficiency of long-term care expenditure and services, which could 
be  done  by  ensuring  sound  policy  governance  (see  section  5.5.1)  as  well  as  increasing  the 
availability and accessibility of long-term care services, which would allow long-term care to 
be provided in the most cost-effective setting. For example, due to a lack of long-term care 
services, people in need of care often stay much longer in hospitals than would be medically 
required,  adding  thus  to  the  pressure  on  healthcare  systems.  Typically,  the  average  cost  of 
residential care per person is higher than home care; if funds are steered in a way that fosters 
home and community-based care, people with low and moderate care needs can continue to live 
at home for much longer and thus avoid being placed in a much more expensive care setting. 
Digitalisation can also help to reduce the need for long-term care services and, in particular, 
residential stays by improving functional independence and the efficiency of care, for example, 
by helping older people ‘age in place’.  

long-term  care  via  employees’ 
Member  States  finance  public  expenditure  on 
contributions  in  social  insurance  systems,  via  general  revenues  from  taxes  or  via  a 

318 International Labour Organization (ILO), 2022, ILO Care Policy Investment Simulator (Geneva, forthcoming). 
319 Famira-Mühlberger, U., Firgo, M., Fritz, O., & Streicher, G., 2017, Österreich 2025: Pflegevorsorge – Künftiger 
Finanzierungsaufwand und regionalwirtschaftliche Verflechtungen. Wien: Österreichisches Institut für Wirtschaftsforschung 
(WIFO). 

92 

 
 
                                                 
combination  of both.  In  addition,  there  may  be  a  role  for  voluntary  private  long-term  care 
insurance in supplementing social protection for long-term care, but due to adverse selection 
and  other  obstacles  resulting  in  high  insurance  premiums  and  usually  limited  coverage, 
voluntary  private  insurance  could  not  ensure  that  people  in  need  can  afford  long-term  care 
services. 

Maximising the available fiscal space to expand the resources available to fund care policies 
would at the same time reduce unpaid care work. Given the ageing population, in the absence 
of  further  investment  in  social  protection  for  long-term  care,  the  costs  to  public  budgets  of 
informal care would increase over time. Thus, policymakers should take unpaid care work into 
account  in  relevant  macroeconomic  analyses  and  decision-making  to  uncover  the  effects  on 
women and men.320  

6.  CONCLUSION  

The  analysis  and  evidence  presented  in  this  staff  working  document  underpin  the  need  to 
urgently  address  the  common  challenges  and  structural  weaknesses  of  long-term  care 
systems in the EU. Firstly, social protection for long-term care is in some cases inadequate and 
long-term care services  are unaffordable for many people in need. Secondly, long-term  care 
services are sometimes not available and a large share of older people report unmet care needs 
in all Member States. Thirdly, there are persisting concerns with the quality of long-term care 
services.  Lastly,  many  Member  States  struggle  to  ensure  a  sufficient  and  adequately  skilled 
long-term care workforce, adding to the pressure on informal carers, most of whom are women. 
These  common  challenges  are  impacted  by  the  different  ways  long-term  care  is  funded, 
organised, delivered and monitored across the EU. 

The COVID-19 pandemic has shed further light on these challenges, highlighting at the same 
time how society and the economy are heavily reliant on care and the essential role of carers. 
The pandemic created a strong momentum to accelerate reforms and investments in long-term 
care and strengthen the resilience of long-term care systems, by expanding the offer of high-
quality and affordable long-term care services and improving the working conditions of care 
staff. To be successful, long-term care reforms and investments need to be underpinned by 
sound  policy  governance,  joint  commitments  and  strong  cooperation  between  public 
authorities, social partners, care providers, carers and those in need of care. 

320 ILO, 2022, Analysis submitted via the call for evidence. 

93 

 
 
 
                                                 
ANNEX 1 

KEY DEFINITIONS 

Key word 

Definition 

Access (to long-term care) 

Accessibility (of long-term care) 

Activities of daily living (ADLs) 

Affordability (of long-term care) 

Possibility of using long-term care services, encompassing the 
dimensions of cost/affordability, availability, awareness (about the 
existence of a particular service), and physical accessibility.  

Degree to which people with limitations in (instrumental) activities 
of daily living have access to products, services, and infrastructure 
on an equal basis with others.  

Personal care activities such as bathing, dressing, eating, getting in 
and out of bed or a chair, moving, around, using the toilet, and/or 
controlling bladder and bowel functions. 

Degree to which people in need of long-term care are able to meet 
the out-of-pocket costs (after social protection or security) 
associated with the use of long-term care. 

Availability (of long-term care) 

Degree to which long-term care goods or services are available for 
purchase or reach people in need of them.  

Cash benefits for long-term care  

Monetary transfers to a person in need of long-term care and/or 
their family to buy long-term care services (as opposed to in-kind 
benefits).  

Community-based care  

Formal long-term care provided and organised at community level, 
for example, in the form of adult day services or respite care. 

Domestic long-term care worker 

Any person engaged in domestic work who provides long-term care 
within an employment relationship. 

Formal long-term care 

Home care 

Independent living 

Informal care 

In-kind benefits 

Long-term care provided by professional long-term care workers, 
which can take the form of home care, community-based or 
residential care. 

Formal long-term care provided in the recipient’s private home, by 
one or more professional long-term care worker or workers. 

Independent living’ means that all people in need of long-term care 
can live in the community with choices equal to others, have the 
opportunity to choose their place of residence and where and with 
whom they live on an equal basis with others, and are not obliged 
to live in a particular living arrangement; 

Long-term care provided by someone in the social environment of 
the person in need of care, including a partner, child, parent or 
other relative, who is not hired as a long-term care professional. 

Social transfers in-kind from government or other authorities, 
including goods and services purchased on behalf of individuals. 
The goods and services may be the output of these institutions as 
non-market producers, or may have been purchased by these 
institutions from market producers for onward transmission to 

94 

 
 
households for free or at prices that are not economically 
significant. These benefits may also take the form of 
reimbursement of the cost of goods or services purchased by 
individuals. 

Instrumental activities of daily living 
(IADLs) 

Household activities such as preparing meals, managing money, 
shopping for groceries or personal items, performing light or heavy 
housework, and using a telephone. 

Live-in carer 

Long-term care 

Out-of-pocket payment 

Residential care 

Social protection  

Domestic long-term care worker who lives in the care recipient’s 
household and provides long-term care. 

A range of services and assistance for people who, as a result of 
mental and/or physical frailty and/or disability over an extended 
period of time, depend on help with daily living activities and/or 
are in need of some permanent nursing care. The daily living 
activities for which help is needed may be the self-care activities 
that a person must perform every day (Activities of Daily Living, 
such as bathing, dressing, eating, getting in and out of bed or a 
chair, moving around, using the toilet, and controlling bladder and 
bowel functions) or may be related to independent living 
(Instrumental Activities of Daily Living, such as preparing meals, 
managing money, shopping for groceries or personal items, 
performing light or heavy housework, and using a telephone); 

Direct payment for long-term care goods and services from primary 
income or savings, where the payment is made by the user at the 
time of the purchase of goods or use of services; or the part not 
reimbursed by a third party. 

Formal long-term care provided to people staying in a residential 
long-term care setting. 

All interventions from public or private bodies intended to relieve 
households and individuals of the burden of a defined set of risks or 
needs, provided that there is neither a simultaneous reciprocal nor 
an individual arrangement involved. The list of risks or needs that 
may give rise to social protection is, by convention, as follows:  

1. Sickness/healthcare  
2. Disability  
3. Old age  
4. Survivors  
5. Family/children  
6. Unemployment  
7. Housing  
8. Social exclusion not elsewhere classified. 

95 

 
 
 
 
 
 
Member States 

BE 
BG 
CZ 
DK 
DE 
EE 
IE 
EL 
ES 
FR 
HR 
IT 
CY 
LV 

Belgium 
Bulgaria 
Czechia 
Denmark 
Germany 
Estonia 
Ireland 
Greece 
Spain 
France 
Croatia 
Italy 
Cyprus 
Latvia 

LT 
LU 
HU 
MT 
NL 
AT 
PL 
PT 
RO 
SI 
SK 
FI 
SE 

Lithuania 
Luxembourg 
Hungary 
Malta 
Netherlands 
Austria 
Poland 
Portugal 
Romania 
Slovenia 
Slovakia 
Finland 
Sweden 

96 

 
 
 
 
 
 
 
 
ANNEX 2 

QUALITY ASSURANCE BODIES AND 
RESPONSIBILITES 

Country 

Quality assurance bodies and responsibilities 

Austria 

Federal Ministry for Social Affairs, Health, Care and Consumer Protection (Voluntary 
National Quality Certificate, consumer protection) 

Regional Governments with individual regulations, standards and procedures (inspections) 

Belgium 

Brussels: IRISCARE (accreditation, inspection) 

Wallonia: AVIQ - Agence pour une vie de qualité 

Flanders: Agentschap Zorg en Gezondheid 

Croatia 

Denmark 

Finland 

Inspection of the Independent Sector for Supervision and Petitions at the Ministry of Labour, 
Pensions, Family and Social Policy 

Ministry of Health and the Elderly (quality framework), Local authorities (implementation), 
Danish Patient Safety Authority (registration, monitoring) 

Ministry of Social and Health Care Affairs (legislation, quality standards, guidance by 
information) 

Institute of Health and Welfare (quality standards, national data-management, evaluation of 
state-financed development-projects) 

VALVIRA – National Supervisory Authority of Welfare and Health (national supervision) 

Regional State Administrative Agencies (regional supervision) 

Municipalities (local supervision as procurer) 

Provider units (reporting and self-assessment) 

France 

Agence Régionale de Sante (control and inspection) 

Cour des comptes (financial audits and control) 

Inspection Générale des Affaires Sociales (inspection) 

Germany 

Medical Review Board of the Statutory Health Insurance Funds’ Federation (Medizinischer 
Dienst des GKV-Spitzenverbandes) (national guidance and supervision) and Medical Review 
Boards of the Statutory Health Insurance Funds (Medizinische Dienste der 
Krankenversicherung) (regional inspections and enforcement) 

Ireland 

Italy 

Regional authorities to inspect structural, hygiene and safety standards 

HIQA – Health Information and Quality Authority (definition, accreditation, inspection and 
monitoring) 

National Agency for Regional Health Services (analysis, monitoring, evaluation of health 
services) 

Regional Agencies for Social and Health Services (accreditation and quality control at 
regional level) 

Latvia 

Methodological Management and Control Department of the Ministry of Welfare (inspection, 
monitoring) 

Luxembourg  Ministry of Family Affairs, Integration and the Greater Region (defining minimum standards 

for accreditation) 

Malta 

SCSA – Social Care Standards Authority (licensing, standard setting, inspection) 

Parliamentary Secretariat for Rights of Persons with Disability and Active Ageing (definition 
of minimum standards) 

National Audit Office (financial audits and control) 

Netherlands  National Healthcare Institute (definition of care standards for nursing homes) 

Healthcare Inspectorate (standard setting, inspection, public reporting) 

97 

 
 
Care Needs Assessment Centres (individual needs assessment) 

Regional care offices (accreditation and accounting of care providers) 

Romania 

National Agency for Payments and Social Inspection (accreditation, monitoring, enforcement) 

Slovenia 

Ministry of Labour, Family and Social Affairs (oversight, inspection) 

Spain 
(examples 
from 
selected 
autonomous 
regions) 

Region of Madrid: Autonomous community (periodic inspection and monitoring of 
implementation of quality standards) 

Region of Catalonia: UCQEC – Quality Control Unit at municipal level (monitoring 
contracts); CatSalut – Catalan Health Service (regional quality assurance regarding indicators 
included in contracts); AQUAS – Agency of Health Quality and Assessment of Catalonia 

(monitoring framework, evaluation) 

Region of Asturias: Inspection Services of the Regional Ministry of Social Rights and Welfare 

Sweden 

National Inspectorate (accreditation and inspection) 

Source:  Barslund,  M.,  Pacolet,  J.,  Leichsenring,  K.,  De  Wispelaere,  F.,  Waeyaert,  W.,  Harald  Hauben,  H,  De  Smedt,  L., 
Schepers, W., 2022, Analytical support under VC/2020/066. 

98