This unit provides a general overview of long-term care (LTC) in Europe, placing the topic within the broader demographic, social, and economic context. The unit begins by examining the demographic crisis in Europe driven by population ageing, together with its social, economic, and health-related consequences. It then highlights national trends in partner countries, with examples from Romania, Cyprus, Greece, Spain, and Italy. Next, the unit addresses the growing care needs of vulnerable populations, focusing on older people who increasingly experience chronic illnesses and limitations in daily activities. Then it addresses the distinction between formal and informal long-term care, and the limitations of current formal care systems, particularly regarding availability, affordability, and quality, which often lead to increased reliance on informal care. The latter is also an important topic addressed by this unit, with a focus on the essential role of family caregivers and the challenges they face in the absence of adequate recognition and support.
Finally, the unit concludes with interactive activities that encourage participants to reflect on the importance of LTC and to engage with realistic care scenarios.
Theoretical Content
Demographic Crisis in Europe
Advances in healthcare and technology in recent decades have led to the demographic phenomenon of population ageing, with individuals aged 65 and above growing in number and even outnumbering younger people.
Source: Image generated by the authors using Canvas AI (2025)
Eurostat (2024a) defines demographic ageing as the shrinking proportion of people of working age in the EU alongside the expansion of the older population.
- The population of older people in the EU-27 is expected to grow from 90.5 million in 2019 to nearly 130 million by 2050 (Eurostat, 2020).
- Life expectancy has increased, but healthy life expectancy has not kept pace: in 2022, the number of healthy life years at birth were 62.8 years for women and 62.4 years for men, indicating that most of the later years of older individuals tend to be lived with activity limitations (European Commission, 2024). This demographic trend has broad social, economic, and healthcare consequences, requiring adaptation of care systems to ensure good quality life for older populations.
Social consequences
- The growing number of older persons will result in more single-person households and, consequently, a higher risk of social isolation.
- Between 2015 and 2024 the number of single-adult households in the EU increased by 16.9%, compared to 5.8% growth in all households (Eurostat, 2024b).
- In 2024, nearly one third of people aged 65 or older in the EU were living alone, highlighting the increased vulnerability of older adults to social isolation and loneliness (Eurostat, 2024b).
This trend will reshape community structures and increase the need for both formal and informal support.
Economic consequences
- The shrinking active population will put pressure on labour markets and productivity.
- The old-age dependency ratio in the EU rose from 27.7% in 2013 to 33.9% in 2024, meaning there are already fewer than 3 people of working age for every person aged 65 and over (Eurostat, 2024c).
- Projections show that by 2100 the old-age dependency ratio may reach 59.7% placing unprecedented strain on pension systems and public budgets (Eurostat 2024c).
Health and care-related consequences
- Demand for health and long-term care services will also rise (Houggard Jensen, Pinkus & Ruer, 2024; OECD, 2025).
- At the same time, shortages of qualified personnel in these systems are expected to intensify (Eurofound, 2020).
- The share of people aged 85 and above – the group most likely to require intensive care – has already reached almost 3% of the population in 2022 and it is projected to double in the next decades (Eurostat, 2024d).
- Chronic diseases and age-related disabilities will therefore become major challenges for both healthcare providers and informal carers (Daly, 2025).
Policy implications
Governments will need to adapt pension, healthcare, and social care systems to these new realities. This will require:
- Stronger policies to promote active ageing (preventive healthcare, promotion of physical activity, healthy diets, lifelong learning programmes etc.) (Malley & Zigante, 2025).
- Greater social inclusion through measures aimed at reducing loneliness and isolation among older adults (e.g. intergenerational programmes, age-friendly communities etc.) (Eurofound, 2024).
- Digitalization of healthcare and social services in order to improve accessibility and reduce exclusion among older people (e.g. telemedicine, electronic health records, online appointments, online platforms for applying for social support, etc.) (World Health Organization, 2021).
- Labour market adaptation in order to keep older workers longer in employment (e.g. incentives such as flexible contracts, part-time opportunities) combined with anti-age discrimination measures (Eurostat, 2020).
- Pension system reform by gradually adjusting retirement ages in line with life expectancy and promoting private pension schemes (OECD, 2023).
- Formal recognition and support for informal caregiving, which remains a crucial component of long-term care provision (financial compensation for carers, carers’ leave and flexible working arrangements, respite services, training and counselling for carers etc.) (Costa-Font & Vilaprana-Pietro, 2025).
- Investment in formal care (in long-term workforce, improving working conditions, integrated care models, public-private partnerships in LTC, use of technology in care etc.) (Barber et al. 2021; Cés & Coster, 2019).
- Community-based care models which are less costly and more sustainable than institutional care models.
National Trends in Partner Countries
Romania
- In 2024, 20% of the population was 65+ (Eurostat, 2025c).
- The 65-79 age group increased by 34% between 2001 and 2024, higher than the EU average.
- The age group 80 years and above presented the second highest increase at EU level, representing 144.4% compared to 79.4% for EU27 (Eurostat, 2024e).
Cyprus
- In 2024, almost 18% of the population was aged 65 or older (Eurostat, 2025c).
- By 2060, almost 32% of the population will be 65+ (Trading Economics, 2024).
- Disability-free life expectancy is 62.4 years for women and 62 years for men, close to the EU average (Eurocarers, 2023).
Greece
- In 2024, 23.3% of the population was 65+ (Eurostat, 2025c)
- By 2050 the proportion of Greeks aged 65 or older will exceed 32%, leading to an inevitable demographic crisis (Pavlopoulos & Rachiotis, 2024).
Spain
- In 2024 20,3% of the population was 65 years old or over (Eurostat, 2025c).
- By 2035 the life expectancy at birth will be 83.2 years for men and 87.7 years for women (Instituto Nacional de Estatística, 2022).
Italy
- In 2024, 24,3% of the population was 65 years old or over (Eurostat, 2025c).
- It has one of the highest ageing indices worldwide: in 2023, for every child there were nearly 6 older people (Istituto Nazionale di Statistica [ISTAT], 2023).
- By 2023, the old age index reached 200% (Istituto Nazionale di Statistica, 2025).
Growing Need for Care in Vulnerable Populations
Older people are more likely to experience chronic illness, functional limitations, and challenges in self-care routines (e.g. bathing, dressing, eating, using the toilet, etc.) or in carrying out activities of daily living (preparing meals, shopping, taking medication, going to the doctor, etc.) (Cleveland Clinic, 2024).
Due to the increasing number of people in the “fourth age” (80+) the care demands have also intensified.
Statistical evidence
- Across the EU, in 2018, almost half of the people aged 65 and over reported difficulties with at least one personal care or household activity.
- 46.6 % of the EU’s older population with an increased difficulty in personal care or household activities reported a lack of assistance with those activities (Eurostat, 2022).
- Almost 30 % of the EU’s older population with difficulties in personal care or household activities used home care services for personal needs (Eurostat, 2022).
Long-Term Care: Formal and Informal Dimensions
Definitions
Long-term care (LTC): a range of health, social, and personal services and support provided to individuals who, due to ageing, chronic illness, disability, are unable to fully manage the activities of daily living over an extended period of time. It is not limited to medical treatment, it includes assistance with personal care (such as bathing, dressing, eating, mobility), household activities (such as meal preparation, cleaning and shopping), as well as emotional support and social participation. LTC can take two forms, formal and informal (World Health Organization, 2022).
- Formal care relates to paid care services provided by trained healthcare professionals or medical institutions (Li & Song, 2019):
- Unlike informal care provided by family and friends, formal care is delivered by paid professionals or organizations.
- It can be provided across various settings, including community-based services, residential facilities, and individuals’ homes.
- The support includes services from nurses, home health aides, physical therapists, and other trained professionals.
- Across the EU, there are 6.3 million people who work in the formal LTC sector (Eurofound, 2020).
- Informal care typically involves unpaid support provided by non-professional caregivers, including family members, friends or neighbours (Li & Song, 2019):
- Informal LTC plays a central role in addressing the caregiving needs of the population.
- Across Europe, as much as 80% of all care is provided by informal carers (European Commission, 2021)
- At least 44 million people (12% of the adult population) provide informal care on a regular basis (Eurocarers, 2021)
- A clear gender divide exists in informal care, with an average of 59% of informal caregivers in the EU being women (Eurocarers, 2021)
- Most long-term carers are spouses, daughters or daughters-in-law who provide such care to their family members on an unpaid basis, invisibly supporting paid and unpaid care work everywhere (UN Women, 2024).
- Mixed care represents a hybrid model where formal and informal care are combined to meet the comprehensive needs of care recipients (Sörensen & Pinquart, 2002; Lee et al., 2020):
- In practice, many LTC arrangements involve both professional services and family support working together, rather than functioning as entirely separate systems (Kemp et al., 2013; Kerpershoek et al., 2016).
- Mixed care models allow families to maintain their caregiving role while receiving professional support for more complex medical or personal care tasks (Pfaff et al., 2024).
- This approach can help prevent caregiver burnout among informal carers while ensuring that care recipients receive specialized professional attention when needed (Gérain & Zech, 2019; ASPE, 1993).
- The integration of formal and informal care can provide more flexible and responsive care arrangements that adapt to changing needs over time (Kemp et al., 2013).
Limitations of formal long-term care
The formal long-term care system, while crucial for many, presents significant limitations related to the availability, affordability, and quality of the services provided. These challenges often create substantial barriers for individuals and families seeking necessary support.
- Availability
Access to formal long-term care services is influenced by a multifaceted array of geographic, infrastructural, and systemic factors. Even in densely populated urban centres, individuals may confront significant barriers such as extended waiting lists, limited facility capacity, and complex administrative processes required for admission (Scott et al, 2024)
Who is most affected? → Vulnerable groups, including individuals with disabilities, low-income households, members of linguistic or cultural minorities, are particularly susceptible to these gaps in service provision (OECD, 2024).
Trends in the EU
- Despite most EU Member States having deinstitutionalisation strategies in place, the number of individuals (children, adults with disabilities, and older people) in residential facilities has risen in the 10 years up to 2022–2023 in the EU (Eurofound, 2024).
- Thus, the need for LTC is increasing, which means that formal care services and provisions are experiencing higher demand (Eurocares, 2021; Eurofound, 2024).
- The observed limitations of formal LTC services lead to heavy reliance on informal care (European Commission, 2022). Most countries examined operate a fragmented, mixed LTC system, balancing public, private, and family resources (OECD, 2025).
Role of informal carers
- The family is still the backbone of LTC, though demographic shifts (ageing population, fewer births) make this model increasingly unsustainable.
- Informal caregivers play a definite role as the primary support system for the LTC of older adults, supporting many individuals to continue living at home (National Institute on Aging, 2023).
- Informal caregivers provide care for persons with whom they have a personal connection, such as a family member, friend or neighbour.
- Their support mainly involves assisting with personal tasks, including activities of daily living (ADLs) like bathing, dressing, mobility, eating, toileting, continence and other chores such as housekeeping, laundry, meal preparation, medication management, shopping, handling finances, transportation and using communication devices (Edemekong et al., 2025).
Additional barriers in rural/remote areas
In rural and remote settings, these obstacles are frequently intensified. Many regions face:
- Insufficient long-term care facilities, with some regions lacking fundamental residential or respite services altogether (OECD, 2020).
- Shortage of specialized professionals, including geriatric nurses, physiotherapists, and occupational therapists, often necessitates that residents travel considerable distances to obtain necessary care, if it is available at all. Such circumstances complicate logistics for families and may discourage consistent engagement with essential health and social support services.
- Infrastructure constraints, which further aggravate these issues. In certain instances, the condition of existing facilities, characterized by aging structures, insufficient equipment, or inadequate accessibility, can compromise both the quality and safety of care provision.
- Persistent difficulties in attracting and retaining qualified staff, partially due to funding limitations. These contribute to variability in service delivery, limiting some organizations’ ability to provide comprehensive, individualized care.
- Policy and regulatory environments have a decisive impact on the availability of services. Regulatory restrictions on the development of new facilities, rigorous licensing requirements, or inadequate public investment can impede the expansion of long-term care networks and heighten regional disparities.
Consequences
- Where formal care options are scarce, families and communities often bear increased responsibility for supporting older adults, children/ adults with disabilities and those with chronic illnesses.
- While this dynamic can foster community cohesion and interpersonal support, it also imposes substantial demands on informal caregivers, who may lack necessary training, resources, or opportunities for respite.
Formal LTC systems are currently struggling to meet the growing demand of the ageing populations, leaving many individuals without the support they need, opting for informal care provision from their loved ones, mainly women in the family.
- Affordability
Affordability can present a significant challenge in accessing formal long-term care, influencing the choices of many individuals and families (OECD, 2024). Affordability pressures are intensifying amid rapid demographic change and limited public provision.
Key facts
- Long-term care is the fastest-growing area of social spending in the EU, projected to rise from 1.7% to 2.5% of GDP between 2019 and 2050. Yet years of under-investment have left deep structural gaps that strain families, workers, and providers alike (European Commission, 2022).
- The growing demand for LTC services has created a significant care gap that, if not addressed, will negatively impact quality of life in old age and place additional pressure on declining labour forces as more people, particularly women, must provide unpaid care (Hougaard et al., 2024).
Types of Costs in Long-Term Care
Direct costs for services
- residential care homes
- in-home nursing
- day programs
- specialised therapies
- various indirect and less visible costs that may accumulate over time (OECD, 2024).
Direct costs generally encompass:
- monthly or daily rates for residential facilities
- payments to professional caregivers or nurses
- fees for therapies or medical treatments not covered by public healthcare plans (Barber et al., 2021).
These costs vary substantially based on factors such as location, the level and complexity of care required, and the facility’s reputation or specialty. Private long-term care facilities can, in some cases, be so expensive per month, that they may significantly affect household savings or force families to liquidate assets (Barber et al., 2021).
Indirect/hidden costs (less visible, but equally important) include:
- caregivers’ reduced work hours and wages,
- earlier retirement
- increased morbidity and stress
- opportunity costs and externalities to other family members (Costa‐Font & Vilaplana‐Prieto, 2025).
Who needs care?
- In 2019 in the EU, almost half of the people aged 65 and over reported difficulties with at least one personal care or household activity (Eurostat, 2022).
- 46.6 % of the EU’s older population with an increased difficulty in personal care or household activities reported a lack of assistance with those activities.
- Almost 30 % of the EU’s older population with difficulties in personal care or household activities used home care services for personal needs (Eurostat, 2022).
Affordability barriers disproportionately affect vulnerable populations, creating social inequalities in access to care.
LTC needs to significantly increase the risk of household poverty, particularly in Mediterranean and Eastern European countries where public service provision is traditionally limited and families bear primary care responsibility (Casanova et al., 2024).
Care has a strong gender dimension:
- Women comprise nearly all the formal care workforce
- Care responsibilities keep significantly more women than men out of the labour market
- Women are more likely to need long-term care but less able to afford it.
Living in already disadvantaged conditions further heightens the probability of sliding into poverty when long-term care needs arise, exacerbating existing social inequalities (European Commission, 2022).
- Quality
The quality of formal long-term care varies across providers and national regulations (Dayly, 2025; Malley & Zigante, 2025). Staff-to-patient ratios, training standards, regulatory oversight, and resource availability play roles in determining the standard of care provided (Cés, & Coster, 2019).
Issues such as understaffing, insufficient training, or limited funding may affect the well-being and dignity of individuals receiving care (Raffnson, Shankar &S Steptoel, 2015).
Achieving consistently high-quality, person-centred services continues to present challenges for long-term care systems (Daly, 2025).
Cross-country differences in the EU
Significant differences across EU member states regarding specific features and policies in the field of long-term care (LTC) make it difficult to establish meaningful comparisons in terms of service quality (Daly, 2025).
Still, the European Strategy on LTC highlights four common challenges, all closely related to the quality of services (Daly, 2025):
- ensuring adequate access to LTC for all those in need;
- guaranteeing the provision of high-quality LTC services;
- securing an adequate and sustainable workforce while supporting informal carers;
- financing LTC in accordance with the growing demand for such services.
Assessing quality in long-term care
Assessing the quality of long-term care services generally requires the examination of their key dimensions and the identification of appropriate indicators to capture the situation under evaluation (Malley & Zigante, 2025). The earliest models of LTC quality assessment derive from frameworks developed within medical sciences.
Different frameworks are used to evaluate LTC quality
- Donabedian model (1980, cited in Malley & Zigante, 2025): distinguishes between outcomes (the effects on the beneficiary health), processes (the interaction between the patients and services providers, and structures (the context of care, such as facilities, equipment or staff involved in providing care). The model remains a cornerstone reference in the field.
- OECD framework (2013), proposes evaluating LTC quality across four main dimensions (Malley & Zigante, 2025):
- care effectiveness,
- user safety,
- person-centredness, responsiveness and empowerment,
- care coordination and integration.
- INTERRAI Quality Indicators: Developed by the interRAI research collaborative[1], uses standardised assessment tools to generate quality indicators for LTC facilities. It enables benchmarking and monitoring of care processes and outcomes internationally and is based on specific quality indicators for home care, institutional care and mental health services.
- European Quality Framework for Long-Term Care: Developed by the European Quality Framework for Social Services[2], it focuses on rights-based, person-centred care, promoting dignity, autonomy, and participation of service users. It emphasises the involvement of users and families in service planning and delivery.
Key factors influencing quality
At the individual level, quality in formal long-term care is influenced by multiple interrelated factors that affect the experiences of residents and service users (Zigante & King, 2019):
- Staff-to-patient ratios; when staffing levels are insufficient, carers may have less capacity to provide individualized attention, respond promptly, or sustain a therapeutic environment. Adequate staffing supports continuity of care, relationship-building, and early identification of health issues.
- Training and qualifications of care personnel. High-quality care environments often emphasize ongoing professional development so that staff stay current with best practices, including dementia care, palliative care, infection control, and communication. Ongoing training enables staff to address complex needs, enhances their confidence, and reduces risks of errors or adverse outcomes (Zigante & King, 2019).
- Regulatory oversight and enforcement of standards serve as mechanisms to help maintain quality Licensing bodies and health authorities conduct inspections, assess compliance with health and safety requirements, and monitor care outcomes. Facilities meeting consistent benchmarks typically deliver higher standards of person-centred care, while lapses in oversight or inconsistent enforcement may permit substandard practices, impacting resident safety and public confidence (Malley & Zigante, 2025).
- Resource availability. Facilities with access to modern medical equipment, mobility aids, and recreational spaces are more capable of supporting overall well-being and independence. Financial limitations, especially in underfunded or rural areas, can limit access to these resources and may influence nutrition, cleanliness, maintenance, and variety of activities available, which all contribute to quality of life (Zigante & King, 2019; Raffnson, Shankar &S Steptoel, 2015).
- Communication and cooperation among care teams, residents, and families also affect the care experience. Transparent decision-making, regular updates, and including residents and advocates in planning support autonomy and respect for preferences. Inadequate communication may lead to misunderstandings and unmet needs.
Quality in LTC depends not only on regulations, professional standards, and resources, but also on adequate staffing – both in terms of numbers and qualifications – as well as the involvement of care teams, residents, and families.
The Role of Families
Families often provide essential long-term care, especially where formal options are limited. Their contribution covers a wide range of daily and emotional needs:
Main caregiving responsibilities:
- Assistance with hygiene, meals, medication,
- Support with appointments, finances, and household tasks
- Companionship and emotional support (Eurocareres, 2021; European Commission, 2021).
Challenges faced by families
Due to the significant costs associated with formal long-term care services, many families encounter a complex array of financial, emotional, and logistical challenges (European Commission, 2021).
Financial challenges
- Services such as residential care facilities, in-home nursing, and specialised therapies involve high costs
- Insurance coverage or public subsidies often fail to fully cover expenses (OECD, 2024).
- Consequently, family members often make considerable personal sacrifices, including reducing paid employment, foregoing leisure pursuits, or utilising personal savings and assets to finance care needs (Eurofound, 2025).
Emotional and logistical challenges
- In addition to financial considerations, families provide essential support grounded in trust, affection, and cultural norms (Costa & Vilaplana-Pietro, 2025). Across various societies, there exists a strong tradition of intergenerational solidarity, wherein younger members are expected to care for elders as a demonstration of duty and respect.
While such arrangements can strengthen familial bonds and foster mutual appreciation, they may also impose significant strain on caregivers, particularly when care demands are substantial and resources for respite or assistance are inadequate (Gérain & Zech, 2019; Raffnson, Shankar &S Steptoel, 2015).Furthermore, the vital yet often unrecognized contributions of family caregivers remain largely overlooked in social policy and public discourse (Costa-Font & Villaprana-Pietro, 2025).
The value of this unpaid labour is considerable, supporting the viability of health and social care systems by addressing gaps in formal service provision.
Insufficient recognition and support can contribute to caregiver burnout, compromised health, and social isolation.
Comprehensive long-term care strategies must recognize and address the pivotal role played by families, ensuring they receive adequate resources, respite opportunities, and acknowledgment for their contributions (Kemp, Ball & Perkins, 2019).