Long-term Care in the Pilot Countries

The six countries in which the pilot monitoring work is being conducted (Belgium, Croatia, Germany, Hungary, Lithuania and Romania) all have different long-term care systems. Find out more about each of them here!


  • About 17% (OECD average 15%) of Belgium’s population is aged over 65 and about 5% (OECD average 4%) over 80.
  • Long-term care (LTC) in Belgium consists of a wide range of services organised at the federal, regional and municipal levels, and is related to health and social service provision.
  • 6.6% (2007) of the population over the age of 65 are recipients of LTC in an institution (almost 50% of those who use formal long-term care services); rate comparable to those found in the Netherlands, France and Switzerland (in the highest in the OECD).
  • In 2008, Belgium’s expenditure on long term nursing care was equivalent to about 2% GDP, of which 1.7% GDP is devoted to institutional care.
  • Belgium’s public health insurance system (INAMI/RIZIV) provides for comprehensive universal coverage for all costs associated with acquiring assistance for daily activities (dressing, eating, washing, etc.) This benefit applies to assistance provided both at home and in an institution, subject to a personal contribution (i.e., ticket moderateur). Different measures exist to minimise out-of-pocket payments.
  • The responsibility for regulating LTC quality lies on the federal and regional governments.
  • The responsibility for monitoring compliance relies on the regional level.
  • There is a regional framework in Flanders for monitoring and controlling quality in residential care settings.
  • Patient-centeredness, responsiveness, empowerment and transparent communication across the LTC services are principles set in laws concerning Patients’ Rights (10/2002) and Privacy (12/1992).



  • About 17.8% of Croatia’s population is aged over 65.
  • In the age cohort 65+, there are 36% (73,794) of disabled persons who are beneficiaries within the system of social welfare.
  • Long-term care in Croatia is organised within the system of social welfare, at the national as well as the regional level.
  • In 2009, expenses for financing of the social welfare system amounted to 0.89% of GDP, but it is not known how much of it was spent on LTC.
  • Currently, LTC schemes focus on two programmes: In-home assistance for the elderly (including delivery of meals, housework, and assistance with personal hygiene to persons having no other assistance from their family members) and day-care. There also exists a range of institutional and day care and in-home assistance for the elderly. Older people mostly rely on permanent assistance, supplement for assistance and care at home and personal disability allowance.
  • Long-term care rests mainly on public funding and organisation of the provision of services, while there are no incentives from the state for private insurance schemes, apart from limited incentives for saving within the voluntary pension insurance schemes.
  • There is a considerable coverage gap regarding the estimated number of dependent people and those who have actually received some type of care and the shortages of formal services in institutionalized context. Waiting lists for county nursing homes are long, while private providers are financially unaffordable for many.
  • According to the second European Quality of Life Survey (EQLS), conducted in 2007–2008, Croatia is among the top three countries in Europe (after Italy and Estonia) with the greatest scale of family care.
  • In Croatia, spouses, especially wives, are the primary caregivers for the elderly. Nevertheless, there is still a large number of the elderly population who live alone and who are at risk of having unmet LTC needs. Informal care is also provided by friends and neighbours.
  • The quality of health care services is regulated through the Act on Quality of Health and Social Care of 2011.
  • In Croatia, there is a lack of comprehensive monitoring and reporting on the scope and types of non-institutional long-term care services, especially in respect to non-state providers and informal caregivers.



  • 11.3% of the population aged 65 and over received benefits for long-term care, of which 3% of the population over the age of 65 are recipients of LTC in an institution.
  • LTC is provided through a mandatory and universal system of social long-term care insurance (LTCI), introduced as a fifth pillar of the social security system in Germany in 1995 (Social Code Book, Part XI, Long-term care insurance). The LTCI covers almost the entire population, according the principle that long-term care insurance follows health insurance. Members of the public health insurance system become members of the public LTCI scheme, and those who have private health insurance are obliged to buy private, mandatory LTCI providing the same benefit packages.
  • The long-term care insurance predominantly provides assistance benefits for domiciliary care, in an effort to enable beneficiaries to remain in their home and their family context for as long as possible.
  • In 2008, Belgium’s expenditure on long term nursing care was equivalent to about 1.3% GDP, of which 0.5% GDP is devoted to institutional care.
  • Social long-term care insurance is funded by means of salary deductions of income-based insurance contributions. The contribution rate is set by law. Since July 2008 the contribution rate has been a uniform 1.95% of income subject to contributions.
  • The costs for long-term caregiving that are not covered by the LTCI funds have to be paid by the care recipients themselves. Sometimes co-payments can be substantial and persons in need of care who are not able to cover these costs can apply for means-tested social assistance.
  • There are some concerns that the LTCI system may not be viable into the future as the population ages. In 2011, Germany’s parliament passed a new law that makes it easier for working people to care for dependent members of their families. The new law is a clever way of spreading the cost and recognizes the central role of the family in the provision of care for older people.
  • Quality management system for nursing homes – which set management standards for organisations – are compulsory in Germany. Germany collects indicators related to clinical effectiveness, satisfaction and experience of long-term care services. There is also a national data collection on waiting times for LTC. However, clinical indicators focus mostly on process of care rather than quality outcomes. Germany publishes reports on performance of LTC providers to stimulate competition among providers and improve transparency. Germany is one of the few OECD countries that has accreditation for both nursing home and home care providers. However, standards for home care are not as strict.



  • Approximately 16.5% of the Hungarian population is aged over 65 (OECD average 15%) with 3.9% of the population over 80 (OECD average 4%).
  • In Hungary, long-term care (LTC) patients can receive services from the health and the social care system, which have different structures and funding. The health care system operates under the National Health Insurance, while the social care system is managed at a local level.
  • The central government is responsible for the health care legislation, as well as the financing for LTC. The local governments assume primary responsibly for organising and delivering social care, which includes home care and nursing care, under the framework set out by the central government.
  • In 2008, approximately 7-8% of Hungarian population over the age of 65 received at least one type of basic social services; and 2.91% of people above 65 were recipients of LTC in institutions.
  • Hungary spent 0.6% of its GDP on long-term care in 2007, of which 0.3% was for health-related LTC, and 0.3% for social services of LTC (OECD Health Data 2010).
  • The number of authorised places in institutional care is just below 50,000 (excluding care centres for temporary care), with these being almost completely filled. The waiting list, of around 17,000 persons, is largely inflated by double or triple registration; sources estimate the effective waiting list to be about 5,000-7,000. Eligibility for home care and institutional care is determined by the national assessment procedure and is restricted to those who need more than four hours care a day.
  • Universal coverage, based on the principle of social equity, is an expressed policy goal of the Hungarian LTC system. Until 2008, age was the only prerequisite for entitlement. In 2008 an eligibility test was introduced, which evaluates the physical and social conditions of applicants.
  • Efforts to develop the quality of professional home nursing in Hungary and to facilitate measurement of the quality of care, commenced relatively late in comparison to other health care services. Following the examples of other Hungarian institutions, the ISO 9001:2000 quality assurance system was chosen. The introduction and ongoing application of the system has resulted in tangible progress towards the establishment of a ‘quality culture’ in Hungary.
  • Since 2007, the Health Insurance Supervisory Authority (HISA), has controlled the quality of and access to health care services and releases evaluations of providers.



  • Up until 1990, the main focus of social care services was institutional care for the elderly and the physically and mentally disabled. Long-term care at home was an activity undert
  • aken mainly by family members. Only recently has the strategy for long-term care provision been concentrated more on the new forms of care at home.
  • The capacity of long-term care homes in both the health and social care sectors is estimated at 2.5 places per 10,000 persons, which is far less than the growing need and far below the average of the EU-15.
  • Home-based LTC provided by the social system was a new phenomenon in Lithuania in the mid-1990s and it is still in a process of continual development.
  • Most of the care provided for the elderly and disabled is still carried out by family, neighbours, friends and volunteers.
  • Social and health care services for elderly people In Lithuania are organized through three main sectors: health care, social system and the private sector. The lack of distinction of the system means that no unified legal arrangements have been created and there is no central or/and regional institution that uniformly regulates the long term care procedures.
  • The quality of social care institutions is overseen by local governments. Since 2008 the Social Care Standards have been used to set out minimum quality standards. A quality assessment mechanism is currently under development.



  • The long term care (LTC) system in Romania includes all medical and social services delivered over a long period of time to those in need such as the chronically ill, terminally ill, the disabled and the dependent elderly who need help with activities of daily living or instrumental activities of daily living.
  • It includes formal/informal home care, day care, and institutional care, though Romania has a major deficit of institutionalized services.
  • The right to social assistance is guaranteed to all Romanian citizens and to all foreign and stateless persons who have residence in Romania and have reached retirement age and have insufficient income to cover the costs of care.
  • Eligibility for long-term care is determined conducted according to the Socio-Medical Evaluation Form for older people. This Evaluation Form is binding and used throughout the nation.
  • Residential care is for the most part funded from the local budgets through the County Council. In case the local budgets become insufficient, then the state budget will complete the extra-budgetary sources of income for retirement homes to ensure their proper functioning. Expenses that are not covered by the health insurance system must be covered by the retirement home where care is provided through the person’s own income, external credits, external grants, donations and sponsorships.
  • Due to limited accessibility and financial resources, there are inequalities in geographical distribution and in the number of services. The need for care services throughout the country in 2008 was evidenced by the large number of people (2900) waiting to access care homes.
  • Quality standards for home and residential care are set out in two separate laws but are not monitored.