LTCcovid Country Profiles

Responses to 1.03. Long-term care financing arrangements and coverage

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 is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

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, Pharoah D (eds.) and LTCcovid contributors. 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.

About this question

This page contains the answers for question 1.03. Long-Term Care financing arrangements and coverage in the LTCcovid International Living Report on COVID-19 Long-Term Care. This report is updated and expanded over time, as experts on long-term care add new contributions.


LTC financing discussions tend to focus on the sustainability of current financing arrangements, given rapidly growing demand due to population ageing and the predicted increase in the frail older people with long-term care needs. Financing refers to mechanisms that are used to raise funds (or resources) for long-term care, and to allocate those resources to particular groups or individuals.

In practice, the largest share of LTC is provided as an “in kind” resource, by unpaid carers such as family members and friends. In Europe, countries such as Denmark the Netherlands and Sweden have higher reliance on formal care, while countries such as Greece, Bulgaria, Cyprus, Estonia, Portugal, Latvia, Romania and Croatia rely almost exclusively on unpaid care. Family carers in some countries, for example Denmark, can be paid by the government for short periods of time. Family care givers may also receive income transfers and, possibly, some payments from the person receiving care. In Low and Middle Income Countries there is little availability of formal care and, while expenditure measured as a share of GDP appears relatively low, families bear very substantial costs of care with little support (see for example this article mapping the long-term care system in Jamaica).

Despite the high concern about the fiscal sustainability of long-term care costs, in most countries long-term care expenditure represents a small share of Gross Domestic Product (GDP). In 2017 total spending on public LTC across OECD countries, was estimated to account for 1.5% of GDP or 730 American dollars (USD) per capita (after adjusting for differences in price levels). This ranged from less than 0.2% of GDP in Greece, and the Slovak Republic to a high of around 4% of GDP in the Netherlands, 3% in Sweden and 2.5% in Denmark. In the US and Republic of Korea the spending was about 1% of GDP, in Canada 1.5%, followed by Germany (2.2%) and the UK and France (2.5% in each). It is important to note, as highlighted in this OECD report, that estimating LTC financing accurately is very difficult as very few countries have information systems that record all out-of-pocket spending on long-term care services.

Countries with the highest LTC spending overall i.e. Sweden and the Netherlands – are also nations where the public share of LTC financing is the highest (at 92-93%). On average across the OECD in 2017, 76% of inpatient LTC was financed by public schemes compared to 91% for home-based care, the gap was widest in Austria, Korea and the United Kingdom, where there was a 30-percentage point difference or more.

Systems with universal LTC coverage tend to provide publicly funded nursing and personal care to all individuals assessed as eligible due to their care-dependency status. They may apply primarily to the older population (e.g. in Japan, Korea), or to all people with assessed care-need regardless of the age-group (e.g. the Netherlands). Universal coverage systems are mostly found in Europe, particularly the Nordic countries such as Sweden, Finland, Denmark although in those countries provision/access often depends on local area and municipal availability of services. Means-tested systems operate in such countries as England, US as well as in many Eastern European countries where free LTC services are available for people with greatest needs and with lowest financial needs, although some services may be universal, needs tested (e.g. such as reablement in England). In some countries co-payments have been introduced, which are either means-tested e.g. in parts of Canada, Japan, France. The rate of co-payments is often means-tested and can vary from 10% to 90%, although it can be a set amount as in parts of Canada. Some countries have LTC insurance which provides a universal coverage (namely Germany, South Korea). LTC insurance in Israel is income-tested (it excludes highest earners) and is available only for home-based personal care.  Differences in social values may also influence the distribution of support between users with and without informal carers. Moreover, in most OECD countries, public coverage is higher for home-based LTC than for inpatient LTC.

International reports and sources

Report from WHO’s Centre for Health Development focusing on pricing long-term care for older persons in high-income countries, with case studies on Australia, France, Germany, Japan, Republic of Korea, the Netherlands, Spain, Sweden and the USA:

Reports on LTC public coverage and co-payments policies can be found on the OECD website, including:

LTC-Spending-Estimates-under-the-Joint-Health-Accounts-Questionnaire.pdf (;

The effectiveness of social protection for long-term care in old age;

There are several World Health Organization reports covering LTC financing, including:

Aging and Health report ( Funding Systems

Help Wanted: LTC Financing.

Several reports can be found about LTC financing and coverage across EU Member States:

Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (

Other sources include: in Europe.

Public spending on Long-Term Care

In 2019-20 government spending on LTC in Australia was estimated to be $21.5 billion, 65% on residential aged care and the remainder on home care and support or other forms of care.  equivalent to 1.2% of Gross Domestic Product (Treasury, 2021)

Long-Term Care Financing mechanisms

Australia has universal public health care through Medicare. The Australian government subsidizes aged care services so anyone who received aged care is eligible for financial support. In 2018-2019, $27.0 billion was spent on aged care, $19.9 billion of which came from the Australian Government (Royal Commission, 2020a).


People who use aged care are expected to contribute in the form of co-payments and means tested fees. People receiving aged care services contributed $5.6 billion to the cost of their aged care in 2018–2019 (Royal Commission, 2020a)

Aged care homes are subsidised by the Australian government. The subsidies are paid directly to the aged care home and the amount of funding that a home receives is based on an assessment of individual needs by the home using a tool called the Aged Care Funding Instrument (ACFI) and how much an individual can afford to contribute to the cost of their care and accommodation (using a means assessment).

Access to publicly funded aged care

Aged care services are rationed and access is determined by where people live, their needs, and availability of services. The Royal Commission into Aged Care Quality and Safety highlighted that in practice there is no universal entitlement to aged care as services are strictly rationed and access is determined by where people live, their needs, and availability of services (Royal Commission, 2020b).

Reliance on unpaid carers

There is significant reliance on unpaid (mostly family) carers in the community, to reduce the need for formal care. In 2018, there were around 428,500 unpaid primary carers providing support to someone aged 65 years or older (sources:; Care, Dignity and Respect report; Parliament of Australia;

Family carers have access to shared care planning tools. Professional carers are also increasingly asked to collaborate with family carers, providing skills training and directing family carers to the services available for them (source: OECD).

Public Long-Term Care coverage:

In Australia 80 per cent of older people will access some form of government funded aged care service before death (2012-2014) (AIHW, 2018).

In 2019-20, over one million people received support from aged care services, around 840,000 used the Commonwealth Home Support Programme, and around 245,000 people lived in residential aged care facilities at some point during the year (AIHW, 2021).


Australian Institute of Health and Welfare (2018) Cause of death patterns and people’s use of aged care: A Pathway in Aged Care analysis of 2012–14 death statistics. Cat. no. AGE 83. Canberra: AIHW.

Australian Institute of Health and Welfare (2021) GEN Aged Care Data

Deloitte Access Economics (2020) Commonwealth Home Support Programme Data Study. Department of Health, Australia.

Royal Commission into Aged Care Quality and Safety (2020a) Financing Aged Care, consultation paper 2. Commonwealth of Australia.

Royal Commission into Aged Care Quality and Safety (2020b) Aged care and COVID-19: a special report. Commonwealth of Australia. 

Treasury (2021) 2021 Intergenerational Report. Australian Government.

Last updated: January 17th, 2022

In 2016 public spending on LTC represented 1.9% of Gross Domestic Product (source: Long-term care is financed in Austria through a combination of public-sector taxed- based support and out-of-pocket payments by care users. The responsibility for long-term care financing is divided amongst the federal government and the federal states. The federal government is responsible for funding the long-term care allowance (Pflegegeld) and various measures for supporting informal carers, while the federal states cover benefits in-kind (i.e. care services) and are responsible for financing social assistance when a care user cannot cover their costs of care (source: ESPN Thematic Report on Challenges in LTC for Austria at Although the federal states are in charge of in-kind services and social assistance, as the federal government is responsible for collecting taxes, the federal government provides transfers to the federal states to cover these costs through the general fiscal eualisation scheme and the long-term care funds (Pflegefonds) (source:  ESPN Thematic Report on Challenges in LTC for Austria at Since 2011, there is a LTC fund (“Pflegefonds”) for the federal government to redistribute to the states and municipalities to help cover home care and nursing home services, as well as palliative and hospice care (source:

The long-term care allowance (Pflegegeld) is a key aspect of the Austrian long-term care system, with over 467,000 beneficiaries in 2020 amounting to €2.71 billion (source: The care allowance is intended to be a contribution towards the cost of care to cover care-related expenses, whether it be formal care services, either privately or publicly provided, or to cover informal care (i.e. routed wage) provided by relatives. Care allowance beneficiaries may use the allowance however they see fit, with no oversight/control on how the allowance is used. The allowance consists of seven levels, characterized by the number of hours needed per month for home help and personal and nursing-related care tasks. To receive the care allowance, the recipient must fulfill several requirements: 1) be in need of support and help for more than 6 months because of a physiological, cognitive or mental health impairment or an impairment of the senses and 2) need support for at least 65 hours per month. To obtain the care allowance, the recipient must first submit a claim to the pension insurance institution before being visited by a certified doctor or nurse who assess their needs regarding (instrumental) activities of daily living.

The federal government also finances support for informal carers, through a number of avenues. In 2016, support for informal care amounted to €72.8 million, primarily covering the social insurance of informal carers (€49.2 million), followed by for respite care (€11 million), for care leave (€10.7 million) and finally for quality assurance (€1.9 million) (Schrank, 2017).

In 2019, gross expenditure on LTC services amounted to €4.2 billion, primarily covered by the federal states and municipalities (59%), followed by out-of-pocket pockets by care users and their families (36%) and the rest (5%) from other sources (i.e. contributions by health insurances). Approximately 84% of this went towards (semi-)residential care facilities, and the rest towards mobile care services (16%) (source:

Last updated: November 29th, 2021   Contributors: Cassandra Simmons  |  

In 2016 public spending on long-term care was estimated to represent 2.3% of Gross Domestic Product (source:

Long-term care is part of an integrated system of health care, complemented by social service provision. Medical care is financed by the federal health insurance system, whereas personal care is organized and financed by the regional governments. Cash benefits only play a small role in the system. Co-payments are means-tested and subject to a maximum limit. Additionally, Flanders has a compulsory social insurance system specifically for non-medical help services that provides cash benefits to people with reduced self-sufficiency (source:

Last updated: November 23rd, 2021

Some public LTC services are provided through the Unified Social Assistance System, this is means-tested and targeted to people without family support, and increasing availability of private care options (source:

Last updated: November 23rd, 2021

In 2016 public LTC represented 0.4% of Gross Domestic Product (source: People in need of care are covered by social assistance, which is managed at municipal level and by disability benefits (as a supplement to pensions for older people, for example). The country was reported in need to develop governance, financing and regulatory framework for LTC (source:

Last updated: November 23rd, 2021

In total, LTC services in British Columbia  cost $2 billion CAD per year, with the majority, $1.3 billion CAD, spent in the contracted sector (source:

LTC services are available through publicly subsidized and privately funded services. Some publicly subsidized home and community care services are provided free of charge. For example, British Columbia has the highest recommended funded hours per resident day at 3.36 hours, higher than the Canadian average of 3.30. For other services, the cost is shared between the Ministry of Health and the person receiving services. The amount paid by individuals receiving care is called the client rate. Client rates are determined by BC’s health authorities and may be calculated based on income or set as a fixed rate, depending on the type of care received. For most LTC facilities, the person receiving care pays up to 80% of their income taxation and can also apply for a reduced rate due to financial hardship (source:;

Unpaid carers (commonly referred to as family caregivers in Canada) are represented by the Family Caregivers of British Columbia (FCBC), a provincial non-profit. FCBC represents over 1 million people in British Columbia. Although there is no data yet on how many family caregivers are present in the province. FCBC provides access to information and education and acts as a voice for family caregivers when liaising with other stakeholders in the health and social sector (source:

LTC residents and individuals receiving continuous care in the community are charged a portion of their after-tax income. Individuals may apply for a reduction in rates due to financial hardship. For the most part, anyone requiring care should be able to receive it (source:

Last updated: November 6th, 2021

Public LTC expenditure in Cyprus was estimated to represent 0.3% of the Gross Domestic Product (source:

Last updated: November 23rd, 2021

Public LTC expenditure in the Czech Republic was estimated to represent 1.3% of Gross Domestic Product (source: Some LTC services such as home care are covered by the health insurance system (if indicated by a general practitioner). Institutional care costs are mostly paid by out-of-pocket payments (source: Informal care plays an important role in the sustainability of LTC, there is growing emphasis on support of informal carers and on improving the availability of respite services and counselling, and the coordination and management of care (source: CEQUA – Czech Country Report (

Last updated: November 23rd, 2021

Public sending on Long-Term Care as % of Gross Domestic Product (GDP):

Denmark spent 2.5% of GDP on publicly funded LTC in 2016, almost twice the EU average (source:

Approach to public funding for LTC and eligibility:

Municipalities are responsible for allocating resources; they obtain funding from the national government, local taxes and equalization money from other municipalities. No co-payments are applied for using long-term home-based care services (cleaning and personal care), although users who choose private providers can purchase additional optional services. Access is based on the principle of free and equal access, regardless of income, wealth, age or household situation. Eligibility for long-term care is based entirely on needs assessment carried out by the municipalities. There are no thresholds or minimum dependence required for in-kind or cash benefits. Needs assessment for long-term care is multidimensional in nature and generally captures a wide range of aspects related to a person’s situation and well-being.  (source:

It has been estimated that 16% of the total population provides unpaid care for a relative, neighbour or friend at least once a week (source: The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. Unpaid caregivers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the European Union countries (source:

Family members may apply to be formally recognised as informal carers by applying to the municipality. If eligible, and after consultation with the person with care needs, the caregiver is employed by the municipality, up to six months, with a pre-specified salary calculated based on the national yearly income. Alternatively, municipalities can compensate for lost earnings individuals caring for close relatives with a terminal illness. Additional services for caregivers include training and education programmes, often focused on improving knowledge and ability to provide the needed support and on attaining coping skills, such as self-help and peer groups (source:

Last updated: November 1st, 2021

In 2016, public LTC expenditure in Estonia was estimated to represent 9.9% of Gross Domestic Product (source: The 2018 Ageing Report: Economic and Budgetary Projections for the EU Member States (2016-2070) (

Last updated: November 23rd, 2021

Public LTC expenditure in Finland represented 2.2% of Gross Domestic Product in 2016 (source LTC services are part of the universal health and social care system in Finland, with organization of services allocated primarily to local municipalities. The state government and municipalities are the major funders of LTC care, however despite most costs being covered by taxes, there are client fees. For example, in 2014, clients paid 18.5% of the costs of elderly people’s services (source: These LTC fees are defined by the user’s ability to pay. There are differences in the LTC provisions between different municipalities, as population demographics as well as availability of services vary between municipalities. Although Finland assigns its municipalities a legal responsibility to provide care services, families still play a major role in unpaid care provision. A restructuring of elder care services over the past few decades has resulted in an increased responsibility for care on individual families, which is financially supported through various cash-for-care schemes (e.g. informal care allowances); amounts and access to these types of supports is, however, relatively low. Municipal informal care support requires a contract between the municipality and the caregiver (source:

Last updated: November 23rd, 2021

In 2016 public LTC expenditure in France was estimated to represent 1.7% of Gross Domestic Product (

LTC funding is fragmented and divided across a complex web of actors, at a local level (local authorities), health insurance (CNAM), not-for-profit (mutuelles) and private insurance policies, National Solidarity Fund for Autonomy (CNSA), central government, pensions, municipalities and individuals (source:

In terms of public spending, costs are shared between: National Solidarity Fund for Autonomy (CNSA), regions, the state, which in 2011 contributed approximately 9.7bn€, health insurance (CNAM), which contributed 11bn€, accommodation costs 7.5bn€ adding to a total of 21bn€, which amounted to 1.05% of GDP. Including the costs of household contributions would brought total spending to 28bn€, 1.41% of GDP.

A market for private insurance for long-term care has developed as contributions are tax-free and is reported to be one of the largest – although take up is still relatively low.

The country’s LTC policy is based on cash-for-care scheme called the Allocation Personalisee a l’Autonomie (APA), which provides some assistance to people over 60 with care needs above a government determined threshold of need (AGGIR 1-6) and is concerned mostly with homecare. In 2018 8% of people over 60s were APA beneficiaries. APA is means-tested based on taxable income and some assets. There are high levels of out-of-pocket payments, individuals pay up to 90% of the care costs. For example, whereas individuals with below a monthly income of €800 do not contribute to the funding of the care, those with income of above €2945 contribute 90% of the care costs. Moreover, the level of the allowance depends on the need level.  Median cost of a room in a care home in 2018 was 1977€.

There were 4.8 million carers recorded in France in 2011. France is a country with a strong family tradition, where unpaid informal carers have always played an essential role. Support is delivered in-kind rather than in-cash. Some of the benefits for carers include the ability to take unpaid leave from employment and paid ‘solidarity’ leave for 3 months with an additional maximum 3 months which must be justified by medical certificate. Although researchers suggested that there is low take up and awareness of these schemes. Other services to support carers include respite care and training (sources: CEQUA France Country report (

Last updated: December 21st, 2021   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  

In 2018, Germany’s expenditures for LTC amounted to 2.1% of GDP, including voluntary insurance and out-of-pocket-spending. Expenditures for compulsory government schemes amounted to 1.5% of the GDP, which is below the OECD average of 1.7% Germany has a LTC insurance system, which is the dominant financing scheme for LTC and is mandatory for enrolees in the statutory or private health insurance (source: Germany_draft.pdf ( The LTC insurance is financed through equal contribution between employer and employees. Childless people pay a slightly higher contribution rate than those with children (3.30% of gross wages versus 3.05%) (source: Financial situation of LTC funds in 2020 can be found online.

In 2019, 4.25 million inhabitants received benefits from the LTCI. Of them, 3.34 million received home care and 0.91 million received residential care, and 4 million were covered by social LTCI and 0.25 million by private compulsory LTCI (source: Germany_draft.pdf ( The LTC insurance is designed to cover only a share of the LTC-related costs. With regards to residential care, people in need of long-term care have to pay up to €2,400 per month out of pocket. This includes costs for food and the resident’s room. Where individuals/families cannot shoulder these costs, this will be provided through social security mechanisms. Costs vary substantially between the different Lander. While the private share of costs for care in residential care settings amounts to more than €1,000 in Baden-Württemberg, they are less than €450 in Thuringia (source:

LTCI grants access to services on the basis of LTC needs and it is not means-tested. Everyone with LTC needs is entitled to receive the services they require regardless of age, income, wealth, personal circumstances (such as living with a carer) and medical diagnosis (whether physical or cognitive). A needs assessment recognizes whether an individual should receive benefits and the amount. Individuals have to take a needs-based, uniform assessment test, which assigns them to one out of five potential “care degrees” ranging from 1 – “little impairment of independence” to 5 – “hardship”. The “care degrees” define the amount of benefits that the individual receives (source: Germany_draft.pdf (

Last updated: November 23rd, 2021

In 2016 public expenditure on LTC was estimated to represent 0.1% of Gross Domestic Product (source:

Last updated: November 25th, 2021

In 2016 public LTC expenditure in Hungary was estimated to represent 0.9% of Gross Domestic Product (source:

Last updated: November 25th, 2021

In 2018 total LTC expenditure in Iceland was estimated to represent 1.7% of Gross Domestic Product (

Last updated: August 2nd, 2021

Public funding for LTC is very limited, but there are a few public benefit schemes such as disability benefits and pension schemes that offer modest support. Most formal LTC is paid for through out of pocket payments (source:

Last updated: August 2nd, 2021

In 2016 the total LTC expenditure in Israel was estimated to represent 0.6% of Gross Domestic Product (source: OECD). The National Insurance (NI) is the primary public funder of home-based long-term care services and does so through the Long-Term Care Insurance Program (LTCIP).  LTCIP is income-tested to exclude the highest income earners. As of 2014, the NII subsidizes the care of approximately 160,000 seniors at the cost of NIS 5.31 billion (appx. 1.2 bill GBP). Assisted living (e.g. LTCFs) is primarily funded by the Ministries of Health and of Labour and Social Affairs, and accounts for 14% of publicly-funded LTC services. Complex inpatient care is funded by the health system and accounts for 6% of public LTC funds. In all, public funds account for 55% of LTC services, with the remaining 45%  privately funded (sources: Taub Centre)

Home care and community-based services are the main LTC service for older people in Israel. At the beginning of 2020, 220,830 individuals (of retirement age) were eligible to receive publicly financed LTC services at home (sources: International LTC Policy NetworkNational Insurance Institute of Israel).

There are also geriatric hospitals and sheltered housing facilities, many of which are owned and managed by the coordinated governmental healthcare system via the four non-profit health plans (HP’s). These provide long-term geriatric treatment (including wards for older people with cognitive disabilities) as well as departments for active geriatric care (including complex nursing, hospice, and rehabilitative care) (source: Tsadok-Rosenbluth et al, 2021); they became the primary source for concern and emergency response during the COVID-19 pandemic.

LTC insurance in Israel is universal ,and LTC services are substantially funded by private and out-of-pocket expenditure (45%). In April 2018, as part of the LTC reform, the National Insurance launched a program to entitle home-based unpaid caregivers to long-term care benefits. Made a national policy in August 2019, family members can be paid as caregivers under certain conditions; statistics on the implementation of the policy are unavailable (source: Adva Centre).

Last updated: December 5th, 2021   Contributors: Sharona Tsadok-Rosenbluth  |  

In 2020 public Long-Term Care (LTC) expenditure in Italy was estimated to represent 1.9% of Gross Domestic Product. 74.1% of this expenditure is devoted to over 65 people. Public expenditure on LTC includes three components: i) LTC  services to dependent people provided by the public health care system, ii) the social component of LTC provisions provided by municipalities and  iii) attendance allowances. The social component of LTC services are generally means-tested. Admission to services based on needs but also on income levels. Co-payments play an important role, together with waiting lists, in shaping the profile of people who use services.

As in many other countries, the bulk of LTC is provided, unpaid, by family carers. Also, a large share of home care is provided by privately employed, primarily migrant care workers. The annual estimated expenditure in this type of household-based care is €17.000 per family. Almost 60% of these care workers are employed totally or partially irregularly, with an annual average estimated expenditure of €11.000.

Access criteria to LTC services are determined at the regional level (with a high level of heterogeneity) and Local Health Authorities (LHA) can established further criteria. Hence, it is very difficult to establish an overreaching picture of access and affordability for these services. The only major intervention that is subject to nationally established criteria is the companion allowance (CA), a cash transfer given to all those with a very severe disability regardless income or other personal features.

On a general level, the general practitioner submits a request to the LHA to require access to a LTC service for his/her patient.  At the LHA a committee will decide whether the citizen is entitled to access services or not. If the application is successful, usually citizens may choose the provider they prefer. Still, the shortage of public – funded services leads people to providers that have capacity. As concerns social services, they are usually activated by the family itself.

Practically all LTC services are based on co-payments and, given the fact that the coverage rate is relatively low, waiting lists are common, although there are no official data on the size of the phenomenon.


Barbarella F, Casanova G, Chiatti C and Lamura G (2018) Italy: emerging policy developments in the long-term care sector. CEQUA LTC network report.

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.

European Commission (2021). 2021 Long Term Care report. Country provides Vol. 2. Joint report prepared by the Social Protection Committee (SPC) and the European Commission (DG Empl).

Fosti G, Notarnicola E, Perobelli E (2021) Le prospettive per il settore socio-sanitario oltre la pandemia. Rapporto Osservatorio Long Term Care 3. Egea. CERGAS. Università Bocconi.

Ministero dell’Economica e delle Finanze (2021) Le tendenze di medio-lungo periodo del sistema pensionistico e socio sanitario. Rapporto n.22.

Last updated: November 9th, 2021   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  

Japan has a relatively well-funded system, based on mix of tax, social insurance and individual co-payments. Revenue raising mechanisms are flexible to allow for extra top ups in difficult times. However, the system is under financial pressure due to the rapid rise in need as a result of rapid ageing. Its generosity has been reduced over time over affordability concerns (source:

On being assessed as needing care by the Long-Term Care Insurance system (LTCI), service users are assigned a monthly in-kind budget to spend on care according to their level of need. Service users pay a co-payment on accessing services which ranges from 10% for most people to 30% for most affluent. Co-payments are capped at fixed monthly level on a sliding scale according to income. People can opt to buy more care beyond assigned level at 100% cost, but care packages are thought to be generous and few people top up beyond their allocated budget. The re-imbursement for care services from the LTCI does not cover room or board.

The 50% of the funding for the LTCI system is from mandatory insurance contributions from all residents aged 40 and older and the rest is from taxation: 25% from the national government and 12.5% each from the prefectural and municipal governments. The insurance rates are set by each municipality on the basis of the insured resident’s income levels (source:

The extent to which the system relies on unpaid care is unclear. The recent reforms were successful in largely shifting the responsibility of caring from families to the state by offering in-kind benefits to those in need. However, there are no cash benefits for people with needs, hence there is no option to use cash benefits to pay for care to relatives or friends. At first, there was concern that people would not take the in-kind benefits up due to stigma attached to using public care provision (traditionally it has always been a family duty), however the design and generosity of the system quickly changed societal views. However, there still is reliance on unpaid care – benefits are generous but may not cover all needs. There is also a 10% co-payment on accessing care, therefore poorer people may need to avoid using formal care for that reason (source:

Last updated: December 4th, 2021

Public LTC expenditure in Latvia was estimated to represent 0.4% of Gross Domestic Product (source: The availability of unpaid carers is considered during assessment for formal provision of home care, consequently, home care is provided mostly for people living alone who have no help from family or close neighbours. No policy planning concerning support for informal carers have been developed in Latvia. In 2017, there were neither cash nor in-kind benefits for carers of dependent adults (source: CEQUA Latvia Country report).

Last updated: November 25th, 2021

Public LTC expenditure in Luxembourg was estimated to represent 1.3% of Gross Domestic Product in 2016 (source:

Last updated: November 25th, 2021

Public expenditure on LTC as percentage of GDP was estimated to be 3.5% in 2016, more than twice the European Union average of 1.6% (source: Seventy five percent of spending is allocated to residential care. Private expenditure on LTC (co-payments and out of pocked payments) is relatively low. However, in residential care, residents have to contribute to their board and accommodation. Co-payments have increased considerably for those with higher incomes. Cash for care has been a recent addition for people receiving community care, but in 2016, only 4.7% of recipients of home care aged 65 and over had a personal budget. Benefits are universal but needs tested. There has been a marked shift over time from institutionalisation to community care, with substantial involvement from patient and client organisations. There has been another more recent shift from collective (state) responsibility to individual responsibility and self-reliance. Involvement of unpaid carers, especially families, is now part of the official policy. This however goes against the widespread view that the state should take responsibility for older people in need of care. It is also recognised that this shifts the burden of care back to women (source:

Last updated: November 25th, 2021

In 2016 public LTC expenditure in Norway was estimated to represent 3.7% of Gross Domestic Product (source:

Last updated: November 25th, 2021

Public LTC expenditure in Poland was estimated to represent 0.5% of Gross Domestic Product in 2016 (source: Public care for dependent older people is provided through health care sector, which includes cases of dependency or palliative care requiring a range of medical and rehabilitation services, and the social care sector, which includes care for dependent older people who are in a socially difficult situation (i.e. those who live alone, come from dysfunctional families, or are poor). Care for older dependent people is predominantly a family domain in Poland. In most cases, caregivers are family members who – in case of care for older dependent people – receive little or no financial remuneration for the care provided. In wealthier households, family carers may be supported by immigrants employed informally (source: Poland Country (

Last updated: November 18th, 2021   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  

In 2016, public LTC expenditure in Portugal represented an estimated 0.5% of Gross Domestic Product (source:

Last updated: November 25th, 2021

Total LTC expenditure in Korea represented 1.0% of Gross Domestic Product (GDP) in 2019 (source:, of this, expenditure through the public LTC Insurance system accounts for 0.37% of GDP (source:

A universal, public LTC insurance (LTCI) for the older population was introduced in 2008, and it requires no means-test (The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf ). Services include institutional and home/community care (COVID_LTC_Report-Final-20-November-2020.pdf).

In terms of eligibility, the intended beneficiaries of the system are all Koreans, it mainly targets older people (age 65+).  In 2018 around 8.8 % of the total older population were covered by LTCI (source:, which comprises 2.7% of older adults living in LTCFs (2018) and 6.2% of older adults in receipt of community based LTC (2018) (source: COVID_LTC_Report-Final-20-November-2020.pdf).

Last updated: November 23rd, 2021

In 2016 public LTC expenditure in Romania represented 0.3% of Gross Domestic Product (source:

Last updated: November 23rd, 2021

Nursing homes in Singapore fall into three categories: public (~31%), private (~40%) and charitable/ not-for-profit (NFP) (~29%). There are a total of 77 nursing homes and 16,221 beds. Substantial government subsidies and donor funding financially assist most of the public and NFP homes, but they also require co-payment from clients. The Ministry of Health subsidy scheme does not cover private nursing homes, for which direct out-of-pocket expenses must be covered by clients (Udod et al., 2021).

Financing for LTC and support to older adults exists within an overall health-care financing that, in turn, is linked to the way in which social care and pension funding is organized. There are three complementary insurance schemes for disability cover: ElderShield and ElderShield Plus, and CareShield. ElderShield is a severe disability insurance scheme under which all citizens and permanent residents born before 1979 who have a MediSave account are automatically covered from 40 years of age (opt-out is possible). To be eligible for the scheme, individuals must be unable to carry out at least three out of six basic activities of daily living. ElderShield Plus offers higher monthly payouts or payouts for a longer period or a combination of both. CareShield Life is a compulsory insurance policy introduced in 2020 that provides payouts for people who are severely disabled. Everyone born between 1980 and 1990 is enrolled automatically and younger cohorts will be enrolled as they turn 30. Another funding scheme introduced in 2020, ElderFund, provides financial support for low income, severely disabled Singaporeans. Additional subsidies and schemes exist to finance LTC. Some schemes focus on financial support to informal caregivers and home-based care (source: Asian Development Bank).

Last updated: January 11th, 2022

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product in Slovakia (source:

Last updated: November 23rd, 2021

In 2016 public LTC expenditure represented 0.9% of Gross Domestic Product (source:

Last updated: November 23rd, 2021

In 2016 public LTC expenditure in Spain was estimated to represent 0.9% of Gross Domestic Product (source: Spain has a tax-based long-term care financing system, with national eligibility criteria and defined benefits, run at regional level and financed by national, regional and local funding. National funding aims to take into account differences in population need (equalization function). Co-payments are means-tested (source: Overall, funding and coverage of LTC services in Spain is considered to be highly inadequate to meet people’s needs, and long waiting lists to receive services are a pressing issue nationwide and at a regional level (source: LTCcovid-Spain-country-report-28-May-1.pdf).

Last updated: December 2nd, 2021

Health spending was 3.8% of GDP in 2017, of which 1.6% was accounted for by public health expenditure and 2.2% by other financing. The government finances most social services, while non-profit sector and private donation financing is limited.  Families currently bear most LTC costs.  Residential care homes are financed by the non-profit sector and fees are paid by the resident or covered by charitable donations. In-home nursing care services are financed by out-of-pocket payments (source: Country Diagnostic Study on Long-Term Care in Sri Lanka (

Last updated: September 6th, 2021

In 2016 public long-term care expenditure represented an estimated 3.2% of Gross Domestic Product (source: About 90% of health and social care is financed by local government, the counties and municipalities, through taxation. The user pays only a fraction (4% or 5%) of the cost and the remaining 5% is covered by national taxes (source: CEQUA Sweden Country Report). LTC in Sweden has been affected by financial cutbacks, which has had negative consequences for e.g. care workers’ working conditions as care workers are increasingly working in under-staffed conditions (source: Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Public policies and programmes providing social services and support, as well as healthcare, are comprehensive. There are no national eligibility regulations, however for home care and institutional care, local governments decide on the service levels, eligibility criteria and a range of services provided. Although the general principle behind LTC policy in Sweden is to provide publicly subsidised, widely available in-kind services thereby removing the burden of providing services from the family; approximately two-thirds of all care for community-living older people is provided by unpaid caregivers. Unpaid carers can claim time off work (care leave) with compensation from national social insurance. Carers may receive cash benefits from municipalities (however these are not covered by national regulation and municipalities can choose whether or not to offer the allowances). Another option is carers’ allowance which involves the municipality employing a family member to provide care work, however it is not payable for people 65 years or older. Direct in-kind support for carers is provided by all municipalities as a general service and not based on needs assessment, it can be in the form of information and advice, counselling, support groups, respite care. The intensity, content and quality of the provided support can, however, vary between the municipalities (source: Sweden Country Report).

Last updated: November 23rd, 2021

In 2018 LTC expenditure was estimated to represent 2.4% of Gross Domestic Product in Switzerland (source:

Last updated: November 23rd, 2021

Total public spending on health-related LTC was 1.7 billion in 2012. The Ministry of Public Health is the major source of finance (1.6 billion). Spending by nongovernment organizations (NGOs) on health-related LTC was 70.3 million. Finance from family members is a major source of funding for LTC in Thailand. Government revenue is a source of finance for the Community-Based Long-Term Care Program, under the National Health Security Office (NHSO). But out-of-pocket payments are the main source of funding for LTC in private residential facilities.


Asian Development Bank (2020) Country Diagnostic Study on Long-Term Care in Thailand. ADB.

Last updated: December 17th, 2021

Turkey has a familiarist welfare, placing intergenerational obligations to provide care on family members, but there are concerns about the sustainability of this model. There is growing support from the non-profit sector and other private providers, some of whom receive public funding from provision of services, this support is means and needs-tested (source: The-COVID-19-Long-Term-Care-situation-in-Turkey-1.pdf).

Last updated: November 23rd, 2021

A large share of the resources that fund long-term care are provided in kind, through the time and effort of unpaid carers. Formal long-term care services in England are funded differently for health care, which is free at the point of use through the National Health Service (NHS) and social care, which is means-tested. Individuals who need care and their families also contribute to the costs of care through purchasing services privately or out-of-pocket payments for services. There is strong consensus on the need to reform social care funding and reforms are under way (see question 4.02).

As an illustration of who bears the costs of long-term care in England, it is useful to look at this study of the costs of dementia, which found that, in 2015, 42% of the £24.2 billion costs of care of people with dementia were attributable to unpaid care, formal social care services represented another 42% and health care 16%. Out of the £10.2 billion social care costs, £6.2 billion were met by people who use care and their families, and £4.0 by the government. This means that the public sector only funds one third (32.6%) of the costs of dementia, leaving users and families to shoulder the rest of the costs through unpaid care or care fees. The cost of dementia estimates include health care costs that are not strictly “long-term care”, for example diagnostic services and hospitalisations, meaning that the share of public funding for long-term care for people with dementia is even lower than this estimate (Wittenberg et al., 2019).

In England Local Authorities (LAs) organise and fund social care for people who are eligible. The LAs are funded largely through a combination of a grant from central government and local revenue-raising mechanisms, including a tax on housing (council tax). Social care funding is not ring-fenced, which means that local authorities can decide how much of their budget they allocate to care. Unlike the NHS, where healthcare is free to those using it, access to social care is determined by both need and means. A restrictive means test, which had not been adjusted since 2010, means that people with property (including housing), savings or income in excess of £23,250 must meet the entirety of their care costs alone. Those with means below the threshold of £23,250 may be eligible for part or full state funding for their care but they must also be deemed to have sufficiently severe care needs.

The King’s Fund Social Care 360 annual report provides a useful overview on public funding for social care in England. In 2019/20, gross social care spending through LAs was £23.3 billion. Of this, £7.5 billion was spent on long-term support for working-age adults (£2.5 billion on nursing or residential care, £451 million on supported accommodation and £4.6 billion on community support, including home care). They also spent £159 million on short-term support for working-age adults. Spending for long-term support for older people was £7.9 billion (£5 billion on nursing or residential care, £121 million on supported accommodation and £2.7 billion on community support, including home care). Theyalso spent £450 million on short-term support for older people (Bottery and Ward, 2021).

During the last decade, funding to councils has been cut by almost 50% (source: National Audit Office), which has put pressure on councils to spend less on care either through reducing the rates they pay providers or by reducing the number of people they fund. Because local authorities have a responsibility to raise revenue locally to subsidise the grant they receive from national government, those local authorities in more affluent areas are able to raise more (source: Institute for Fiscal Studies). The result is wide variation in the eligibility for care between local areas, despite the intention of the Care Act (2014) being to standardise eligibility.

The distinction between ‘health’ and ‘care’ creates further inequity. A person deemed to have health needs may be able to access social care via the NHS’s continuing healthcare programme (although subject to restrictive eligibility criteria and long waiting times), but someone with personal care needs (e.g. arising from dementia) and no medical requirements is subject to the means test (source: Nuffield Trust).

In 2018, LTC expenditure in the United Kingdom was estimated by the OECD to represent 1.8% of Gross Domestic Product.


Bottery S and Ward D (2021) Social Care 360. The King’s Fund.

Wittenberg, RKnapp, MHu, B, et al. The costs of dementia in EnglandInt J Geriatr Psychiatry2019341095– 1103

Last updated: December 20th, 2021   Contributors: Joanna Marczak  |  Adelina Comas-Herrera  |  

Principal responsibility for providing services to social care clients falls on Scotland’s 32 local authorities. For home care, each local authority has their own charging policy which, together with a financial assessment of the persons income, will determine how an individual contributes towards their care services. Since 2002, anyone in Scotland aged 65 and over, whether living at home or in a care home is entitled to Free Personal and Nursing Care if they need it.

Before entering a care home, the local authority will carry out needs assessment and a financial assessment to work out what care the individual needs and how much they need to pay towards the care home fees and services. The amount a person will have to pay depends on if they fall above or below the capital limits (lower limit £18,000 and upper limit £28,750 as of April 2021). Care home residents who have capital above the upper limit are classed as self-funders and those who have capital falling below the lower limit are funded by their local authority. Those whose capital lies in between the upper and lower limits receive some help from the local authority and fund the remainder themselves. However, Free Personal and Nursing Care in a care home means that self-funders who are aged 65+ receive a weekly payment towards their personal care (£193.50 as of 1st April 2021). Any self-funder in need of nursing care will also receive a weekly payment towards the cost of that care (£87.10 as of 1st April 2021). Finally, those who are funded by the local authority will receive personal care for free.

Last updated: December 5th, 2021   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  

In 2018 LTC expenditure represented 0.8% of Gross Domestic Product in the United States (source: The financing of LTC in the United States is a continuous and growing challenge. Medicaid is the primary payer for formal LTC services, accounting for over half of national spending in 2017, however it is means-tested: it requires proof of need and exhaustion of individual financial resources (e.g. low-income status and/or limited savings). In 2016, the majority of Medicaid LTC funding was spent on home and community-based services (57%), but several states still apply their Medicaid dollars primarily to institutional care. Coverage and spending on LTC schemes also vary significantly by state (source:

Some states fund home and community-based services through Medicaid waivers, and some even allow for self-directed Medicaid funds for payment of informal carers (source:; An estimated 7.4 million Americans own private LTC insurance policy (around 15% of persons 65 and over). The system relies heavily on informal (unpaid) caregivers: 75% of those needing LTC rely solely on informal caregivers and approximately 41 million Americans are unpaid caregivers (source: These demands are also disproportionately experienced by women, individuals of low socioeconomic status, and minority racial and ethnic populations. Over the past 10 years some states used provisions in the Affordable Care Act to redistribute some Medicaid funds towards at-home, informal caregiving, nationally this shift has been small (source:

Last updated: November 23rd, 2021

Given the large number of people in Vietnam in need of social care – a figure that is increasing rapidly – the provision of services is considered inadequate and underfunded (source: UNDP report). The state has a minimally developed LTC system and is heavily reliant on informal care, which is funded by families as out-of-pocket expenses. However, these are unaffordable by many members of the population, and family carers are not entitled to benefits other than in exceptional circumstances (source: Royal Commission into Aged Care Quality and Safety). Furthermore, according to a UNDP report, the majority of working age people in Vietnam do not have a pension to look forward to (with over half of people over age 65 unable to access one); thus, many face income insecurity at an older age and need to work until they are too frail to continue doing so. They may be entitled to social assistance payments, but total state expenditure on these payments is low compared to other middle-income countries (such as Brazil and South Africa), and even some low-income countries (such as Bangladesh). This makes the possibility of purchasing private LTC unlikely for most.

Most of the financial support that does exist is to support those who qualify for institutional care, rather than providing people with support to remain in their homes or with their families. State-funded care is based around a nationwide network of social protection centres, which provide residential accommodation for various vulnerable segments of the population, including some elderly people. There are a total of 393 social protection networks around Vietnam; 180 are run by non-state entities and 213 are publicly run. Thirteen of the social protection centres serve the elderly population. The centres are all financed by the government: the public units are financed directly, and the non-state units are financed indirectly via tariffs paid to the provider, based on what services are delivered. Expenditure is approximately $35 per person per month. A range of weaknesses have been highlighted in these public care centres; mostly due to limited financing, which translates into low-quality standards of accommodation, poor services, an absence of various key services (such as counselling) and difficulties recruiting staff due to low salaries. Furthermore, they are only available to a small segment of the elderly population, leaving many without access to LTC outside of their families (source: UNDP report).

Due to the abovementioned government-funded services failing to meet the increasing demand for LTC in Vietnam, the government provides some incentive payments for volunteer primary caregivers in the community to cover elderly members of the population who are unable to live independently, are poor, and do not family to care for them. In these cases, social assistance payment s are provided to both the recipient of care and caregiver  (source: Royal Commission into Aged Care Quality and Safety).

Last updated: January 3rd, 2022   Contributors: Daisy Pharoah  |  

Contributors to the LTCcovid Living International Report, so far:

this list is regularly updated to reflect contributions to the report, if you’d like to contribute please email

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Jorge 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, Stefania Ilinca, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, 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, 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.