LTCcovid Country Profiles

Responses to 1.04. Approach to care provision, including sector of ownership

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It was compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project moderated the entries and edited as needed. It was updated regularly until the end of 2022.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Patel D, Pharoah D (eds.) and LTCcovid contributors.  (2022) LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science.

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.




Provision of  LTC services in recent decades have often relied on market mechanisms and New Public Management (NPM) theories. These approaches generally have led to increased provider competition, together with greater emphases on formal contracts and performance measurement. These arrangements have been based on the believes that the free markets,  competition and a split between financing/purchasing and providing services could lead to more efficient service delivery (Marczak et al. 2015).

Public and private providers (for- and non-for-profit)

Across OECD LTC services are often outsourced to private for-profit and not-for-profit providers, although public providers still play a role in some countries.  Some countries (e.g. Australia, the US or Canada) have a long history of private providers delivering publicly funded LTC services and state role involves the registration, licensing and monitoring. In other countries (e.g. UK, France, Central and Eastern European countries) involvement of private, especially for profit providers is a more recent phenomenon. In countries such as Germany and Japan entry of for-profit providers was related to the implementation of LTC insurance. In Nordic countries, despite a growth in for-profit providers, some LTC services across the region are still provided by public organisations (Marczak et al. 2015; 2021 Long-term care report).

Institutional versus community care

Most countries prioritise providing care at home and in the community to reduce reliance on (more costly) institutional care. The emphasis on providing care at home is also related to people’s preferences to be cared for at home  (Lipszyc et al., 2012; OECD, 2013). Despite of the emphasis to provide care in the community, these services are still limited in several countries (e.g. in Eastern and Southern European countries, the US).


Lipszyc, B., Sail, E., & Xavier, A. (2012). Long-term care: need, use and expenditure in the EU-27 Economic Papers. Brussels European Commission.

Marczak J, Wistow G. (2015) Commissioning long –term care in OECD, in Gori C, Fernandez JL, Wittenberg R (eds) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol

OECD. (2013). Health at a glance 2013: OECD indicators: OECD Publishing.




International reports and sources


Some information on care provision in EU countries can be found in the following reports:

European Commission (2016) Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability.

2021 Long-term care report Volume 1 and Volume 2 – Publications Office of the EU


Gori C, Fernandez JL, Wittenberg R (2015) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol



The Aged Care Financing Authority (ACFA) produces a report providing an overview of the funding and financing of the Aged Care Industry.  In 2019-2020, there were over 3,000 providers; 845 of these were residential services, 920 were home care providers, and 1,452 were Commonwealth Home Support Programme providers (ACFA ,2021).

The number of residential care providers has decreased from 1,121 in 2010-11 to 845 in 2019-20. The number of beds has increased from 182,302 to 217,145 in the same period of time, in 2019-20 36% of all beds were from providers with more than 20 facilities. With regards sector ownership, 56% of residential care providers are not-for profit (with 55% of the beds), 33% are for-profit (41% of the beds) and 11% are public (4% of beds). Of home care providers, 12% are government owned, 36% are private for-profit and 52% are not-for profit (ACFA, 2021)


Aged Care Financing Authority (2021) Ninth Report on the Funding and Financing of the Aged Care Industry – July 2021.

Last updated: February 15th, 2022

While by law the federal states are responsible for the provision of long-term care services for older adults in Austria, in practice, the responsibility for carrying out these services is shared with several entities, such as the municipalities, non-profit organisations and private operators (Rechnungshof Österreich, 2020). The share of publicly- and privately-provided care providers varies immensely between the federal states and between the home and residential care sector.

In residential care, approximately 50% of care providers are public, 25% are non-profit, and the remaining 25% are for profit (Molinuevo & Anderson, 2017; Rodrigues & Nies, 2013). Approximately 900 nursing homes were in operation in 2017, providing 78,000 beds. Around 400 of these nursing homes were run publicly, with the remainder run by mostly non-profit (religious) organisations, such as Volkshilfe, Sameriterbund and Caritas.

In the home care sector, 91% of providers are non-profit, 8% are public and 1% are for-profit (Rodrigues & Nies, 2013). Mobile services are primarily provided by non-profit (often faith-based) organisations, while day centres (not connected to inpatient facilities) are mostly run by private providers (Grossmann & Schuster, 2017).


Grossmann, B. & Schuster, P.  (2017). Langzeitpflege In  Österreich:  Determinanter  Der  Staatlichen Kostenentwicklung. Studie Im Auftrag Des Fiskalrats. Wien: Fiskalrat. Retrieved from

Molinuevo, D. & Anderson, R. (2017). Care homes for older Europeans: Public, for-profit and non-profit providers. Luxembourg: Publications Office of the European Union. Retrieved from Eurofound website

Rechnungshof Österreich (2020). Bericht des Rechnungshofes: Pflege in Österreich. Wien: RH Österreich

Rodrigues, R., &  Nies, H. (2013). Making Sense of Differences – The Mixed Economy of Funding and Delivering Long-term Care. In Leichsenring, K., Billings, J., & Nies, H. (eds), Long-term care in Europe: Improving policy and practice. Basingstoke: Palgrave Macmillan.

Last updated: February 15th, 2022   Contributors: Cassandra Simmons  |  

Publicly subsidized services are provided by regional health authorities who deliver them through health authority owned or contracted private/not-for-profit facilities. For-profit, private facilities are often regarded as inferior to publicly owned/health authority owned facilities in terms of care, access to equipment, and government support.

In 2020, 33% of publicly funded LTC beds are operated directly by health authorities. The remaining 18,000 beds are delivered by for-profit companies (35%) and not-for-profit societies (32%) who have been contracted by one of the five regional health authorities in B.C.

A recent paper situates the contemporary crisis of COVID-19 deaths in seniors’ care facilities within the restructuring and privatisation of this sector. Through an ethnographic comparison in a for-profit and non-profit facility, they explore what they identify as brutal and soft modes of privatisation within publicly subsidised long-term seniors’ care in Vancouver, British Columbia, and their influence on the material and relational conditions of work and care. Workers in both places are explicit that they deliver only bare-bones care to seniors with increasingly complex care needs, and they document the distinct forms and extent to which these precarious workers give gifts of their time, labour, and other resources to compensate for the gaps in care that result from state withdrawal and the extraction of profits within the sector. They nonetheless locate more humane and hopeful processes in the non-profit facility, where a history of cooperative relations between workers, management, and families suggest the possibility of re-valuing the essential work of care (Molinary and Pratt, 2021; COVID-19_Response_Review.pdf; ABillionReasonsToCare.pdf).


Molinari, N. and Pratt, G. (2021), Seniors’ Long-Term Care in Canada: A Continuum of Soft to Brutal Privatisation. Antipode

Last updated: February 11th, 2022   Contributors: William Byrd  |  

Home care

Free choice of home care provider was introduced in 2003, which banned public monopolies in service provision. Municipal councils are required by law to ensure private for-providers of home care exist in each municipality. Unlike the tendency for market concentration as is the case for instance in Sweden, where for-profit provision of care is increasingly concentrated on the hands of a few, multi-national providers run by private equity firms (Erlandsson et al, 2013), the care market remains more scattered on small and locally operating providers in Denmark.

The tender rules require that municipalities either operate by competition by procurement (udbudsmodellen) or by endorsement (godkendelsesmodellen). If municipalities use the former model, they invite public as well as for-profit home care providers to compete based on a written tender. Here, there is wide possibility for providers to compete on price and quality. If they use the latter model, which was by far the most popular model until 2013, municipalities retain the power to set prices and quality standards for tendering procedures with home care providers.

Since changes in the law of 2013, many municipalities now apply the procurement model and invite competition on price as well as quality. The intention was not least to introduce real competition but also to decrease the number of contracted providers – which for instance in Copenhagen municipality alone amounted to 37 different providers – and thus make the choice more manageable for the user and make administration easier and less costly for the municipality. The total number of for-profit providers operating accordingly dropped from 459 in 2013 to 387 in 2017.

Since 2017, agencies have also been required to provide documentation of solvency. This change followed after a number of bankruptcies, affecting users and care workers, as well as the municipalities who had to introduce costly emergency response systems. The market seems to have stabilized since and the number of agencies has been reduced significantly, to around 80.

Once the individual has been assessed for need, there is the choice between the public and at least one for-profit provider. The latter is not permitted to refuse to provide care for any individual. The for-profit companies offer the same services as the public provider, personal care and practical assistance, and in addition many for-profit providers also deliver reablement services. It is possible to purchase topping up services from a for-profit provider. A study has shown that it is more expensive for the municipalities when it is the private provider that delivers cleaning services (Kjær and Houlberg, 2015).

Nursing homes

The law on free choice of provider does not apply to nursing homes, so local authorities are not obliged to contract out these services or to offer a choice of provider, but can opt to do so. Marketisation of nursing home services via user choice is, instead, facilitated by the Law on Independent Nursing Homes (Lov om friplejeboliger) which was enacted in January 2007. The aim of the legislation was to increase choice for users of nursing home care, and to introduce more variation in service delivery through competition between various providers. This includes the possibility of buying additional services which nursing home providers are allowed to offer. The municipality is not responsible for the allocation of places in the private Fripleje nursing homes, but nevertheless have to subsidize these institutions, as long as they are have achieved certification. The spectrum of nursing home providers within this model in addition to for-profit providers, however, also includes municipal as well as non-profit private providers.

There are no regular statistics on the types of providers, but as of 2013, private for-profit providers included Aleris, which operated 4 nursing homes, and Attendo Care, which operated one nursing home. Looking at the proportions of residents living in private for-profit nursing homes it is less than 1 %.

Non-profit private providers of long-term care services also deliver nursing home care under the Friplejebolig scheme and in addition also often under contract with the local municipality. Operators include Danske Diakonhjem who in 2013 operated 28 nursing homes, and Fonden Mariehjemmene with 13 nursing homes. Non-profit organisations often promote themselves as having a special value foundation. Non-profit providers in general do not operate in the home help.


Erlandsson, S., Storm, P., Stranz, A., Szebehely, M. & Trydegård, G.-B. (2013). Marketising trends in Swedish eldercare: competition, choice and calls for stricter regulation, in Meagher, G. & Szebehely, M. (eds.), Marketisation in Nordic Eldercare: a Research Report on Legislation, Oversight, Extent and Consequences (Stockholm Studies in Social Work, No. 30). Stockholm University: Department of Social Work.

Kjær, S. and Houlberg, K. Hjemmehjælp. Frit valg koster i kommuner,

Marczak, J., Wistow, G. (2015). ‘Commissioning long-term care services’, in Gori C, Fernandez JL, Wittenberg R (eds) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol. Accessed at Commissioning long-term care services

Rostgaard T. (2011) Care as you like it: the construction of a consumer approach in home care in Denmark. Nord J Soc Res. 2011;2..

WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at:

Last updated: May 24th, 2023

Municipalities determine whether they provide services themselves, work with other municipalities, purchase services from for- or non-profit actors, or set up cash benefit informal care systems (Ylinen et al., 2021).


Ylinen, T., Ylinen, V., Kalliomaa-Puha, L. Ylinen, S. (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Finland’, MC COVID-19 working paper 04/2021.

Last updated: February 1st, 2022

In 2020 there were 7,502 residential long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people.

Last updated: January 6th, 2022   Contributors: Camille Oung  |  

Prioritisation of private and third-sector providers

The Long-Term Care Insurance act stipulates (§ 11 (2)) that private and third sector providers take priority over public providers in the provision of long-term care (, n.d.).

Home care

Between 1999 and 2019 the number of home care providers in Germany has grown by 36%, an increase of 3,868 providers. Over the same period the number of people using home care doubled to 982,604 recipients in 2019 (Milstein, Mueller & Lorenzoni, 2021). The press release of another report states that the share of those receiving home care has increased from 20.6% to 25.4%, while the share of those living in residential care remained constant over the same period. This may be indicating a trend towards people’s preference of remaining in the community (RWI, 2021).

The largest share of care providers in 2019 were private for-profit providers (66.52%). Private for-profit providers served over half of home care recipients (52.33%). The second largest group were private non-profit providers (32.14%), providing home care for 46.13% of recipients. The smallest group were public providers (1.35%). This group provided home care for 1.54% of recipients (Gesundheitsberichterstattung des Bundes, 2022b; Milstein, Mueller & Lorenzoni, 2021).

Residential care

In 2019, residential care providers in Germany had a capacity of 969,553 beds. In comparison to other OCED countries Germany had a greater availability of beds in residential long-term care for those aged 65 and older than (53.6 beds per 1000 inhabitants vs. 47 beds per 1000 inhabitants).

Between 1999 and 2019 the increase in the number of residential care providers was larger (74%) than that of home care providers (36%).

Over the same time period, the share of private for profit care providers in residential care increased from 34.90% to almost 43%. In comparison to private-for profit and public providers, the share of full-time places also increased from 25.82% to 40.57%.

At the same time, the share of private non-profit organisations declined from 56.63% to 52.76%. The proportion of full-time places also declined (63.01% in 1999 to 53.81% in 2019).

As with home care, the share of public providers played a declining role in the provision of residential care (8.47% in 1999 declining to 4.52% in 2019). Over the same time period the share of full-time places also declined (11.7% in 1999 to 5.62% in 2019) (Milstein, Mueller & Lorenzoni, 2021).


Gesundheitsberichterstattung des Bundes (2022b) Ambulante Pflege- und Betreuungsdienste (Anzahl). Gliederungsmerkmale: Jahre, Deutschland, Art der Pflege- und Betreuungsdienste, Träger. Available at:!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=876&p_ansnr=98223306&p_version=2&D.000=1&D.374=2&D.983=1(Accessed 31 January 2022).

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. License: CC BY-NC-SA 3.0 IGO

RWI (2021) Pflegeheim Rating Report 2022: Wirtschaftliche Lage deutscher Pflegeheime is angespannt, jedes fünfte im “roten Bereich”. Available at: (Accessed 5 February 2022). (n.d.) Sozialgesetzbuch (SGB XI) Elftes Buch Sozial Pflegeversicherung. Available at: (Accessed 11 February 2022).

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Municipalities, local health authorities and the National Institute of Social Security (INPS) are directly involved in the organisation of LTC services, but others are involved in planning and funding these services, including the central state, regions and provinces.

The table below classifies the Italian LTC system according to initiative and actor involved:

Typology Service/Intervention Actors involved
Cash transfer Companion Allowance (CA – Indennità di Accompagnamento) National Social Insurance Agency
Monetary vouchers to finance informal caregiving or care services Municipalities


Local Health Authorities

In-kind services Home care

Nursing homes

Day care

Informal caregiving

Local Health Authorities and Municipalities

Municipalities and regions; providers (public, private, or not for profit)

Relatives or migrant care workers

(source: Notarnocola et al., 2021).

Informal care and migrant care workers, often with irregular contracts, play an important role in the organisation and provision of home care (European Commission, 2016).


European Commission (2016), Italy – Health Care & Long-Term Care Systems. Excerpt from Joint Report on Health Care and Long-Term Care Systems & Fiscal Sustainability. Institutional Paper 37, volume 2, country documents. Economic and Financial Affairs, Economic Policy Committee. Retrieved from update_joint-report_it_en.pdf (

Notarnicola, E., Perobelli, E., Rotolo, A., & Berloto, S. (2021). Lessons Learned from Italian Nursing Homes during the COVID-19 Outbreak: A Tale of Long-Term Care Fragility and Policy Failure. Journal of Long-term Care, (2021), 221–229. DOI:

Last updated: February 4th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

The 2000 LTC insurance reforms sought to create a competitive and mixed market of provision. Today, the Japanese LTC market consists of a mixture of public, quasi-public and for-profit service providers. Although the non-profit sector has long dominated Japan’s LTC sector, the overall picture has changed due to the growth of the for-profit sector in recent years.

Non-profit providers dominated the residential LTC market because of regulatory restrictions. Aside from public sector providers, only two types of private non-profit organizations—social welfare corporations and medical corporations—were allowed to provide residential LTC services (Estévez-Abe and Ide 2021a). Because local governments are the licensing agents of social welfare corporations, the government and private non-profit actors work in tandem to plan and provide nursing services within the jurisdiction (ibid.).  In other words, these two non-profit organizations fulfilled quasi-public roles within the Japanese LTC sector.

The government has encouraged the growth of for-profit nursing homes by introducing favourable reforms since 2006.[1] It should be noted that there are two types of for-profit eldercare facilities—one provides nursing care but the other one doesn’t. The growth of the for-profit LTC sector has increased the range of choices for users.

As for the market for day care and home care services, for-profit providers have always dominated.  It is important to note here that non-profit providers such as social welfare corporations are allowed to operate for-profit services. Many social welfare corporations, which operate non-profit quasi-public residential LTC facilities, operate as for-profit providers of day care and home care services.

Providers are reimbursed by the LTCI according to a national fee schedule although municipalities have some freedoms to adjust it to suit local needs (Curry et al. 2018).


Curry, N., Castle-Clarke, S. Hemmings, N. (2018). ‘What can England learn from the long-term care system in Japan?’ Nuffield Trust Research Report. Retrieved from:

Estévez-Abe, Margarita & Hiroo Ide (2021a) “COVID-19 and Long-Term Care Policy for Older People in Japan,” Journal of Aging & Social Policy, 33:4-5, 444-458, DOI: 10.1080/08959420.2021.1924342

[1] Undated document created by the Ministry of Health, Labour and Welfare.  accessed on March 16, 2022.





Last updated: January 20th, 2023

The long-term care (LTC) system in Malaysia is fragmented; this comes as a result of separate health and social care systems, as well as a divide between publicly and privately funded care. Malaysia has focused on family and community provided car; the result of this is that the burden of care tends to call on female members of the population (both in terms of formal and informal care providers. It is estimated that Malaysia’s LTC system serves only about 1% of the total population (Hasmuk et al., 2020).

For those who are terminally ill, Malaysia has 2 government-run homes and 15 government-run residential homes; there are an additional 320 registered LTC facilities, all of which are registered (as of 2020) under the Private Healthcare Facilities Act (2018). It is estimated that over a thousand care homes in Malaysia remain unregistered. There are also some facilities that are operated by non-governmental organisations (NGOs), but these generally lack the resources to care for those with nursing-level care needs and are primarily residential homes.  The majority of nursing homes are privately run, and there has recently been an emergency of privately-run day-care facilities. However, the majority of LTC in Malaysia is provided at home, often through domestic workers who are hired through agencies from the Philippines, Cambodia, Sri Lanka, and Indonesia. This home care is generally unregulated, and is not mentioned in the new Private Aged Care Facilities Act (Hasmuk et al., 2020).


Hasmuk K, Sallehuddin H, Tan MP, Cheah WK, Rahimah I, Chai ST (2020) The Long-Term Care COVID-19 Situation in Malaysia available at, International Long-Term Care Policy Network, CPEC-LSE, 2 October 2020.

Last updated: February 16th, 2022

LTC is typically viewed as a family responsibility, although this is being challenged as society undergoes change. The government acknowledges that family caregivers require support and allocates a monthly allowance to caregivers of older people experiencing significant declines in capacity. Some efforts have been made to provide practical training to family caregivers. A number of residential facilities also exist. Currently, approximately 25 charitable homes are operated by nongovernmental organizations and funded by the government. Nursing and medical care is provided on site. Access to these homes is first-come, first-served and based on means testing. Overall, the demand for admission into these homes far outweighs their bed capacity. The number of private retirement homes, for those who can afford them, has increased in recent years (source:

Last updated: January 6th, 2022

The prevalent family structure in Pakistan is the joint/extended family system: respect is shown to older people, and historically families take care of older people as they age. However, there has been a shift in recent years: an increasingly ageing population and migration of younger generations to areas where there are better career and employment opportunities as well as the entrance of women to the workforce has meant that more elderly people are compelled to reside in shelter homes (Cassum et al., 2020). There is still taboo around old-age homes, and as a result there are still relatively rare in Pakistan (Majid, 2018).


Cassum, L.A., Cash, K., Qidwai, W. et al. 2020. Exploring the experiences of the older adults who are brought to live in shelter homes in Karachi, Pakistan: a qualitative study. BMC Geriatr 20, 8.

Last updated: January 27th, 2022   Contributors: Daisy Pharoah  |  

LTC services in Poland are provided by both private and public providers. The former includes unpaid carers and a grey zone (including immigrant carers) as well as non-for profit and for-profit residential care providers. Non-governmental organizations are active in the provision of care for older people – in supporting hospitals, care, and nursing facilities (Golinowska et al. 2017).


Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: February 15th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

The right to health care and social protection for all citizens is enshrined in the Seychelles’ Constitution of 1993. A number of government-funded long-term care services are available, including both home care and residential services. Long-term care provision remains mainly in the public sector, with some involvement of civil society and limited participation of the private sector. The country’s home care scheme was established in 1987. This programme makes it possible for people to remain at home rather than using residential or institution-based care. Caregivers are chosen by the beneficiary, usually a family member of the older person (source:

Public residential facilities take the form of regional homes for older people and one 136-bed long- term care nursing facility. The regional homes usually consist of ten single-occupancy independent living units. Residents do not pay rent but are responsible for living costs. The country’s sole long-term nursing facility is in high demand: the waiting list is long (source:

Last updated: January 6th, 2022

LTC in the community is mostly provided informally by family and surrogate carers. Formal community services (e.g. day care) and residential care are largely provided through Voluntary Welfare Organisations or Social Service Agencies. In 2019, Singapore had 7,600 day care places, 10,300 home care places, 1,986 community hospital beds and 16,059 nursing home beds. Of the available nursing home beds, 75% were supplied through the Social Service Agencies and the government and 25% through private providers (source:

Last updated: January 6th, 2022

Traditionally, long-term care has been seen as a family responsibility yet few schemes are in place to support family caregivers. Private retirement villages cater mainly to older people with financial means. Publicly funded long-term care is available to only a small fraction of the older population. The majority of this type of care is provided in residential facilities which tend to be clustered in urban settings. Applicants are subject to a comprehensive assessment of their current living situation, family support, financial means and care needs. Only those who meet the criteria are eligible for admission. Individual care homes usually have their own admission policies and procedures, in addition to the formal criteria for obtaining public financial support. Availability of beds is another hurdle: most facilities have waiting lists for admission (source:

Last updated: January 6th, 2022

In Spain, a number of public services are provided by private entities, both for and non-profit. In the care home sector, although marketisation has led to an increase in the available places, this is considered to have been at the expense of the quality of services, Public administrations have difficulties in terms of inspecting and evaluating services. Additionally, migrant workers, often without an official contract, provide a share of home care in Spain (Zalakain et al. 2020).

Data on the social care workforce in different settings:

Looking at the settings in which the social care workforce is employed gives a good indication of the scale of different types of care in Spain. Analysis by Martinez-Bujan et al (2021) shows that in 2020 there were estimated 684,949 people working in social care (based on data from the EPA survey), representing 3.7% of the total number of employed persons in Spain. 66.3% of social care workers were employed in private households, either as home carers (17.7%) or as domestic workers (82.3%).

Carers working in care homes represented 19.9% of the total care workforce (with most employed as nursing assistants), and carers in social services without accommodation (mostly home help services, usually referred to as SAD) represent 13.9% of the care workforce.

The Dependency Law

The Dependency Law states that an attempt should be made to provide adequate care for a person in a situation of dependency. If this is not possible, then money/cash will be provided to pay for care. The law also states that official/recognised benefits and services should be integrated into the Social Services Network of Autonomous Communities.

Within this starting framework, the Law itself also states that:

  • Recognised benefits and services are integrated into the social services network of the respective Autonomous Communities.
  • The network of centres will be made up of the public centres of the Autonomous Communities; the state centres for the promotion of personal autonomy and care of situations of dependency; and accredited private centres.

In short, some of the services The Dependency Law recognises are provided by public administrations aside from the autonomous communities, and by privately run centres that are regulated by the Autonomous Communities.

Non-subsidized private centres and services that provide services for people who rely on care from others must also have the proper accreditation from the corresponding Autonomous Community.

In conclusion, the services that are recognized within the framework of the Dependency Law must be provided through public or publicly funded places in private care homes . In cases where this is not possible, cash benefits can be provided for an accredited private centre to provide the service.


Martínez-Buján, R.; Jabbaz, M. and Soronellas, M. (2021) El cuidado de mayores y dependientes en España ¿En qué contexto irrumpe la covid?. In Comas-d’Argemir, D. and Bofill-Poch, S. (eds.) (2021): El cuidado importa. Impacto de género en las cuidadoras/es de mayores y dependientes en tiempos de la Covid-19, Fondo Supera COVID-19 Santander-CSIC-CRUE Universidades Españolas.

Zalakain, J. Davey, V. & Suárez-González, A. (2020). The COVID-19 on users of Long-Term Care services in Spain. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 28 May 2020. Retrieved from: LTCcovid-Spain-country-report-28-May-1.pdf

Last updated: June 29th, 2022   Contributors: Carlos Chirinos  |  Sara Ulla Díez  |  

State and NGO operated day-care centers. The NSE supports 662 day-care centers around the country.  HelpAge Sri Lanka and other NGOs have also supported day-care centers. There may be other day-care centers and Elders’ Clubs operated by small NGOs and village-level

Sri Lanka has two main types of residential facilities: those primarily designed to provide housing for older people who lack shelter, and those that aim to provide LTC support and nursing care. Most facilities fall into the first category and are known as “elders’ homes” or “eldercare homes.” Even if the primary aim is to provide shelter, some residents have or develop needs for LTC support over time. Sri Lanka currently has around 255 eldercare homes serving approximately 7,100 elder residents, two owned by the central government and three by provincial councils. The private sector operates around 20 homes; others are not-for-profit and funded by private donations and some government funding. Not-for-profit eldercare homes are usually operated by faith-based organizations and NGOs. Homes for elders registered under the Department of Social Services increased from 68 in 1987 to 162 in 2003. Five public eldercare homes house 7% of all elder residents, and 220 private (i.e., not for-profit) eldercare homes house 85% of all elder residents.

The 2017 survey of eldercare provider institutions, it was estimated that there were about 25 home nursing care service providers, although the exact number is not known due to gaps in the implementation and monitoring of the formal registration system of such providers and regulation of the industry. These home nursing care services provide 24-hour nursing care to about 900 older clients. The services are usually expensive and not affordable for lower-income families (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (

Last updated: January 6th, 2022

Within Sub-Saharan Africa, national efforts to develop long-term care systems exist only in Mauritius, Seychelles, and South Africa. The expansion of organized long-term care has been organic and uneven in terms of geographical spread, populations served, and services offered. Most organized care is clustered in urban metropolitan settings. Two major service models appear to dominate: charitable care for the most destitute older people (usually operated with few resources by faith-based, civil society or public welfare bodies) and private for-profit services, mostly in the form of residential homes for those who are able to pay. There appear to be few, if any, organized services for the majority of older people who fall between these extremes of the spectrum (source:

Because organized systems of long-term care are generally lacking, families constitute the major source of care for older people who are no longer able to live independently. However, evidence also reveals that a substantial group of older people receive no family care whatsoever. The majority of family care is provided by female relatives, ranging in age from children to older adults, although some studies document significant involvement of men in caregiving. Some further evidence points to a role played by unorganized and unregulated domestic workers in long-term care provision. Care is provided either in older people’s homes or in the home of caregiving relatives (source:

Many researchers and some policy-makers in sub-Saharan Africa have concluded that it is no longer feasible to rely on kin as the mainstay of long-term care provision, given a perceived weakening of extended family support systems. Key factors assumed to underly this shift include increased rural to urban migration and labour force participation, especially among young women; increasingly monetized economies; the impact of the HIV/AIDS epidemic (increased deaths among younger adults); and loosening norms and structures for extended family solidarity. Although perhaps intuitive, it is important to note that presumed declines in family care provision have not yet been studied formally and considerable debate continues about the ways in which social trends are shaping the experiences of families and later life in sub-Saharan Africa (source:

Last updated: January 6th, 2022

In Sweden, the provision of long-term care (LTC) is a local-level government responsibility. Increasingly, private care providers (including private companies as well as trusts and cooperatives) provide at home and institutional care in conjunction with municipalities, but financing, quality, and overall provision are still controlled by the municipalities (source:

The provision of care provided privately has been steadily increasing. In 2018, private providers delivered around 24% of all nursing home and 18% of all homecare. It is noted that these figures vary substantially between municipalities. In general, payments to private providers follow a public tendering process, and are contract-based (sources: The Commonwealth Fund and SocialStyrelsen, 2020).

Last updated: February 10th, 2022   Contributors: Daisy Pharoah  |  

Care is provided by approximately 9,000 home care providers and over 15,000 care home providers. Around 78% of all adult care services are privately owned and run (ICF, 2017). The Care Act 2014 places a duty on local authorities to ensure that there is diversity and quality in the market of care providers. However, due to the downward pressure on fees stemming from cuts to local authority budgets, many providers find that the fees paid by local authorities fall short of covering the full costs of providing care. People who fund their own care are being charged on average 41% more than local authority funded residents because of this shortfall (CMA 2018). It is increasingly common for care providers to go out of business, struggle to stay in business, or hand back contracts to local authorities. A survey in 2019 found that some 75% of councils reported that organisations had either closed or handed back contracts in the last six months of 2020, creating enormous disruption and discontinuity for those receiving care (ADASS, 2019).  Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: CQC).


ADASS (2019). ADASS Budget Survey. Association of Directors of Adult Social Services

CMA (2017). Care homes market study. Competition and Market Authority

ICF (2018). The Economic Value of the Adult Social Care sector – England. ICF Consulting Limited, London

Last updated: March 8th, 2022

Care at home is either provided by the local authority, the health board (in the case of NHS Highland), by private firms or voluntary/not for profit firms. According to data collected by the Care Inspectorate, as of 31st March 2020, of the 1,046 registered care at home for adults’ services, 495 (47%) were run by voluntary or not for profit organisations, 406 (39%) by private firms, 136 (13%) by the local authority and in NHS Highland 9 (<1%) care at home services were provided by the health board (Source: Care Inspectorate).

Within the care home setting, ownership types are the same but unlike care at home, in Scotland most care homes are privately owned. Specifically, as of March 2020, 680 (63%) of care homes for adults were privately owed. The remainder were owned by voluntary or not for profit organisations (24%), local authorities (12%) and the Health Board (1%).

Last updated: March 8th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

Contributors to the LTCcovid Living International Report, so far:

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica BreuerJorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, Jessica J. Yu

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.