This chapter sets the scene for discussion on the adequacy and effectiveness of social protection for long-term care by presenting the current prevalence of long-term care needs in OECD and EU countries. A standardised classification of needs is used as it allows for cross-country comparison of the severity and distribution of older people’s needs. The analysis shows that the level of needs is overall high while prevalence varies significantly by socio-demographic characteristics, such as age or gender. In the coming decades, long-term care needs will continue to grow across the analysed countries due to population ageing and healthy ageing will only partially mitigate the demand for long-term care in the future.
Is Care Affordable for Older People?
OECD Health Policy Studies
Abstract
Determining whether people are living in better health than before is important to predict the additional demand that will be put on long-term care (LTC) systems given population ageing. While life expectancy has increased in all OECD countries over the past half century, not all these years are lived in good health. In 2021, less than half the population aged 65 and over in 36 OECD countries reported being in good or very good health (OECD, 2023[1]). Older individuals in Europe are also more likely to suffer from chronic diseases with 60% of them having at least one chronic disease (OECD/European Commission, 2024[2]). The prevalence of limitations in everyday tasks or so-called activities of daily living (ADLs), such as bathing, and instrumental activities of daily living (IADLs) increases with age. The evolution of activity limitations among older people is uncertain, raising questions about whether people will age healthily: several OECD countries are observing an increase in the prevalence of the need for help with ADLs, such as the United States (Lin et al., 2012[3]), whereas others, such as Denmark and Sweden recorded a decrease (Badache et al., 2022[4]).
The demand for LTC is directly tied to the needs of older individuals measured by the amount of such limitations in activities. Those experiencing more severe limitations require more intensive services and possibly more qualified caregivers. Understanding the extent and severity of these care needs is essential for predicting both current and future demand for LTC, as well as the financial implications for care recipients and state budgets. Accurate predictions become increasingly relevant with an ageing population. It remains important to evaluate and predict future demand for LTC depending on the possible scenarios about how the health and limitations of older people could evolve.
This chapter first analyses the prevalence of needs across 27 OECD and 2 EU non-OECD countries, identifying the share of people with different level of needs (low, moderate, and severe as described in Chapter 1, Box 1.1). It then investigates the heterogeneity of needs across socio‑economic characteristics, such as age, gender, or income, highlighting that people from more vulnerable groups are at higher risk of developing LTC needs earlier in life and face more difficulties in meeting them. The chapter also examines the coverage of formal and informal LTC, with a special focus on the role of gender. Women, partly due to their longer life expectancy, often outlive their partners and become caregivers. Although when they develop care needs, they frequently have to rely on external help. The chapter concludes with predictions of future needs and estimates of the future demand for LTC.
The need for support among older people is high in OECD countries: nearly one out of four older individuals has long-term care (LTC) needs, requiring help with daily activities. On average, an estimated 12% of older people in OECD countries have low LTC needs, 8% have moderate needs, and 4% have severe needs. The prevalence of LTC needs varies widely across countries: in Portugal, Hungary and Lithuania, more than one‑third of older people have LTC needs, while less than half of this number have such needs in Malta, Korea and Ireland.
Older people with LTC needs are more likely to be 80+ years old, female, live in single households, and earn lower incomes. The majority of older people with moderate and severe needs are 80 years old or older with 60% of those with moderate needs and two out of three older people with severe needs being aged 80 and above. Women make up two‑thirds of older people with LTC needs independent of the level of care needed. An important share (45%) of individuals with LTC needs live in single households, that would not be able to find informal support in their own homes. Across the OECD, around 27% of older people with any needs earn low incomes, compared to 16% of older people without LTC needs. Women tend to accumulate disadvantage as they are more likely to suffer needs and also have low income.
In all analysed countries older people rely heavily on informal care. Significantly more older people report receiving informal care than formal care, with substantial variations between countries. Nearly all older adults with severe needs in Latvia and Hungary receive informal care, while formal care is more common in the Netherlands and Belgium. These patterns are significantly influenced by the availability and affordability of formal care, along with cultural and family dynamics.
People with severe needs are more likely to receive all types of care, both formal and informal. Across OECD countries, approximately 25% of older people with low care needs report receiving formal or professional care, compared to 44% with moderate needs and 53% with severe needs. In OECD countries, on average, 78% of people with severe needs receive informal care, while this is 71% for those with moderate needs and every second older person with low needs receives some informal care.
The share of older people with LTC needs will rise in all OECD countries by 2050, though the increase will vary significantly across countries. On average, the share of those with LTC needs is expected to increase by 30% (or 1.2 percentage point). This increase ranges from 147% in Korea to an increase of less than 3% in Hungary. In a Healthy ageing scenario, the projected growth in the share of people with severe LTC needs is lower by an average of 64%. However, the share of older people with severe LTC needs is still anticipated to grow by 57%.
There is no single internationally accepted and standardised definition of LTC needs. Consequently, cross-country, and subnational area comparisons are challenging when using administrative data on LTC recipients. To address this limitation, researchers and analysts often rely on survey data (European Commission, 2021[5]; Scherbov and Weber, 2017[6]; Szenkurök, Weber and Bilger, 2024[7]). The most commonly used definition is based on reported numbers of ADLs and IADLs that a person needs help with. This approach focuses on the general level of needs without differentiating between levels of severity. It limits the analysis of the generosity and effectiveness of LTC systems, as individuals with varying levels of needs might face different costs. Additionally, countries often vary in their support based on the number of limitations an older person faces. A few studies, such as (Kristinsdottir et al., 2021[8]), examine different degrees of needs but do not analyse the financial implications for care recipients and state budgets. Furthermore, their analyses are limited to six European countries.
To fill this gap, the OECD has developed a set of typical cases to compare the prevalence and characteristics of older people requiring LTC. This methodology allows for the assessment of the effectiveness of social protection for LTC. The cases are based on activities described by the number of hours of need for help with ADLs, IADLs, and social activities (see Chapter 1, Box 1.1). These typical cases span different levels of care severity (low, moderate, and severe) and different ways in which these needs can be met (professional home care, informal care, and institutional care).
2.1.1. Almost one in four older people have LTC needs
On average, across OECD countries, 24% of older people have LTC needs. Figure 2.1 shows the prevalence of LTC needs among older populations, categorised by the severity of these needs. Most people with LTC needs have low needs (12%), followed by a smaller share with moderate needs (8%), and the smallest share with severe needs (4%). However, there are notable exceptions to this pattern. In Spain, the proportion of individuals with severe needs exceeds those with moderate needs. In Japan, the number of people with severe and moderate needs is higher than those with low needs. These exceptions can be partially attributed to the high proportion of individuals over 85 years old in these populations, as they are more likely to develop severe needs compared to those younger than 85.
The composition of older people with low, moderate, and severe needs varies significantly across countries. Japan has the highest share of the older population with severe needs, while the share is nearly zero in Hungary. The share of people with moderate needs ranges from 16% in Lithuania to 1% in Malta. Hungary also has the highest estimated prevalence of low needs among older people, whereas in countries like Malta, Korea and Japan, the share is six times lower.
Note: Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
The distribution of needs is partly aligned with the age structure of countries, but other factors are also driving the differences. Portugal has one the highest share of older people needing LTC. This aligns with the fact that, despite a long overall life expectancy, the share of healthy life years in older ages is relatively small. Additionally, Portugal has a relatively high proportion of individuals aged 85 and older. Hungary has a similar share of people with LTC needs, but these are mostly low and moderate needs. This corresponds with Hungary’s age structure, as it has one of the highest numbers of people aged 65‑74, a group more likely to have low or moderate needs compared to older age groups. Lithuania, with the third highest share of older people with LTC needs, has one of the highest proportions of individuals aged 75‑84, who are more likely to have moderate or severe needs compared to the younger age group in Hungary. Meanwhile, countries like France and Greece also have a large population of individuals aged 85 and older but show a smaller share of older adults with severe needs. This discrepancy could be due to cultural factors in self-assessment of LTC needs or existing support structures in terms of health and care.
2.1.2. People with LTC needs belong predominantly to more vulnerable groups
In the analysed countries, on average, most older persons with moderate or severe LTC needs are 80 years old or older (see Figure 2.2). As populations age, the prevalence of care needs increases, with adults over 80 years old more likely to require LTC compared to younger adults. While the experiences and needs of older individuals vary widely, data indicate that, on average, two out of three older people with severe needs are aged 80 and above. Among those with moderate needs, over half (60%) are also 80 years or older. Conversely, most older individuals with low needs are under 80 years old, with only 45% being 80 or older. However, there are some countries that deviate from this pattern and have a high share of older individuals with moderate needs among those aged 80 and above. Finland, in particular, has a very high share of older individuals with low and moderate needs who are 80 years or older, while the majority of those with severe needs are between 65 and 79. Finland has one of the highest shares of older people in international comparisons, with a particularly high share of people aged 65‑74 and relatively few individuals aged 80 or more, which partly explains its distinct situation. The situation is similar in the Netherlands, Ireland, Croatia, Korea, Sweden, Lithuania and Greece.
Among older people with low, moderate, and severe needs
Note: Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
The share of people aged 80 and above among those with needs varies significantly by country. Japan and Malta have the highest share of the older population with severe needs who are 80 years old or above, exceeding 90%. In Japan, a very high share of people above 80 exists among those with any level of needs, including moderate and low needs. This might be driven by Japan’s relatively old society and high life expectancy. Conversely, in Hungary, Finland, the Netherlands and Croatia, over half of the older people with severe needs are between 65 and 79 years old.
On average across OECD countries, women make up around two‑thirds of older people with low, moderate, and severe needs (Figure 2.3). There is no clear relationship between the share of women among older people estimated to have LTC needs and the severity of those needs. However, in almost all countries, the share of women among older people with low needs (except in Korea and Spain) and moderate needs (except in Czechia) is above 50%. This pattern is slightly less pronounced in the case of severe needs, but in the majority of countries – except for the three Scandinavian countries, Belgium and Hungary – the share of women among those with severe needs is also above 50%. This is partially driven by the fact that women generally have a longer life expectancy and that they are more likely to live longer with any level of needs (Kingston, Comas-Herrera and Jagger, 2018[9]).
Among older people with low, moderate, and severe needs
Note: Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
In addition to greater life expectancy, other factors drive this trend. For example. conditions of the musculoskeletal system, such as arthritis, joint replacements and backpain, are more common in women than men at old age (Woolf and Pfleger, 2003[10]). Hormonal changes, particularly after menopause, also contribute to health deterioration and autoimmune disorders, which disproportionately affect women, can lead to long-term health complications (Sammaritano, 2012[11]). Women are also more likely to experience poverty, especially in old age, due to lower lifetime earnings, career interruptions, and the gender pay gap (Gough, 2001[12]). This financial insecurity can limit access to healthcare, proper nutrition, and other resources that contribute to healthy ageing. Finally, women are more likely to suffer from mental health issues such as depression and anxiety (Behere et al., 2021[13]), which can exacerbate physical health problems as they age.
There is also heterogeneity in the share of women among older people with needs across analysed countries. On average, East and Central European OECD countries tend to have a higher share of women. At the other end of the spectrum are Scandinavian and Northern European OECD countries, which typically have a lower share of women among older people with needs, closer to or below 50%. This is clearly correlated with data on the gender gap in life expectancy across OECD countries, where East and Central European OECD countries generally have the highest gender gap in life expectancy (OECD, 2023[1]).
Across all analysed countries, older people with LTC needs (low, moderate, or severe) are more likely to live in single households than older people without LTC needs (Figure 2.4). On average, 45% of older people with LTC needs live in single households, compared to 32% of those without needs. It is unsurprising that higher shares of older people with LTC needs live alone, as individuals with LTC needs are, within the 65+ age group, consistently older in all countries than those without needs and thus more likely to have outlived their partners. Exceptions of such pattern include Hungary, Croatia and Korea where there is little difference in the share of people with and without needs living in single households.
Living in a single household also has important consequences for the demand for formal LTC. These individuals constitute a significant share of the population that would not find informal support in their own homes and will have to either rely on formal care or seek help from outside their household (e.g. relatives, friends, and neighbours). In Sweden, 63% of people with LTC needs live alone, followed by Lithuania, Denmark and the Netherlands. In these countries, the demand for formal LTC might be the highest.
Note: Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries. Estimates for Ireland are missing as data for Ireland contain only observation from non-single households.
Source: OECD analysis based on responses to surveys listed in Annex A.
Related to this, the difference between the number of older people living alone with care needs and those without care needs is indicative of the type of LTC in the country (formal versus informal). A large difference suggests that older people have lost their household members and that developing LTC needs does not lead to moving in with family members or to an institution. Examples of countries with a large difference include Malta (34 percentage points), Lithuania, the Netherlands and Belgium (each 24 percentage points). Possible explanations are that there is accessible and affordable formal home care, that families care for them without co-residing, or that there is no support, and their needs are unmet. Conversely, in Hungary, Croatia and Korea, the difference in living situations between older people with LTC needs and those without is insignificant. In these countries, older people who lose their household members and develop LTC needs may move in with family.
On average, older women are almost twice as likely to live in single households compared to men (Eurostat, 2020[14]). While living alone generally tends to have a positive effect on women’s well-being as there is no caregiving burden on them, this changes once they develop care needs and require help with daily activities (Sakkeus, Rudissaar and Abuladze, 2023[15]). In such cases, women are more likely to rely on formal care or care provided by informal carers living outside the household.
In all analysed countries, older people with any level of needs are more likely to be on low income, compared to those without LTC needs (Figure 2.5). On average, around 27% of older people with any level of needs have low income, compared to 16% of older people without LTC needs. The difference in the share of people with low incomes between older people with and without care needs varies significantly across countries. Differences are particularly large in Lithuania and Finland, where the difference exceeds 20 p.p. Conversely, in Korea, Czechia and Croatia, the difference is less than 5 percentage points
The higher share of people with low incomes among those with LTC needs suggests that they face even greater barriers to covering out-of-pocket expenses than the average older person. This disparity has implications for the affordability of LTC services for older individuals and the projected total spending at the government level. Across countries, the level of public support for LTC would need to be targeted on income to address concerns about affordability for that group. Yet, Chapter 3 would still highlight that challenges in affordability might still be apparent for those with median income.
Note: Low income refers to the upper boundary of the 20th percentile of the income distribution among older people. Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
The gender gap in income is higher for those having LTC needs (Figure 2.6). The share of women with low income among older people without LTC needs is higher than among men (19% vs. 12%), and this disparity becomes more pronounced among older people with needs, especially for low and moderate needs. The gap between men and women without needs is 7 percentage points, while it increases to 14 percentage points for those with low needs and 19 percentage points for those with moderate needs. The reduction in the gap (to 9 percentage points) for people with severe needs is primarily driven by the lower share of older women with severe needs and low incomes. This could be attributed to the fact that many women with severe needs receive survivor pensions, which are designed to protect widows or widowers from the risk of poverty (OECD, 2018[16]).
Unweighted OECD averages
Note: Low-income older people are defined as those with a disposable income below the second decile of the income distribution among older people. Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). Presented estimates are the unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
2.1.1. Older people with severe LTC needs more likely to report receiving care
On average, formal care receipt is higher among individuals with severe care needs than among those with moderate and low needs but there is heterogeneity. Across OECD countries, approximately 25% of older people with low care needs report receiving professional care, compared to 44% with moderate needs and 53% with severe needs (Figure 2.7). Notable exceptions include Hungary and Sweden, followed by Latvia, Japan, Italy, Malta, Germany and Luxembourg. There are striking differences across analysed countries. For instance, only about 8% of older Latvians with severe LTC needs report receiving professional or formal care, followed by Hungary (18%), Lithuania (20%) and Poland (21%). On the other end of the spectrum, nearly all older Dutch and Belgian adults with severe needs report receiving professional care. The greatest differences between individuals with low needs and those with severe needs reporting to receive formal care are found in the Slovak Republic (27% vs. 94%), the United States (11% vs. 69%), Belgium (41% vs. 98%), and the Netherlands (45% vs. 100%). Conversely, there is almost no difference in reporting by level of care needs in Latvia, Italy and Malta.
Based on self-reported information, among older people with low, moderate, and severe needs
Note: Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
Similarly, overall use of informal care tends to be higher for greater severity of needs (Figure 2.8). In OECD countries, on average, every second older person with low needs receives some informal care. The country where most older people with low needs rely at least partly on informal care is Hungary (75%) and the lowest number is found in Malta, where one out of five people with low needs receive informal care. For people with moderate needs, the overall use of informal care is higher and differences between countries are smaller. Fewest users can be found in the Slovak Republic (56%) and most in Finland (94%). The share of people receiving informal care is highest for individuals with severe needs while differences between countries are also high. The lowest share of people with severe needs receiving informal care is reported in Estonia and Malta (50% each), and the highest is in Hungary, Finland and Latvia at almost 100%.
Significantly more older people report receiving informal care than formal care at all levels of need (see Figure 2.7 and Figure 2.8). Only in two countries (Malta and Luxembourg), older individuals with low needs are more likely to receive formal care than informal care. For those with moderate needs, this is the case in four countries (Belgium, the Netherlands, Israel and Luxembourg). Among those with severe needs, four countries (Austria, Belgium, the Netherlands and Israel) also follow this pattern. The difference among older people with severe needs is most pronounced in Latvia (92 percentage points) and Hungary (82 percentage points), where the use of formal care is very low, but nearly all recipients receive some informal care. In some countries like Denmark or the Slovak Republic, the share of people receiving formal and informal care is very high, suggesting complementary between these two forms of care.
Several factors contribute to the differences in care use by needs. A possible explanation for the increasing reliance on informal care as needs become more severe is that older individuals manage their daily life for as long as they can, until it becomes impossible to manage daily activities on their own. Another important factor is the availability and affordability of formal care. Especially in countries where formal home care is less common, such as in Latvia and Hungary, access to formal care might be more limited for individuals with low care needs. They would need to rely on their own funding, rely on informal care instead or forego the necessary care, increasing the gap in the use of formal care between people with different levels of needs.
In addition, the main providers of informal care are children and spouses. Especially female relatives are more likely to provide informal care than men and bear most caregiving duties. Informal care availability differs across countries depending on labour market attachment, gender wage gaps and life expectancy, as well as cultural norms that determine children’s willingness to act as caregivers. In countries where formal care is scarce, becoming a caregiver leads to lower labour market participation (Vangen, 2020[17]; Barszczewski et al., forthcoming[18]) and higher mental and physical health risks (Bauer and Sousa-Poza, 2015[19]).
Based on self-reported information, among older people with low, moderate, and severe needs
Note: Estimates are first calculated using adjusted survey weights separately for each matching method (X and Y) and then averaged to obtain the final estimates (see Annex A). The figure includes an unweighted average across 27 OECD countries.
Source: OECD analysis based on responses to surveys listed in Annex A.
Population ageing will bring significant challenges to LTC systems, but the degree of challenge depends on how people’s health evolves with age. Over the past decades, countries have recorded impressive gains in the number of years people can be expected to live. While there is hope that individuals will age better and the level of LTC needs will be lower for given ages than for previous generations, there are a number of factors that may run against this hypothesis. A decline in healthy lifestyles, fewer gains from medical improvements prevent populations from reaching the full potential of healthy ageing. In addition, an increase in inequalities in education and socio‑economic status leaves some population groups to be particularly worse off. This section estimates future demand for LTC based on projections on the evolution for levels of needs for different scenarios.
On average, the share of older people requiring care is expected to rise across all analysed countries. This share is expected to increase by 30% by 2050 or 1.2 percentage points (Figure 2.9, Panel A). However, the magnitude of this increase varies widely between countries. Korea will see the highest rise (4.4 percentage points), followed by Greece (2.2 percentage points) and Italy (1.9 percentage points), primarily due to faster population ageing. On the opposite end of the scale, Hungary and the United States will experience the smallest increases (0.15 percentage points and 0.35 percentage points respectively). The method for predicting LTC needs follows the methodology proposed by de la Maisonneuve and Oliveira Martins (2013[20]). The severity of needs (low, moderate, and severe) is determined by factors including the importance of each age group (65‑79 or 80+), expected life expectancy at birth, and public spending on health (see Box 2.1 for details). Older individuals are more likely to develop LTC needs compared to younger ones. As life expectancy at birth increases, resulting in longer periods of good health, the onset of LTC needs may occur later in life. Additionally, increased health expenditures can lead to higher longevity across all age groups, particularly among older people, thereby affecting the prevalence of LTC needs.
Note: The figure presents the points estimates (average of two matching methods X and Y) for the share of people with needs in the total population (see Annex A). The figure includes an unweighted average across 27 OECD countries. The Healthy ageing scenario assumes that all additional years of life due to higher life expectancy are lived in good health.
Source: OECD analysis based on responses to surveys listed in Annex A, OECD Population projections database, UN World Population Prospects, and Global Burden of Disease Collaborative Network. Global Expected Health Spending 2020‑50, Institute for Health Metrics and Evaluation (IHME).
The increase in the number of people with severe needs could be partially mitigated by healthy ageing (see Box 2.1 for the definition of healthy ageing applied here). In the Ageing scenario (see Chapter 1, Table 1.3), the share of older people with severe needs will nearly triple, rising from 0.6% to 1.5% by 2050 (see Figure 2.9, Panel B). Korea is expected to see the largest increase (2 percentage points), followed by Greece and Italy (over 1.5 percentage points each). Only the United States will see an increase below 0.5 percentage points Healthy ageing could reduce this increase by an average of 0.6 percentage points through a lower increase in the share of individuals with severe needs. Gains from healthy ageing vary widely between countries, with minimal impact in e.g. the United States and Lithuania, but significant benefits in Japan, Korea, and Southern European OECD countries, where severe needs and ageing populations are more prevalent.
The methodology employed in this report to estimate the number and share of older people with LTC needs in the total population in 2050 closely follows the methodology proposed by de la Maisonneuve and Oliveira Martins (2013[20]). In order to predict the evolution of the number of people with needs, its past determinants have been investigated using variation across countries. is defined as the number of older people with being the level of needs (low, moderate, or severe) in the age group living in country . is a dummy variable for each age bracket (either 65‑79 or 80 and above), are the total real public health expenditures per capita in country and is life expectancy at birth in country . With these variables the following equation was used:
In the Healthy ageing scenario, all additional years of life are spent in good health, resulting in no impact from the increase in life expectancy. Methodologically, this translates into setting the coefficient for life expectancy to zero.
In the main specification, as anticipated, the dummy variable for the age group 65‑79 is significant and negative, indicating that younger individuals are less likely to develop care needs. The magnitude of this parameter decreases with increasing levels of needs, suggesting that individuals aged 65‑79 are more likely to develop low needs rather than moderate or severe needs. The impact of increasing life expectancy is significant and negative for low and moderate needs, indicating fewer years spent with these levels of needs. Conversely, the coefficient for severe needs is significant and positive, implying that higher life expectancy may extend the period of living with severe needs. Lastly, the impact of health expenditures appears to be insignificant.
The projection method used in this paper relies on a reduced form equation, in contrast to the macro-simulation models used in some works, such as the Ageing Report (European Comission, 2023[21]). This approach has the advantage of requiring only a limited number of assumptions and being primarily data driven. However, this advantage also comes with drawbacks. Macro-simulation models typically allow for simulating more advanced scenarios and incorporate a wider range of factors that can influence future levels of needs.
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