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As global populations continue to age, long-term care (LTC) has emerged as a critical pillar of contemporary health and social policy. This introduction offers a comprehensive exploration of LTC through conceptual, ethical, and systemic lenses, emphasizing foundational values such as dignity, autonomy, and cultural responsiveness. It critically examines prevailing models of care, including institutional, community-based, and integrated approaches, and evaluates their alignment with person-centered principles.
The demographic transition toward aging populations has placed long-term care (LTC) at the forefront of global health and social policy. With life expectancy rising and fertility rates declining, societies face increasing pressure to provide sustained, high-quality care for individuals experiencing chronic illness, disability, or age-related dependency. The World Health Organization (WHO) projects that by 2050, the number of people aged 60 and older will double to 2.1 billion globally [1]. This demographic shift demands not only technical and financial responses but also ethical and philosophical reflection on the value of human life and the societal obligation to care.
Over the past 10 years, we have had the opportunity to conduct research on support systems for individuals with advanced dementia and their family caregivers. Studies were carried out in collaboration with researchers and healthcare professionals from over 30 countries across five continents. The overall conclusion indicated that countries are at different stages of development regarding long-term care. Most notably, the findings indicate that the majority of these systems remain underdeveloped, poorly adapted to the demographic realities of their respective countries, and characterized by insufficient public investment, as measured by the percentage of GDP allocated to this sector.
One study explores the relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia [2]. Despite receiving structured home-care via Integrated Community Care Teams, participants – especially those with severe frailty – exhibited high levels of unmet needs in areas such as food preparation, medication management, toileting, and communication. The study highlights that even within organized LTC frameworks, care remains fragmented and insufficiently tailored to the complex realities of advanced dementia. Critically, findings suggested that current LTC models may not adequately address the intersection of frailty and dementia, underscoring the need for more responsive and flexible care strategies that reflect demographic shifts and evolving clinical demands. This calls for policy and practice reform in dementia care.
Later, another study was related to family caregiver burden and psychological distress linked to the frailty and functional dependency of a relative with advanced dementia [3]. Long-term care is addressed through the lens of community-based support. The study highlights the role of Integrated Community Care Teams in supporting dyads of dementia patients and their caregivers. Findings reveal persistent high levels of caregiver burden and psychological distress, suggesting that current long-term care provisions may be insufficient. Despite ongoing support, a large part of caregivers reported moderate or severe burden, indicating a gap between policy intentions and lived experiences. The study underscores the need for more robust, proactive long-term care strategies to sustain family caregiving and protect caregiver well-being.
LTC, as explored worldwide, is more than a set of services – it is a societal commitment to uphold dignity, autonomy, and inclusion. As [4] argue that effective long-term care systems must be fundamentally anchored in the principles of respect for individual dignity, responsiveness to evolving needs, and a person-centered approach that prioritizes the unique preferences, values, and autonomy of older adults. Only through such ethically grounded frameworks can these systems adequately address the complex and diverse requirements of aging populations.
Long-term care refers to a range of services and supports provided to individuals who need help with daily tasks or more complex activities (IADLs) over a long period. These services may be delivered in institutions (e.g., nursing homes), community settings, or private homes, and they include medical, emotional, social, and recovery-related support.
According to the World Health Organization [1], long-term care (LTC) includes a coordinated system of care activities delivered by both informal caregivers – such as family members – and trained professionals. These services are designed to support individuals experiencing a lasting decline in intrinsic capacity, helping them maintain a level of independence that aligns with their basic human rights, personal freedoms, and inherent dignity. This definition highlights the ethical imperative of care and the need for systems that respect personal independence and social inclusion.
Long-term care and palliative care overlap in their shared commitment to person-focused, dignity-preserving support, and in practice through combined service delivery for people with chronic or serious conditions. From an idea-based view, LTC and palliative care (PC) both focus on full, long-term support for people with declining health, chronic illness, or terminal conditions. Despite different main goals – recovery and maintenance in LTC versus symptom relief and emotional support in PC – both models share values of care, relationships, and respect for dignity [5]. In practice, combining LTC and PC is increasingly seen as necessary in health systems dealing with aging populations and multiple illnesses. Silva et al. [6] note that many people in LTC settings – like nursing homes or home care – develop conditions that need palliative care, such as advanced dementia, cancer, or organ failure. In these cases, PC methods are added to LTC routines, allowing for timely pain relief, planning ahead, and family support. This overlap is especially clear in elderly care, where the line between long-term and end-of-life care is often blurred.
Separation between LTC and PC services can leave needs unmet, especially in systems where palliative care is narrowly defined or lacks resources. Clear ideas and aligned policies are needed to ensure people in LTC get the right palliative care as their conditions change. As [7] notes, newer PC models support early integration, which fits well with LTC’s focus on prevention and flexibility.
2. The long-term care systems worldwide: The nordic leadership
As populations age in societies, long-term care (LTC) systems face growing pressure to provide accessible, high-quality services. Following this, we offer a comparison of LTC spending across EU Member States, using country-specific laws to show structural differences. It argues that strong legal systems are essential to ensure fairness, sustainability, and readiness for demographic change.
Due to the rapid aging process, Europe and Japan have intensely problematized their Long-Term Care systems, as they face demographic pressures that are greater than those of many southern countries with younger populations. Looking at EU countries, by 2050, nearly one-third of the population will be aged 65 or older [8]. This shift increases demand for LTC services, which support people with chronic illnesses or physical limitations. National health services must adjust through smart spending and legal changes to maintain care standards and social protection.
As Europe sees more older adults – many with dementia, cancer, or other chronic conditions – the need for LTC is rising. At the same time, fewer births and smaller younger populations mean fewer family caregivers, putting more pressure on formal care systems. EU countries currently spend between 0.5% and 3.2% of GDP on LTC, with Nordic countries spending the most. National policies vary widely, affecting how care is given, paid for, and organized. Growing pressure on public health budgets, like the NHS, is worsened by the use of expensive hospital beds for people who need long-term help, not emergency care.
These systems are no longer optional – they’re essential to handle rising dependency and ensure lasting, respectful care for Europe’s aging population.
LTC systems in EU countries are key for:
Supporting independence and dignity in older adults [9].
Reducing hospital use through community-based options [10]
Helping informal caregivers, who provide most of the care in many countries [11].
Ensuring fairness and access, especially for vulnerable groups. [12]
Here’s a look at LTC spending (% GDP) and key laws in some selected countries [13–20], [21–25]
Sweden: ~ 3.2%. LTC follows the Social Services Act (2025 update), focusing on equal access and local government responsibility.
Netherlands: ~ 3.0%. The Long-Term Care Act (WLZ) ensures full coverage for both home and institutional care, managed by the Care Needs Assessment Center.
Germany: ~ 2.5%. The LTC Insurance Act covers all citizens; 2025 updates added more care funds and flexible budgets.
France: ~ 1.9%. LTC is managed by the ALD system and regional health offices; 2025 changes aim to improve funding and expand palliative care rights.
Belgium: ~ 2.0%. LTC is managed by regions; recent changes focus on reintegration and tighter benefit rules.
Spain: ~ 1.1%. The Dependency Law (2006) serves as the foundation for LTC; the 2025 updates focus on reducing institutional care and expanding the workforce.
Poland: ~ 0.6%. Managed by the Ministry of Family and Social Policy; LTC is still developing and lacks coordination.
The legal setup shows significant differences among countries. Countries like Sweden and the Netherlands include LTC in their welfare systems, providing access to all. Others, like Spain and Poland, are updating their systems to include informal care and reach more people. Clear laws and funding are needed to address gaps, regional differences, and staff shortages.
Respect for human life is a cornerstone of LTC philosophy. The principle of autonomy, the right to age with dignity, and the imperative to avoid institutional neglect are recurrent themes in the literature. Bos et al. [26] highlight the ethical imperative behind long-term care by stating that it should be seen not just as a policy area or service system, but as a deep moral responsibility carried by societies toward their most vulnerable people.
LTC systems differ widely across countries, shaped by welfare systems, cultural traditions, and historical practices. Common models include:
Institutional care: Residential facilities offering round-the-clock support, often for people with high needs.
Home-based care: Services provided in the person’s home, including nursing, personal care, and recovery support.
Community-based care: Day centers, short-term relief care, and social support that help people stay in their homes.
Informal care: Unpaid care provided by family or friends, often without official recognition or assistance.
Barreira et al. [27] describe a basic framework for LTC systems, identifying three connected ideas: continuity of care, cross-sectoral integration, and personalization. These are key to building care plans that are clear, flexible, and suited to each person. Continuity means support continues over time and through changes in health or living situations; integration helps connect medical, social, and community services; and personalization focuses on adjusting care to match each person’s needs and values. The authors warn that fragmentation between services weakens LTC, emphasizing that the fragmentation of services undermines the very essence of LTC, which is to provide seamless, person-centered support across time and settings.
Scott et al. [28] identify a series of ongoing and connected problems that especially limit access to long-term care (LTC) services for minority groups. One of the biggest challenges is language mismatch, which seriously affects both the admission process and the quality of care – especially for recent immigrants and people from language minority backgrounds. Cultural incongruence makes access to and quality of care more difficult. Many older adults from minority backgrounds prefer care settings that match their cultural habits, such as food choices, religious practices, and social traditions. When LTC services don’t meet these needs, people may feel isolated, less healthy, and unwilling to use available services. These systems must recognize and support the different cultural, language, and social backgrounds of those receiving care. As [28] point out, the challenge is to balance consistent care with the need for personalized support that reflects each person’s background. With global demand for LTC growing, it’s more important than ever to design policies that not only recognize but actively support ethnic diversity. This includes offering high-quality care at home, where cultural comfort and personal independence can be better maintained.
Despite the growing body of literature on LTC, significant research challenges persist, particularly in understanding and addressing disparities in access and outcomes. These challenges are compounded when considering minority populations, whose experiences are shaped by intersecting factors such as race, ethnicity, language, migration status, gender identity, and socio-economic position.
The review by [28] identifies major methodological weaknesses limiting the reliability of long-term care (LTC) research, especially for minority populations. Significant heterogeneity in study designs prevents comparable analyses and hinders generalizable conclusions. Many studies lack adjusted statistical models, reducing validity by failing to account for key confounders. Qualitative depth is also insufficient, offering limited insight into minority elders’ lived experiences and cultural expectations. The authors call for intersectional, participatory, and culturally sensitive research approaches that meaningfully involve minority communities. Future work should evaluate targeted interventions, compare international systems, and use longitudinal designs to track evolving trends. Without more rigorous, inclusive research, disparities in LTC access and outcomes will persist, undermining equity and quality of care.
Long-term care is a multidimensional challenge that connects with ethics, policy, culture, and economics. As populations age and become more diverse, national health and social care systems must change to ensure dignity, fairness, and inclusion for everyone who needs long-term support. The way LTC is integrated into national systems varies widely across countries, reflecting different welfare models, government structures, and cultural values. Yet, common problems remain: fragmentation, underfunding, staff shortages, and inequitable access.
Paying for LTC is still a difficult and unsettled issue. In many places, LTC receives less funding than hospital care, even though it’s becoming more important. Public support varies, with some countries relying heavily on personal payments or income-based benefits, which increase inequality and hinder access. The question of who should pay – individuals, families, insurance companies, or governments – is not just technical but deeply political, reflecting choices about fairness, shared risk, and justice between generations.
Given these challenges, LTC systems must explore new paths. This doesn’t mean giving up core values but rethinking them for today’s world. Several new ideas are emerging, each with significant impacts.
Governments must find solutions that fit their own societies. Change can start locally. One direction is to connect care across different services. Gaps between health, social, and housing services hurt continuity and personal care. Joined-up care models – like case managers, shared budgets, or team-based approaches – try to fix this. Digital tools, such as shared health records, remote monitoring, and AI support, can help but must be used carefully, respecting privacy and digital skills.
Another promising direction is to grow community and home-based care. Most older adults prefer to stay at home, and it’s often cheaper and better for their independence. However, it requires strong support systems, such as safe housing, transport, short-term relief for caregivers, and training. Shared housing, mixed-age living, and age-friendly cities are part of this, challenging traditional ideas of care homes.
A third direction is to rethink the role of families and communities. While unpaid care shouldn’t be taken for granted, policies can better support those who provide it. This includes pay, legal rights, flexible jobs, and emotional support. At the same time, community involvement and volunteering can build care networks beyond family ties. These models require cultural change and strong support, but they offer strength and deeper relationships.
Finally, new ideas must come with responsibility and open discussion, as expected in democratic societies. The future of LTC is not just a technical issue but a social decision. Leaders, professionals, researchers, and citizens must talk openly about values, priorities, and trade-offs. Pilot programs, policy trials, and learning from other countries can help but must be tested carefully and openly. The WHO (2022) [29] highlights that strengthening community-based and long-term care (LTC) services can significantly reduce avoidable hospital and emergency-department use. When older adults or people with chronic conditions receive timely support at home or in community settings, deterioration and crises are less frequent. Investing in LTC prevents unnecessary long hospital stays for patients who primarily need social or functional support rather than acute care. This shift improves care quality, reduces pressure on hospitals, and helps rebalance costs across the National Health Service by allocating resources to more efficient, person-centered services that maintain independence and prevent institutional overuse.
In short, aging and caregiver shortages are not isolated problems but symptoms of wider transformations in population, work, family, and welfare systems. Long-term care (LTC) must, therefore, respond not with minor adjustments but with bold, value-driven, and research-based reforms. Integrated care, community support, caregiver protection, rights-based approaches, and shared leadership are not idealistic ambitions – they are necessary directions that require investment, creativity, and strong institutions. These challenges are substantial, but they also offer an opportunity to build care systems that are fair, compassionate, and resilient for future generations. Addressing them demands a commitment to ethical principles, better coordination, and culturally sensitive practices, supported by research grounded in real-life experiences and diverse perspectives.
Long-term care encompasses a wide range of important matters that shape its development, implementation, and future direction. Among these are matters involving the preparation, training, and continuous development of staff, including the relevance of learning modalities, skill acquisition, and competencies that support care for individuals with complex needs. There are also important matters connected to the design of policies, procedures, and service pathways that guide communication, coordination, and overall care experiences.
Another set of matters relates to the organization of long-term care across home, community, and primary healthcare settings, including the alignment of these environments with cultural preferences and structural capacities. The circumstances of family caregivers present further important matters, including those associated with the multiple responsibilities they balance, the financial and employment implications of their role, and the broader impact on family wellbeing. Matters linked to caregiver burden, emotional strain, and the need for supportive interventions also stand out, affecting quality of life and care provision.
Finally, the development of coherent conceptual models, adequate state investment, and sustainable organizational structures emerges as an overarching matter that determines the functionality, continuity, and effectiveness of long-term care systems. One aspect to note is what emerges in countries that, in demographic terms, have very young populations. Studies systematically appear that attempt to problematize conceptual and operational perspectives of long-term care (LTC), adopting a proactive approach to preparing for the future.
This book brings together a broad set of LTC situations from different societies and cultural contexts, all united by a concern for how effectively care systems support people.
The author acknowledges the use of AI tools for language checks.
References
1.World Health Organization. State of Long-term Care: Conceptual Framework for Assessment and Continuous Learning in Long-term Care Systems. Copenhagen. 2024. Available from: https://www.who.int/europe/publications/i/item/WHO-EURO-2024-10363-50135-75508
2.AbreuW, TolsonD, JacksonGA, StainesH, CostaN.The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia. New Jersey: Health Soc Care Community. 2019;27(3):642-653. DOI: 10.1111/hsc.12678
3.AbreuW, TolsonD, JacksonG, CostaN.A cross sectional study of family caregiver burden and psychological distress linked to frailty and functional dependency of a relative with advanced dementia. London: Dementia: the international journal of social research and practice. 2018;1:1
4.KringosDS, BosVLLC, PoldrugovacM, WammesJD, BarbazzaE, IvankovićD, MertenH, MacNeil VroomenJL, KlazingaNS. Performance indicators on long-term care for older people in 43 high- and middle-income countries. BMC Health Services Research. 2025;25:Article 460. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-025-12573-4
5.BertaudS, WilkinsonD, KelleyM. The heart of palliative care is relational: A scoping review of the ethics of care in palliative medicine. BMC Palliative Care. 2025;24(150). DOI: 10.1186/s12904-025-01784-5
6.SilvaDAA, MachadoGRR, da SilvaBG. Relationship Established between the Concepts of Palliative Care and Long-term Care: An Integrative Review. São José dos Pinhais, Brazil: Home Publishing; 2023. DOI: 10.56238/homeIIsevenhealth-117
7.YangX, ChenX, LiuQ, YaoL. A brief literature review of conceptual models in palliative care. In: BolligG, ZelkoE, editors. Palliative Care – Current Practice and Future Perspectives. London: IntechOpen; 2024. DOI: 10.5772/intechopen.1003782
8.European Commission. Long-term Care Report: Trends, Challenges and Opportunities in an Ageing Society. Vol. II. Brussels: Country profiles, Publications Office; 2021a, 2021. Available from: https://data.europa.eu/doi/10.2767/183997
9.Eurocarers. National Reports on the Implementation of the Council Recommendation on Access to High-quality Long-Term Care. Brussels, Belgium, 2024
10.ThapaBB, LiX, GalárragaO. Impacts of community-based care program on health care utilization and cost. American Journal of Managed Care. 2022;28(4):187–191. PMID: 35420747. DOI: 10.37765/ajmc.2022.88862
11.CARES Project. Benchmark report on social care sectors at the national and EU level. CARES Project No. 2024-1-RO01-KA220-ADU-000251559. Brussels: Eurocarers; 2025
12.European Commission. Healthcare and Long-term Care Workforce: Demographic Challenges and Potential Contribution of Migration and Digital Technology. Brussels: Publications Office of the EU; 2021. Available from: https://op.europa.eu/en/publication-detail/-/publication/de896328-771b-11eb-9ac9-01aa75ed71a1/language-en
13.European Commission. Poland Long-Term Care Implementation Reports. 2024. Available from: https://commission.europa.eu/publications/implementation-reports-2024_en
14.European Commission. Romania LTC Implementation Report. 2024b. Available from: https://commission.europa.eu/publications/implementation-reports-2024_en
15.Asensio VázquezM, García CiriaC, López MolinaG. Funcas.Spain’s Long-term Care System at a Crossroads: Demographic Pressures and Workforce Challenges. 2025. Available from: https://www.funcas.es/articulos/spains-long-term-care-system-at-a-crossroads-demographic-pressures-and-workforce-challenges/
16.Government of Sweden. Preventive, Accessible and Knowledge-based Social Services. 2025. Available from: https://www.government.se/articles/2025/03/preventive-accessible-and-knowledge-based-social-services/
17.Government.nl.Long-term Care Act (WLZ). - Bundesministerium Für Gesundheit. (2025). Pflegeversicherung.). 2025. Available from: https://www.government.nl/topics/nursing-homes-and-residential-care/long-term-care-act-wlz
19.RothgangH, MüllerR, UngerR. Long-term care in Germany: Between social insurance and demographic pressure. Health Policy. 2024;128(3):345–358
20.Sowa-KoftaA, Badora-MusiałK. Long-term care in Poland: Challenges and policy directions. European Journal of Social Policy. 2024;34(2):210–225
21.World Bank. Romania’s Way Forward in LTC. Technical Inputs to the 2023-2030 LTC Strategy. Bucharest: International Bank for Reconstruction and Development; 2022
22.World Bank. Strategic Review of Long-Term Care Services in Poland. International Bank for Reconstruction and Development; 2025. Available from: https://hdl.handle.net/10986/43111
23.TsutsuiT. Japan’s long-term care insurance system: Achievements and challenges after two decades. International Journal of Health Planning and Management. 2024;39(1):1–15
24.VaboSI. The Territorial Dimension of Long-Term Care for Older People. In: KazepovY, editor. Rescaling Social Policies towards Multilevel Governance in Europe: Social Assistance, Activation and Care for Older People. London: Routledge; 2017. DOI: 10.4324/9781315244433-9
25.SzebehelyM, MeagherG. Nordic eldercare: Weak universalism becoming weaker?Journal of European Social Policy. 2024;34(1):45–60
26.BosVLLC, PoldrugovacM, WammesJD, BarbazzaE, IvankovićD, MertenH, MacNeil VroomenJL, KlazingaNS, KringosDS. Performance indicators on long-term care for older people in 43 high- and middle-income countries. BMC Health Services Research. 2025;25. Article 460. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-025-12573-4
27.BarreiraLF, PaivaA, AraújoB, CamposMJ. Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review. International Journal of Environmental Research and Public Health. 2023;20:1698. DOI: 10.3390/ijerph20031698
28.ScottMM, MayhewA, JeongA, ShaverN, LapenskieJ, HsuAT, Tanjong-GhogomuE, TanuseputroP, HuangE, WelchV. Access to long-term care for minority populations: A systematic review. Canadian Journal on Aging/La Revue Canadienne du Vieillissement. 2022;41(4):577–592. DOI: 10.1017/S0714980822000046
29.WHO. Rebuilding for sustainability and resilience: strengthening the integrated delivery of long-term care in the European region. 2022. Copenhagen: WHO Regional Office for Europe Available from: https://iris.who.int/server/api/core/bitstreams/69795ee0-d42f-4af2-889a-dd9c5b439af1/content
30.AbreuW, TolsonD, JacksonGA, StainesH, CostaN. The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia. Health & Social Care in the Community. 2019;27(3):642–653. Epub 2018 Nov 7. PMID: 30402986. DOI: 10.1111/hsc.12678
31.TorresS. Ethnicity and old age: Toward a contextualized understanding of ethnic minority aging in Europe. Journal of Aging Studies. 2019;49: 1–9. DOI: 10.1016/j.jaging.2019.100772
Written By
Wilson Abreu
Submitted: 03 December 2025Reviewed: 03 December 2025Published: 20 May 2026
Open access peer-reviewed chapter
