Long-term care in the European Union: Situation, challenges and perspectives

24/09/2025 10:47 AM


Over the past decades, long-term care has emerged as an increasingly significant priority within the European Union (EU) policy, driven by demographic ageing, gaps in existing services and the rising costs of providing quality care. Despite this growing importance, long-term care policies and service frameworks remain less developed than other areas of social protection, such as health and pensions. In many countries, the availability of formal care is still limited, and the boundaries between health care, social assistance, and long-term care are often blurred, weakening social protection and constraining public funding.

Demographic projections indicate that between 2015 and 2050, the global share of people aged 60 and over will nearly double, from 12 to 22 per cent. EU countries are no exception to this trend, with demographic ageing set to drive profound changes. In the EU, life expectancy increased from 78.3 years in 2004 to 80.1 years in 2021, and by 2100 the proportion of people aged 80 and above is projected to more than double. These shifts will lead to increased demand for care, raising concerns about the financial sustainability of health and social coverage. At the same time, they will amplify the need for assistance for the most vulnerable, as ensuring independence and dignity in old age becomes a key social challenge. 
Figure 1. Population pyramids, EU, 2022 and 2100 (% of total population)
Source: Eurostat, 2023
This demographic transition goes hand in hand with a rising prevalence of chronic diseases, such as cardiovascular disorders and dementia, that undermine independence in daily life. While age is a key factor in the need for long-term care, it is far from the only one. The onset of chronic conditions, accidents stemming from risky behaviours, and complications related to poor treatment adherence are also major drivers of a loss of independence.
The ageing of Europe’s population is driving a sustained rise in long-term care needs, shaped by structural demographic and epidemiological shifts. This challenge is exacerbated by the decline of traditional forms of solidarity, both within families and across society. Despite rapid growth, the demand for long-term care remains largely underestimated. In many European countries, it is still approached predominantly from a financial perspective, focusing on old-age benefits, labour market implications and health care expenditure, while its broader complexity, and its social, societal and human dimensions, receive far less attention.
This fragmented perspective hampers a full understanding of the structural challenges linked to long-term care and hinders the development of coherent, appropriate, and sustainable public policies. In the broader context of global ageing, establishing national long-term care systems that are responsive to the specific needs of older people has become a pressing priority, especially in those EU countries most affected by demographic change.
Understanding long-term care: Key concepts and approaches
Defining long-term care
Long-term care lacks a universally accepted definition and while research on the subject is expanding rapidly, its scope remains highly variable. The variety of definitions reflects the range of different perspectives. Some consider beneficiaries in terms of their needs, thus encompassing all age groups requiring long-term care due to disability or illness. Other definitions focus on the type of service provided, the location of provision (specialized institutions, clinical settings, communities, or the beneficiary’s home) and the type of worker providing the service (health care staff, carers, domestic workers, or unpaid family members).
The concept of long-term care is usually framed around two components: Health and social care.
Table 1. Long-term care components: Health and social care
The health component is related to survival and maintaining health. It encompasses medical, paramedical, and nursing care, as well as personal health-related care provided in response to autonomy limitatons caused by illness or disability. This care includes assistance with activities of daily living (ADLs), such as eating, bathing, dressing, getting in and out of bed, using the toilet, or managing incontinence. Most hospital care, along with certain day services and home-based services, also include these provisions, which are generally delivered under the supervision of nursing staff.
The social component encompasses social assistance services that enable people with reduced autonomy to live independently at home.  It includes assistance with instrumental activities of daily living (IADL), such as shopping, meal preparation, housekeeping, laundry, and managing personal finances.
The health component is related to survival and maintaining health. It encompasses medical, paramedical, and nursing care, as well as personal health-related care provided in response to autonomy limitations caused by illness or disability. This care includes assistance with activities of daily living (ADLs), such as eating, bathing, dressing, getting in and out of bed, using the toilet, or managing incontinence. Most hospital care, along with certain day services and home-based services, also include these provisions, which are generally delivered under the supervision of nursing staff.
The social component encompasses social assistance services that enable people with reduced autonomy to live independently at home.  It includes assistance with instrumental activities of daily living (IADL), such as shopping, meal preparation, housekeeping, laundry, and managing personal finances.
The health component is related to survival and maintaining health. It encompasses medical, paramedical, and nursing care, as well as personal health-related care provided in response to autonomy limitations caused by illness or disability. This care includes assistance with activities of daily living (ADLs), such as eating, bathing, dressing, getting in and out of bed, using the toilet, or managing incontinence. Most hospital care, along with certain day services and home-based services, also include these provisions, which are generally delivered under the supervision of nursing staff.
The social component encompasses social assistance services that enable people with reduced autonomy to live independently at home. It includes assistance with instrumental activities of daily living (IADL), such as shopping, meal preparation, housekeeping, laundry, and managing personal finances.
To meet its objectives, long-term care must encompass a comprehensive spectrum of medical and social services. These range from screening and health promotion to functional rehabilitation, support for independent living, and palliative and end-of-life care. In addition, this care addresses emerging needs, prompting several countries to recognize a new social risk at the intersection of health and social protection policies.
At the global level, the World Health Organization (WHO) defines the objectives of long-term care systems as being to “enable older people, who experience significant declines in capacity, to receive the care and support that allow them to live a life consistent with their basic rights, fundamental freedoms and human dignity”. This broad definition covers continuous or intermittent care services, delivered in a variety of settings to address the health, personal care and social needs of people and with the goal of recovering (whenever possible), maintaining or optimizing their functional ability.  
The WHO has initiated the United Nations Decade of Healthy Ageing 2021–2030, with long-term care as one of the areas of action (WHO, 2021). Healthy ageing is defined as "the process of developing and maintaining the functional ability that enables well-being in older age” and is based on three components: functional ability, intrinsic capacity and environments.
At European level, several official EU acts and reports provide definitions of long-term care. The most recent legislative act is the Council Recommendation (2022/C 476/01) on access to affordable high‑quality long‑term care, one of the two pillars of the European Care Strategy launched on 7 September 2022. The European Commission (EC) defines long-term care as "the 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 need some permanent nursing care” (European Commission, 2021).
To gain a clear understanding of long-term care beneficiaries and services, the adoption of national definitions is essential, as they determine both eligibility and the scope of benefits. However, defining long-term care is challenging due to its complexity, which lies at the intersection of health and social care systems, and the diversity of care provision, which can be formal or informal. The European Commission report (European Commission, 2021) highlights the lack of a common definition among Member States.
Main themes in national definitions
Three main themes can be identified from the definitions of long-term care adopted in EU countries. The majority of them focus on physical disability, often assessed through activities of daily living (ADL) and instrumental activities of daily living (IADL). However, person-centred approaches, physical disability and mental capacity form the common basis for national definitions, as illustrated in Table 2. (Gonzalez-Aquines et. al., 2024).
Table 2. National definitions of long-term care
Theme Code(s) Examples
No official definition   Bulgaria, Croatia, Estonia, Greece, Hungary, Malta
Physical disability
  • Physical dependence based on ADL/IADL
 Most countries (19) include the assessment of activities and/or instrumental activities of daily living in their definition of long-term care.
Person‑centred care
  • Quality of life
  • Social support
  • User’s preferences
  • Family support
  • Financial capacity
  • Humanised care
  • In Denmark and Latvia, the aim of the long-term care system is to improve the quality of life of users.
  • Finland and Ireland consider the level of social support and the preferences of the user in the provision of long-term care.
  • Germany assesses the social life of users.
  • Spain considers the role of the family and financial capacity when determining long-term care services.
Mental capacity
  • Mental capacity
 Belgium, France, Germany and Spain have specific tools for assessing the mental capacity of long-term care users in order to determine access to services.
Source: Codes and themes identified in the long-term care definitions (Gonzalez-Aquines et al., 2024 Table 2)
Table 2. National definitions of long-term care

Diverse national practices despite an increasingly structured EU legal framework

The diversity of long-term care models

Box 1. EU Member States and country codes

 

European Union (EU) (07/2025)

Greece

(EL)

Lithuania

(LT)

Portugal

(PT)

 

Spain

(ES)

Luxembourg

(LU)

Romania

(RO)

 

France

(FR)

Hungary

(HU)

Slovenia

(SI)

 

Croatia    

(HR)             

Malta             

(MT)                

Slovakia    

(SK)

 

Italy

(IT)

Netherlands

(NL)

Finland

(FI)

 

Cyprus

(CY)

Austria

(AT)

Sweden

(SE)

 

Latvia

(LV)

Poland

(PL)

    

 

 
A key aspect of the EU context is the wide diversity of long-term care models across Member States (European Commission and Pavolini, 2022), which can be examined from multiple perspectives.
 
Firstly, the public organization of long-term care can be analysed according to two criteria: the existence or otherwise of a dedicated public branch (integrated or split system), and the territorial level of management (national, regional, municipal). Ten EU countries have an integrated system (AT, BE, DE, DK, ES, FI, FR, LU, NL, SE), sometimes with shared responsibilities. In the other 17 countries, the organization is fragmented between health care, social assistance, cash benefits and services in-kind.
 
Social protection for long-term care can take three forms: services, cash benefits for dependent persons and financial support for carers. All countries offer services – residential care, semi-residential care, home care (social or nursing) and material assistance such as home adaptations – but coverage varies greatly.
 
Three approaches can be used to group public long-term care systems in the EU (Saraceno and Keck 2010; European Commission and Pavolini, 2022). Familialism by default refers to a policy context in which the State does not offer publicly provided arrangements and leaves the family, often women, to take on the burden of care. Supported familialism also relies on the family as the main provider of care, but the family receives public support, under the form of relatively generous long-term care public expenditure through cash transfers. Finally, defamilialisation entrusts the State with the direct provision of care through services, allowing beneficiaries to avoid dependence on their family and friends.
 
There are thus six main models of social protection, depending on their ability to control public expenditure, cover long-term care needs and limit dependence on informal family carers.
 
Table 3. Six main models of social protection and long-term care among EU Member States
  Model Countries
1

Limited State intervention 

Nine EU Member States are characterised by a very low level of public expenditure on long-term care (on average 0.4% of GDP).

CY, EL, PT, BG, EE, HR, HU, LV, RO

  • With no role or a limited role for cash benefits (EE, EL, HU, PT, RO)
  • With a moderate/strong role for cash benefits (BG, CY, HR, LV)

 
2

Mild State intervention through cash benefits

Five EU Member States belong to a model in which public expenditure on long-term care as a share of GDP is higher than in the previous model (0.8% on average), and nearly half of this expenditure is financed by cash benefits (46%).

ES, LT, PL, SI, SK

Moderate to strong role for cash benefits
3

Mild State intervention through services

Three EU Member States invest more resources in long-term care than in the previous models, but remain below the EU-27 average; funding goes mainly to home care and residential care services.

IE, LU, MT

No or limited role for cash benefits
4

Strong State intervention through cash benefits

Four EU Member States belong to a model in which financial support for long-term care needs is relatively consistent (1.7% of GDP) and often takes the form of cash transfers.

AT, CZ, DE, IT

Moderate to strong role for cash benefits
5

Strong State intervention model through services

Three EU Member States devote a relatively large share of their GDP to long-term care policies (2.0%), using mainly services as the tool of provision.

BE, FR, FI

No or limited role for cash benefits
6

Very strong State intervention through services

Three EU Member States invest a very large share of public resources to cover long-term care needs (3.5% of GDP) and rely primarily on benefits in kind to support individuals and households.

DK, NL, SE

No or limited role for cash benefits
Source: ESPN elaboration on European Commission, Economic Policy Committee data (European Commission and Pavolini, 2022, pp.17-18, Box 1).
 
Amid this diversity, four common challenges emerge: ensuring equitable and affordable access to services for all; ensuring quality care; having a sufficient and well-protected workforce while supporting informal carers; and finally, ensuring sustainable financing in the face of increasing demand (European Commission and Pavolini, 2022).
 
Public funding models for long-term care
In the EU, long-term care is financed according to a variety of models, reflecting the social traditions and political choices of each country. 
 
Table 4. Main types of funding for long-term care
Types of long-term care funding Examples

Compulsory contributory systems    

These systems are based on compulsory insurance contributions, generally deducted from earned income.

 Five countries mainly use compulsory social contributions (BE in the Flemish federated entity, DE, EL, LU, NL)

Voluntary contribution systems

These operate on the basis of voluntary insurance and generally supplement basic public benefits.

 Less common, but they exist for example in Slovakia.

Non-contributory systems financed by taxation

These systems are based on general taxation and offer universal coverage, regardless of individuals' previous contributions.

 12 countries mainly use taxation (AT, BG, CY, DK, ES, FI, HR, IE, IT, LV, RO, SE).

Mixed models

Compulsory schemes coexist with voluntary or semi-compulsory schemes, offering greater flexibility but also a certain degree of complexity.

 Ten countries combine taxation (which generally finances social care) and compulsory social contributions (which generally finance health care) (CZ, EE, FR, HU, LT, MT, PL, PT, SI, SK).
Source: European Commission and Pavolini, 2022, p.13-14.

In general, these differences translate into a combination of funding sources, including social contributions, taxes and private contributions. This diversity is reflected across the Organisation for Economic Co-operation and Development (OECD) countries, as illustrated in Figure 2 (OECD, 2023), which shows that on average 54 per cent of all long-term care expenditures are publicly funded through taxes (20 per cent on average) or social security contributions (34 per cent on average) - while a significant share is funded privately, often supplementing the services provided by the government.

Figure 2. OECD countries – Funding sources for long-term care
 
                                                    Source: OECD, 2023, p.10
Socio-economic effects of long-term care
Although they rely on assumptions, current projections indicate that demographic shifts could drive demand for long-term care up by around 30 per cent by 2050, with particularly pronounced impacts in some countries.
 
This rise is driven by a combination of interdependent structural factors. Smaller family sizes and greater geographical dispersion are eroding traditional family-based support networks. At the same time, the growth of female employment is reshaping household care patterns. The long-term care sector itself faces a persistent workforce shortage, compounded by the low value still attached to such work. Informal carers, for their part, struggle to reconcile professional responsibilities with the demands of caring for a relative. Finally, health care systems remain overly focused on acute care and are poorly adapted to the continuous, chronic, and evolving nature of long-term care needs.
 
In EU countries, the rising demand for long-term care disproportionately affects women, due to their higher life expectancy. Yet substantial disparities persist: the rate of long-term care use differs by a factor of two between Portugal and Sweden. While the need for action is increasingly recognized, a significant portion of the population still lacks effective access to these services. Barriers include the absence of an appropriate legislative framework, inadequate infrastructure, high service costs, limited information, and the complexity of administrative procedures, challenges that are particularly acute for disadvantaged or isolated groups. Social and regional inequalities further impede equitable access to care.
 
Too often seen merely as a cost, long-term care should be acknowledged as a strategic investment. Ensuring adequate access to these services helps prevent unnecessary hospitalization, promotes more appropriate care, and safeguards the efficiency, accessibility, and sustainability of health systems. In addition, a well-functioning long-term care system can act as a driver of economic growth: it creates skilled employment, alleviates the financial burden on families, and facilitates workforce participation, particularly among women.
 
In this regard, long-term care should be recognized as an essential service. It is vital for preventing social exclusion, enhancing the quality of life of older people, individuals with disabilities, and those with chronic illnesses, and for reinforcing social cohesion by fostering intergenerational solidarity and ensuring dignified living conditions for the most vulnerable.
Innovation in long-term care
Innovative financing for loss of autonomy
In this context, several financing mechanisms can help ensure the sustainability of long-term care. Examples observed in EU countries include France’s Generalised Social Contribution (Contribution sociale généralisée – CSG), which is levied on all income to finance loss of autonomy; the “solidarity day” introduced in France and Germany, which allocates one unpaid working day per year to support such care; and behavioural taxes on products considered harmful to health, the revenues from which often feed into health insurance.
The revenue generated by these measures varies according to each country’s tax legislation. Employing a mix of funding sources strengthens the resilience and sustainability of long-term care systems, reducing reliance on social security contributions alone, which do not fully capture the universal scope of this emerging risk.
Organizational transformations
A collaborative approach is driving the development of innovative solutions to support people in vulnerable situations. In France, the PAERPA project (Healthcare Pathways for Elderly People at Risk of Losing Their Independence) seeks to preserve the autonomy of senior citizens by ensuring timely access to appropriate care, delivered by the right professionals and services, while also limiting the financial burden on individuals (Ministry of Labour, Health, Solidarity and Families, 2025).
Some initiatives, while not directly part of long-term care services, help create more supportive and cost-effective environments for vulnerable populations. In Germany, multi-generational homes, funded by the federal states (Länder) and managed by volunteers, foster intergenerational solidarity and support the independence of older people (Oldyssey, 2021). In the United States, time banking – which allows participants to exchange services for time credits – enhances community cohesion and promotes mutual aid among individuals (FasterCapital, 2024).
Structural reforms
Furthermore, structural reforms can enhance the accessibility of long-term care services, ensuring they are better adapted to the needs of both beneficiaries and their caregivers (ISSA, 2024).
In Germany, the 2023 reform increased the cash and in-kind benefit amounts for home and ambulatory care by five per cent and extended the Support Allowance for loss of earnings for family carers to ten days per year (Federal Government, 2023).
In Austria, the care allowance paid to individuals with severe psychological disabilities and dementia was increased in 2022 to cover an additional 20 hours of care per month, while an income-based supplement was introduced for carers who have interrupted their professional activity (Federal Ministry of Social Affairs, Health, Care, and Consumer Protection, 2023).
In Slovakia, since 2021, carers are eligible to receive up to 90 days of cash benefits that cover 55 per cent of lost wages while providing home or palliative care.
Proposing a common methodological framework
In a complex context, marked by a diversity of definitions, organizational models and methods of financing long-term care, it is useful to establish a common methodological framework.
 
Many international organizations, such as the WHO (WHO, 2024a), the European Commission and the International Social Security Association (ISSA), have published documents, reports and recommendations aimed at raising global awareness of the challenges associated with ageing populations and growing long-term care needs, which impact the sustainability of social security systems.
 
At the end of 2024, the WHO Regional Office for Europe published a new toolkit on the state of long-term care (WHO  2024b), marking a major step towards improving the quality and accessibility of long-term care in Europe. This practical and innovative tool is designed to support regional, national and local decision-makers in reorganising care systems to make them more responsive, inclusive and sustainable.
 
Since 2020, the ISSA has been actively engaged with its member organizations to improve knowledge, share good practices and advance programmes in the field of long-term care. In particular, it has organized a series of webinars on long-term care and published the analysis article Long-term care in ageing societies: challenges and strategies (ISSA, 2021), as well as the technical report Long-term care: global efforts and international attention from a health perspective (Elziniy and Oraby, 2021). In this regard, two ISSA publications released in 2022 address the challenges of ensuring affordable and adequate access to quality medical and social care for the growing number of older people around the world: the first is a special double issue of the International Social Security Review (ISSR) (International Social Security Review, 2022) and the second is a working paper published jointly with the ILO entitled Long-term care in the context of population ageing: a rights-based approach to universal coverage (Tessier, De Wulf and Momose, 2022).
 
The Technical Commission on Medical Care and Sickness Insurance has played a key role in these efforts and will continue to monitor progress during the ISSA’s 2026–2028 triennial programme period. These issues are being addressed at the World Social Security Forum 2025, with the launch of the ISSA Guidelines on Administrative Solutions for Long-Term Care, which aim to enhance the capacity of social security administrations to deliver effective high-quality long-term care services. The role of social security institutions in long-term care varies by country, reflecting differences in social security systems and mandates assigned by public authorities.
 
Final remarks
Access to social security is a fundamental right, essential for coping with the uncertainties of the life cycle. Yet in the European Union as elsewhere, the right to long-term care is still not sufficiently guaranteed. This reality calls for urgent collective action to build more equitable, accessible and sustainable systems that can meet the growing needs of ageing populations.
 
In the complex context of EU countries – characterized by diverse definitions, organizational models, and financing approaches for long-term care – it is challenging to adopt uniform responses. Effective strategies should prioritize prevention, the training of professionals, and access to high-quality, personalized care tailored to individual needs. Equally crucial is the coherent integration of health and social care policies, which can help contain costs while improving the quality of care. In addition, creating supportive environments that allow people to age safely and in line with their personal preferences is essential to extending healthy life years, bringing benefits not only to individuals but to society as a whole.
 
Despite ongoing reforms, the diversity of national approaches remains a challenge. However, the exchange of good practices and the development of common methodologies are paving the way for better administration of long-term care services. In this context, the ISSA will continue its efforts during the
2026–2028 triennium by strengthening knowledge development and cooperation between member institutions through webinars, publications and the sharing of concrete experiences aimed at improving the efficiency and sustainability of social security systems worldwide, leaving no one behind.

 

ISSA

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