Home Sweet Home? Public Financing and Inequalities in the Use of Home Care Services in Europe

Income-related inequalities in health care access have been found in several European countries, but little is known about the extent of needs-adjusted inequalities (inequities) in the provision of long-term care (LTC) services. This paper fills this gap: it addresses equity issues related to the provision of home care services across three macro areas in Europe that are highly heterogeneous in terms of the degree of public financing of LTC and the strength and social value of family ties. Using cross-country comparative microdata from the Survey of Health, Ageing and Retirement in Europe (SHARE), we estimate and decompose an Erreygers concentration index of the use of both paid domestic help (‘unskilled’ care) and personal nursing care (‘skilled’ care), measuring the contribution of income, need and non-need factors to overall inequality. We base the decomposition on a bivariate probit model that takes into account the interaction between formal and informal home care use. We find higher inequities in the use of unskilled home care in areas where public financing of LTC is relatively low (‘Southern Europe’) than in areas where the public–private mix of financing is more balanced (‘Continental Europe’). At the same time, we do not detect inequity in ‘Northern Europe’, which is characterised by high public spending on universal, equitable services, including LTC public coverage. In all areas, we find informal care is a substitute for paid unskilled care among the poor, and this contributes to further skewing of the distribution of the use of formal care services towards the rich