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Meeting Unmet Long-Term Care Needs in an Ageing Europe

Demography, Dependency and the Hidden Costs of the Care Gap

For decades, population ageing in Europe has been described as a gradual demographic transformation. Today, it is clear that it represents a profound structural change, with economic, fiscal, and social implications that are reshaping the balance between generations. Europe is entering a phase in which demand for long-term care (LTC) will grow more rapidly than the institutional and family-based capacity to respond to it. At the core of the issue is not only rising longevity, but the widening gap between care needs and available services. Unmet long-term care needs do not represent a simple organizational mismatch: they are associated with tangible deteriorations in older people’s physical and mental health, while also generating indirect costs for healthcare systems and the economy as a whole.


When Demographic Change Becomes Structural Pressure

Europe is experiencing a dual dynamic: “ageing at the top,” driven by increasing life expectancy, and “ageing at the bottom,” driven by persistently low fertility rates. The result is a marked increase in the share of the elderly population and a contraction of the working-age population.


As shown in Figure 1, the share of the population aged 65 and over is projected to increase steadily until mid-century, while the share of those aged 20–64 gradually declines. At the same time, the old-age dependency ratio rises significantly: the number of individuals aged 65+ relative to the working-age population will increase from roughly one third to levels close to 60% by the end of the century. This change implies a profound transformation of the support ratio: fewer workers per pensioner, greater pressure on pension and healthcare systems, and rising demand for long-term care services. Some countries, such as Italy, are already at an advanced stage of this demographic transition. With around one quarter of its population aged 65 or over, Italy represents an emblematic case of the challenges awaiting the European Union as a whole.


Figure 1. Population structure indicators, EU-27, 2001–2050
Figure 1. Population structure indicators, EU-27, 2001–2050

Economic Sustainability and the Limits of Family-Based Care

Population ageing affects not only social expenditure, but also economic growth. If labor market participation rates remain unchanged, the number of retirees per 100 workers will increase dramatically by 2050. Policies aimed at extending working lives and reducing the gender participation gap could mitigate this effect, but not eliminate it entirely.


However, the issue of long-term care is not only fiscal. It is also social. Traditionally, care for frail older individuals has been provided by families. Today, this model is under strain: smaller family sizes, higher female labor force participation, and geographic mobility reduce the capacity to provide continuous informal care. The economic value of informal care is estimated at around 2.4–2.7% of EU GDP, exceeding public spending on formal LTC in many countries. Yet this form of care entails significant costs for caregivers, in terms of health, income, and professional opportunities. At the same time, the formal care sector faces structural staff shortages, low wages, and high turnover rates.


The result is a system under strain: growing demand and limited supply capacity.


The Care Gap: Unequal Spending, Unequal Protection

Differences across European countries clearly emerge from Figure 2, which shows LTC expenditure as a percentage of GDP. Northern European countries invest significantly more than Southern and Eastern countries. In countries with lower public investment, reliance on informal care is greater. But even where services formally exist, access barriers persist: high costs, waiting lists, and infrastructural shortcomings. This is where the “care gap” arises — the gap between the care required and the care actually received.


Figure 2. Total long-term care spending in Europe as a share of GDP (2021 or nearest year)
Figure 2. Total long-term care spending in Europe as a share of GDP (2021 or nearest year)

Unmet needs are not marginal. A significant number of older Europeans report not receiving sufficient support for essential daily activities. The consequences are substantial and include the worsening of chronic conditions, an increase in avoidable hospital admissions, greater use of emergency services, and a progressive loss of autonomy. But the impact is not only physical. Studies based on European data show a strong association between unmet care needs and depressive symptoms. Lack of access to care undermines not only health, but also dignity and psychological well-being.


When Care Deficits Become Mental Health Risks

The COVID-19 pandemic put mental health under severe strain. As shown by Eurostat statistics, a substantial share of the European population reported negative effects on mental health during the pandemic, with particularly marked impacts among women and vulnerable groups.


For older adults, the combination of social isolation and disruption of care services represented a double shock. Evidence collected over time shows that during the pandemic many older adults delayed or skipped medical appointments and care services. In fact, about one in six reported that they were unable to access the healthcare they needed during the first year of the crisis. Research indicates that unmet long-term care needs during this period were strongly linked to a decline in self-perceived health among people aged 50 and over, and that these effects persisted even after the most acute phase of the health emergency had passed.


The data also highlight clear inequalities: women, people aged 80 and over, those living alone, and individuals experiencing financial hardship were more likely to face ongoing difficulties in accessing the care they needed. The pandemic acted as an amplifier of pre-existing vulnerabilities, disproportionately affecting women, individuals aged 80 and over, people living alone, and those facing economic hardship. Long-term care thus emerges as a crucial determinant not only of physical health, but also of mental health.


A Structural Challenge, Not a Temporary Crisis

The picture that emerges is clear: European ageing is not a temporary crisis, but a structural transformation. The care gap does not reflect an episodic failure, but a systemic tension between demographic dynamics and institutional arrangements.


If left unaddressed, the gap between needs and services risks amplifying territorial and social inequalities, increasing avoidable healthcare costs, worsening older people’s quality of life, and placing additional burdens on families and labor markets. Effective responses will require stronger integration between health and social care, sustained investment in the care workforce, a reduction of financial barriers to access, structural support for informal caregivers, and the design of systems that are more resilient to systemic shocks. Ultimately, long-term care is not merely an expenditure item. It is an investment in social cohesion and intergenerational sustainability. If public debate often describes ageing as a “grey wave,” the real issue is not age itself, but our collective capacity to transform longevity into security, dignity, and well-being for all.


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