Abstract

Background: The increasing share of frail older people in the European population and the considerable costs associated with their long-term care (LTC) needs has received much attention in academic and policy arenas over the last decade. Conspicuously absent from this discourse have been considerations of distributional fairness. This is a remarkable gap in light of the generally high co-payments for LTC services and the well-documented inverse association between care needs and socio-economic status in later life. Further, considering the wide diversity in terms of both public resources allocated and the breadth and depth of coverage offered by social protection systems in Europe, we argue a comparative cross-country analysis of inequality and inequity in use of LTC is timely.

Methods: Using equivalized household income as a proxy for socio-economic status, we analyze whether the use of formal home care services (personal care and help with domestic tasks) and informal support among older Europeans varies between higher and lower groups. We use data from the 5th wave of SHARE (collected in 2013) and include 14 European countries in the analysis sample. We calculate concentration indexes for each country and use decomposition analysis to ascribe the identified inequalities to five categories of factors: income, care needs (health status, functional limitations, age and gender), household composition, education achievement and regional characteristics. Finally, in order to assess to what extent differences in use between groups are explained by differences in care needs, we calculate horizontal inequity indexes.

Results: The results of the analysis of inequality in formal LTC service use reveals that most European countries succeed in targeting services towards lower income groups. The noteworthy exceptions are Italy and Spain where despite means-tested benefits, low provision levels of home care services are coupled with a traditionally high reliance on family and live-in informal carers. However, after adjusting for differential need levels between income groups, we found that only Denmark, the Netherlands and Estonia manage to successfully target home care services to poorer individuals, while in many European countries the distribution shifts considerably in favor of richer individuals. The case of Spain again stands out with a marked pro-rich distribution of home care services. Another alarm signal is raised by the results for the distribution of informal LTC use across income groups in Europe. Both before and after accounting for higher care needs, we find disproportionately higher informal care utilization among lower income groups, for the majority of countries included in our study. Finally, the decomposition analysis reveals that inequality in formal home care service use is driven by household composition more so than by income differences between household.

Conclusion: While most European countries do a good job in ensuring access to home based formal care services for individuals with care needs, the marked inequity in informal care utilization and the strong influence of household structure on levels of inequality raise questions with respect to equity achievements in European long-term care systems but also with respect to the equity effects of carer sensitive policies.