Long-term Care Assessment Toolkit: Application to Denmark Diego Wachs1 World Bank Social Protection and Jobs Global Practice – December 22, 2022 Objective The Long-Term Care (LTC) assessment toolkit is a guide for a systematic and exhaustive assessment of LTC demand and supply in a country. Methods and organization The assessment toolkit was built by reviewing a range of peer-reviewed articles published in academic journals and reports published in the grey literature.2 The toolkit is organized as a questionnaire divided in six sections that correspond to the intersection between three domains (1) POLICY, (2) PROVISION, and (3) HOUSEHOLD STRUCTURE AND GENDER, and two perspectives (1) SUPPLY PERSPECTIVE and (2) DEMAND PERSPECTIVE. The first two domains separate the stewardship of the system from the provision of services. The third domain helps assessing how the characteristics of households and gender dynamics interact with long-term care. The Supply and Demand perspectives help to understand how both forces shape the existing LTC structure. The intersection of the Supply perspective with the three domains guides an assessment of policies and regulations governing LTC, the existing distribution of services and supply factors that condition the availability of services, and how gender inequalities in the provision of long-term care interact with socioeconomic opportunities, among other issues. The interaction between the Demand perspective and the three domains guides an assessment of how demographic and epidemiological factors drive the demand for LTC, the capacity of the demand to sustain paid-for services, and how gender interacts with LTC needs, access and satisfaction with care (Figure 1). Each of the six sections within this matrix is divided into sub-headings containing several questions guiding the assessment (Figure 2). 1 This toolkit was prepared with the support of a grant from the Rapid Social Response Trust Fund. 2 The background paper associated with the toolkit provides a discussion of the state of the literature and a list of recent publications and other information sources relevant for completing an LTC assessment and available for several countries. Figure 1. Organization of the toolkit. The Policy domain has The supply perspective guides the assessment of policies and regulations governing LTC. For a macro perspective example, how different forms of regulation affect the market structure, financing, or quality of and guides an LTC systems. In addition, it looks at the interaction between policy, the geographical distribution assessment of how the of services, and migration. It ends with a discussion of the main challenges of the system regulatory framework according to its stakeholders. of LTC interacts with supply and demand forces. The demand perspective guides on assessment of how the demand of LTC shapes LTC policies and programs. For example, how demographic and epidemiological factors drive LTC regulation. The demand perspective also looks at other public sector services that influence what is expected from the state in terms of LTC, like pensions and healthcare. Other factors that drive the demand related to the household structure or gender issues are covered in domain three. The Provision domain The supply perspective guides an assessment of services and programs available including formal guides an assessment and informal LTC, the availability of facilities, and the LTC labor force. It also discusses the role of of practical issues each stakeholders in addressing the LTC demand. Last, it covers a discussion of barriers for the related to LTC, development of the market, factors affecting prices, geographical challenges and the effect of including what migration. programs are available, who provides care, and how the The demand perspective guides an assessment of pull factors that drive or limit LTC provision. demand for care These include financial restrictions of households, migration, and the effect of non-profit influences the market. providers on the development of the market. The Household The supply perspective discusses how the household composition, residence patterns, and structure and gender migration interact with the supply of LTC, particularly through the availability of familial care. domain guides an The section also discusses gender inequalities in familial care provision and how these assessment of the inequalities translate into economic outcomes (labor force participation, education, and income). interaction between the characteristics of households, gender dynamics, and LTC. The demand perspective guides an assessment of how gender interacts with LTC needs, access and satisfaction with care. Source: Authors’ work. Figure 2. Graphical representation of the toolkit. Perspectives, Domains, and subheadings. DOMAINS POLICY PROVISION HOUSEHOLD STRUCTURE AND GENDER • Policy and regulatory framework • Services and programs available • Household composition and residence • Institutional arrangements and integration • Facilities patterns S U P P LY P E R S P E C T I V E • Geographical rules for LTC • LTC workforce • Migration • The market structure, rules, standards and • The market structure and the role of • Expectations for gender roles in LTC purchaser-provider relations stakeholders in provision provision • Competition • Geographical challenges for provision • Economic outcomes • Price-setting • Migration • Financing • Other supply-side barriers for the • Quality regulation, monitoring, evaluation development of provision and assurance • Prices • LTC workforce • PERSPECTIVES Emigration and immigration • Challenges according to stakeholders • Demographic trends • Poverty and inequality • Gender differences in LTC needs and access • Epidemeological profile DEMAND PERSPECTIVE • Eligibility • Coverage • State of the pensions and social assistance programs • State of healthcare systems • Intergenerational contract Source: Authors’ work. The following characteristics should be considered when utilizing the toolkit. Diversity. The toolkit is meant as a guide for the assessment of LTC across countries with diverse systems and contexts. Some countries will have a well-developed LTC system, with decades of experience in the delivery of care, well-rounded institutions, and extensive data, while others will be on the opposite extreme of these circumstances. In addition, countries can be at an advanced stage in their demographic transition or rural to urban migratory process while others may be only starting to experience these phenomena. The toolkit is built to cover this diversity of contexts. Thus, the relevance of different sections will vary according to the circumstances of each country. Granularity. The lower-level subheadings lead into a degree of granularity that may be unavailable in many cases. In such instances, the subheadings should be understood as a general guide for the assessment rather than a mandatory check list of required information. At the same time, sections for which a systematic review cannot provide any information will highlighting knowledge gaps that may be essential for the performance of stakeholders or the development of appropriate policy. In other words, the toolkit does not only provide a discussion of what is known, but also a description of what is unknown about the LTC system. To this end, the toolkit provides a space to summarize any identified knowledge gaps at the end of each section. Comparability and standardized terminology. The lack of international definitions and the diversity of systems that we intend to cover make it unfeasible to have a survey that smoothly fits all systems. We provide an annex with definitions based on the terminology that better matches the different sources consulted to build the toolkit. To the extent of possible, users of the toolkit should try to utilize the provided terminology to complete their assessment in order to maintain comparability. When such option is not possible, for example due to data restrictions, users should make a note describing this specification. 1 Policy domain The Policy domain guides an assessment of how the regulatory LTC framework interacts with supply and demand forces, in the respective economy. The supply perspective guides the assessment of policies and regulations governing LTC. For example, how different forms of regulation affect the market structure, financing, or quality of LTC systems. In addition, it looks at the interaction between policy, the geographical distribution of services, and migration. It ends with a discussion of the main challenges of the system according to its stakeholders. The demand perspective guides on assessment of how the demand of LTC shapes LTC policies and programs. For example, how demographic and epidemiological factors drive LTC regulation. The demand perspective also looks at other public sector services that influence what is expected from the state in terms of LTC, like pensions and healthcare. Other factors that drive the demand related to the household structure or gender issues are covered in domain three. 1.1 Supply perspective 1.1.1 Policy and regulatory frameworks This section discusses the laws, acts, institutional strategies, and other legal vehicles regulating the general administration of the LTC system in the specific economy. The resulting description of the system can be chronological or based on the relative importance of currently governing acts, laws, and other vehicles regulating LTC, whichever better fits the case. LTC regulation 1.1.1.1 What are the acts, laws, and other vehicles regulating LTC at a national or subnational level? 1.1.1.2 Under what ministry(s) is LTC regulation and administration organized? 1.1.1.3 What are the ministries tasked with the coordination and implementation of LTC? 1.1.1.4 How is the regulation on LTC formulated and approved? 1.1.1.5 Are there programs tasked with the development of LTC policy and implementation? 1.1.1.6 Is there a regulation on environmental factors that influence needs and capacity? 1.1.1.7 Does the legislation of social insurance and social assistance (pensions and/or other social services) affect the regulation of LTC? 1.1.1.8 Is there specific regulation that considers the needs and characteristics of the elderly population, including LTC among other issues like housing, poverty, human rights, etc? This regulation usually appears as elderly law, elder policy, elder acts, policies for senior citizens, etc. 1.1.1.9 Is there specific regulation that considers the needs and characteristics of the population with disabilities? This regulation may cover other age groups. The Danish Ministry of Health is the government ministry tasked with the regulation, oversight and planification of health system performance, including long-term care. The Ministry of Health determines and implements national health policies and designs legislation on several aspects related to the functioning and organization of the health and long-term care systems. The Ministry also sets the overall financial framework in which the health and long-term care systems operate and plays an important role in their financing (WHO 2020a). The role of administrative regions and municipalities. Although national legislation sets a broad framework for service provision, municipalities maintain responsibilities for long-term care policies. These include establishing eligibility and entitlement criteria and the level and content of service delivery, regulating services’ delivery and organizing the public provision of services (Roostgard and Langins 2022). The five Denmark administrative regions determine local funding and can deal with providers (WHO 2020a). The Danish Institute for Quality and Accreditation in Healthcare oversees safety and quality standards for private hospitals, primary care practices and pharmacies (WHO 2020a). The main law regulating social service provision and, implicitly, long-term care provision is the 1998 Social Services Act, which replaced the earlier Social Assistance Act. The Social Services Act emphasizes the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long- term care. The municipalities became responsible for offering personal aid and nursing care to support necessary domestic tasks, and for helping the elderly maintain their physical and mental abilities. The municipalities were also obliged to provide a subsidy to persons with substantial and long-lasting declines in their physical and mental abilities to cover the expenses of caregivers. The Act has been amended multiple times, most recent through the Consolidated Act on Social Services of 7 August 2019. The Social Services Act does not stipulate minimal standards but requires that the care needs of older individuals be met and states that older people remain in their homes for as long as possible. The 2015–2018 healthcare agreements, one for each administrative region, identified key areas of action for reducing inequalities among regions and for promoting the engagement of beneficiaries and their families (WHO 2020a). The 2003 legislation on free choice of provider is key for the market structure and was also central to the development of private sector providers. The act prohibits monopolies in service provision and constrains municipalities to ensure a choice between at least two providers, who compete based on quality and price. The legislation was the culmination of a process that started in 1990 which increased the focus on efficiency in service provision and quality of care based on marketization of LTC provision (notably in-home care) (WHO 2020a). LTC strategy 1.1.1.10 Is there a public sector strategy for the development of the LTC system? 1.1.1.11 Is there a public sector strategy for LTC service development reported in periodic institutional reports? 1.1.1.12 Is there a regular follow-up on the completion of the national strategy for LTC? 1.1.1.13 Is there a strategy and/or regulatory framework on healthy aging? 1.1.1.14 Is there a strategy, regulation, or protocols to maximize the independence of older age people, staying in the community, or a policy of deinstitutionalization? 1.1.1.15 Are there flagship reports prepared by the public sector or other stakeholders that discuss the existing TLC strategy? The Danish welfare state has three primary characteristics: universalism, primarily tax financed provision and single string provision (Schulz and Berli 2010). The Danish LTC system has the dual goal of increasing the life quality of persons in need of care and to increase their ability to take care of themselves (Kvist 2018). Deinstitutionalization. Denmark was one of the first European countries to implement a policy of deinstitutionalization during the 1970s – culminating in the legal ban to construct traditional care institutions in 1984 – and has since championed community-based care solutions. The prioritization of a user-centred, preventive and proactive approach based on Reablement. The long-term care strategy most recent development is the introduction of reablement, initially as a pilot initiative but more recently rolled out as a national-level policy (WHO 2020a). Reablement emphasizes a user-centred, preventive and proactive approach to care by working towards maintaining and regaining the skills older people need to continue to live independently. In a mid-term perspective, the new reablement approach is likely to change the criteria for defining and assessing need and the provision of appropriate services. Decentralization. The Danish LTC system is also characterized by its high level of decentralization. The national government is responsible for the overall regulation of provision, overseeing and planning, and setting the financial framework for LTC. However, municipalities maintain certain responsibilities for long-term care policies, including eligibility rules, determining the level and content of service delivery for those entitled to care, and regulating services delivery and organizing the public provision of services. 1.1.2 Institutional arrangements and integration of LTC Countries have considerable scope for diversity, innovation and flexibility in terms of how to apply different elements of the LTC system. In all cases, however, effective and integrated partnerships among governments, families, volunteers, nongovernmental organizations, health and social care professionals and the private sector are essential and will affect many attributes of the system. For example, the delegation between levels of the government (e.g., national and regional) can increase the accuracy to target local needs while enhancing local accountability and fiscal responsibility. Coordination between government institutions and providers is essential to develop coverage or to support carers. The integration between LTC and healthcare systems can speed up the allocation of services and improve outcomes for users. Coordination between stakeholders 1.1.2.1 Are there protocols for the coordination between government institutions and providers, including private for-profit providers, civil society organizations, and for-profit providers? 1.1.2.2 Are the mechanisms to integrate stakeholders in the organization of LTC? 1.1.2.3 Are there mechanisms to integrate LTC users, for example through surveys, ratings, or other formal outlets? 1.1.2.4 Are there mechanisms to integrate carers and providers, for example through surveys or other formal outlets? 1.1.2.5 Are there mechanisms to integrate advocacy groups, volunteers and other non-profit, stakeholders, for example through surveys or other formal outlets? The Danish LTC system is regulated nationally but delivered locally by the 98 municipalities. Five regions are responsible for primary health services. Municipalities are increasingly working towards involving relatives and voluntary organisations in LTC activities. Many municipalities have a policy that provides a framework for how relatives may be engaged in care activities. All municipalities coordinate with voluntary organisations for the provision of LTC, for example, activities for the elderly, such as walks and visits. The important caring roles of voluntary organisations and of the relatives of caredependent persons are increasingly recognised and various initiatives have been taken to strengthen their role. Voluntary organizations are the ones providing most in-kind benefits to support the relatives of caredependent people are not run by public authorities but by voluntary organisations. There are mechanisms for involving beneficiaries in decision-making bodies such as the Danish Medicines Council, where they can contribute in activities. The newly established national quality goals, also include enhancing patient engagement as an objective. Lastly, all municipalities partner with voluntary organizations to roll out community programmes to engage and reach out to older people (WHO 2020a). Integration of LTC and health services 1.1.2.6 Is LTC a recognized subsector of healthcare? 1.1.2.7 Are there mechanisms or institutions tasked with the coordination between LTC and healthcare administration and provision? 1.1.2.8 Is there provision of select rehabilitative care by nursing home facilities? Or linkages between nursing home facilities and physical and occupational therapy? 1.1.2.9 Is there a protocol for the coordination between health and LTC services tasked with the reduction of length of stay in hospital or faster hospital discharge? 1.1.2.10 Are there statistics on delays in hospital discharge to measure the coordination between health services and LTC at the point of discharge? 1.1.2.11 Are there structures for data and information exchange between health and LTC providers? The regulation and oversight of care for older people was transferred from the Ministry of Social Affairs and the Interior to the Ministry of Health in 2015. This represents a clear step towards integrating central and strategic decision making for health and social services. In 2016, a position of Minister for Senior Citizens was created within the Ministry of Health, transferring to it a portfolio that was previously under the control of the Minister for Health (WHO 2020a). In general, health care and long- term care are public responsibilities, however, while long-term care financing and providing is the responsibility of the local municipality, health services are financed, planned and operated by the counties. Most long-term care staff members work in multidisciplinary teams and interact regularly with practitioners from the health sector. Multidisciplinary work is a characteristic of the system and is increasingly expected in all settings. Hospital based multidisciplinary teams and community-based workers, provide post-discharge follow-up. These arrangements emphasize home-based care to reduce the length of stay in hospitals and lower readmission rates. Multidisciplinary work has also been featured in the rabblement program which includes physiotherapists, occupational therapists and social helpers or assistants (WHO 2020a). Integration between primary and secondary care at discharge point. For beneficiaries who need long-term care on discharge, the hospital discharge management team communicates and works closely with the general practitioner and local home services. It is at this interface between health and social services that providers have made a range of efforts to improve seamless service delivery, focusing on identifying the needs for and potential of systemic prevention. Measures have focused on improving collaboration between primary and secondary care, including the implementation of pathway coordinators and the enhancement of communication among providers through information platforms (WHO 2020a). 1.1.3 Geographical rules for LTC provision The responsibilities for the administration of LTC may be delegated to different government levels. For example, the national government may delineate general guidelines for LTC quality while the local governments may be the responsible for its assurance. Similar dynamics may apply to the financing, provision, or other aspects of the LTC system. This section should discuss how these responsibilities of distributed between government levels, how different government levels coordinate the provision of care, and how does the decentralization of the LTC system interact with the geographical availability of care? 1.1.3.1 How does the national administration coordinate with sub-national organizations? 1.1.3.2 How are the LTC administration, provision, financing, and quality assurance duties distributed between national and regional governments? 1.1.3.3 What policies are in place to measure and address geographical differences in care availability? 1.1.3.4 Is there regulation to adequate the supply of care to geographical variation in needs? In Denmark, the government is responsible for the legislation concerning social services and assistance, but the local authorities are responsible for providing social services and for their performance. As long- term care is a part of social assistance, the provision of personal care and help with practical duties will be organized and managed by the local authorities. The local council in the local authority is the body obliged to offer long-term care services, nevertheless, they may hire private providers to manage their provision (Schulz and Berli 2010). Municipalities are also responsible for carrying needs assessment. There is no standardized national needs assessment process. Each municipality follows its own protocols. This feature of the Danish LTC system was bolstered by the Social Services Act from 1998 and its multiple updates which emphasize the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long-term care. Coherence and coordination in service delivery is a stated goal of the Danish Health Act of 2005 and one of the key drivers behind the major reform of local government of 2007. In reducing the number of municipalities and administrative regions, the reform effectively represented a large step towards centralizing health and social services and has actively pursued the reduction of geographical inequalities in access and quality of care and the facilitation of coordination between the administrative regions and municipalities in providing care (WHO 2020a). Healthcare agreements are political and administrative documents agreed on by each municipality and the corresponding administrative region at the beginning of each election cycle and are renewed every four years. The goal of these agreements is to provide a platform for negotiation between the main stakeholders and a framework for the practical collaboration of actors at different government levels (WHO 2020a). These agreements include six mandatory thematic areas: hospitalization and discharge processes, rehabilitation, devices and aids, disease prevention and health promotion, mental health and follow-up on adverse events and feedback mechanisms. Healthcare agreements have proven to be an effective form of vertical integration and show how soft regulation can be successfully applied to increase coordination in highly complex interactions between decentralized authorities (WHO 2020a). 1.1.4 The market structure, rules, standards, and purchaser-provider relations This section discusses the rules for the allocation of care. The responsibility of care provisions could be assigned to different government levels. In turn, government agencies may provide care themselves or subcontract private sector providers under different arrangements. These arrangements could include licensing or other requirements and will dictate what providers are allowed to do, who owns and manages the different types of services, and the facilities available. Ultimately, the section helps describing what is the role of the government, private firms and faith-based organizations in the ownership and management of LTC services. 1.1.4.1 Is there a government-built and privately operated modality for LTC provision? 1.1.4.2 Is there a government-sponsored (and, as applicable, subsidized) and regulated LTC insurance, including interface with National Health Insurance systems? 1.1.4.3 Is there a mixed financing or a private-public partnership? E.g., the government purchases beds from private nursing homes. 1.1.4.4 Is there a system of licenses for public LTC provision by the private sector? 1.1.4.5 What is the process for buying beds or license accreditation for private sector providers? 1.1.4.6 Is there a policy or trend for the privatization of care? Municipalities can provide long-term care services directly or purchase services from private providers. They are autonomous from national authorities regarding the provision of long-term care, including needs assessment and care pathways, resulting in variations across Denmark. The local council will lay down the framework within the providers are to solve the tasks. According to the local government act, the local council must decide whether services should be tendered and, if so, which ones. Entitled users are free to choose between private and municipal providers of services and the local authorities are obliged to establish a framework and unit costs that enable private providers to enter the market for personal and practical assistance (Schulz and Berli 2010). Residential care follows a similar arrangement, however, the deinstitutionalization strategy continuous to dominate the sector, and no new nursing homes have been constructed since 1987. Various forms of service-enriched housing can be developed instead with the active support of the municipal and national governments. 1.1.5 Competition The functioning of the aged care system is a “quasi-market� and its performance depends to a large extent on transparent rules and standards for provision. Fair and transparent rules are needed to enable the market entry and survival of private providers. For this goal, the government’s role is to assure a “Leveled Playing Field� between suppliers. Moreover, supporting competition can improve quality and encourage the growth of provision, particularly when users are provided information and freedom of choice between providers. 1.1.5.1 Are there policies in place to increase competition? E.g., by prohibiting monopolies, mechanisms to assure a minimum number of providers, subsidies, rental payment exemptions, tax incentives like tax holidays, vouchers for qualifying beneficiaries, or other policies. 1.1.5.2 Can individuals entitled to care freely choose between alternative providers? 1.1.5.3 Can cash transfers be used to freely choose between alternative providers? 1.1.5.4 Is there free and open information about prices and the quality of providers? How is the disclosure about information about prices regulated? 1.1.5.5 Are there policies in place to facilitate market entry? E.g., an option to operate multiple residential care sites with one single business license, rules for operation while in the process of seeking an operation permit or minimum registered capital requirement. 1.1.5.6 Is there an active policy towards the marketization of LTC? The legislation on free choice of provider in 2003 prohibits monopolies in service provision and constrains municipalities to ensure a choice between at least two providers, who compete based on quality and price. This change marked the creation of a private sector of providers. Competition is boosted by giving beneficiaries the option to choose between providers, including residences for older people, gated communities, assisted living units, nursing homes or day-care centres. Beneficiaries can also access quality indicators of providers, including the waiting times and performance of hospitals and other providers. Legislation from 2013 aimed to increase real competition among providers and to reduce the number of contracted providers to a level that would render choice more manageable for people. To remain in the market, for-profit providers lowered prices too much and, consequently, a string of bankruptcies followed. Hence, the law resulted in a reduction of for-profit home care providers after 2013. The lower prices came at the cost of a reduction in supply. The Danish Union of Public Employees estimates that the number of beneficiaries affected by the bankruptcies of for-profit providers exceeded 10,000 individuals between 2013 and 2016. In response, a new law has recently been enacted to reduce the number of bankruptcies and ensure better continuity of care for the beneficiaries of for-profit home care. 1.1.6 Price-setting LTC prices may be regulated, particularly when the responsibility of provision is delegated to the private sector. In such cases, the price setting will be grounded on estimates of input costs. Regulation will also have provisions for how and when prices are updated. 1.1.6.1 Is there regulation on the fees and prices of LTC provision? 1.1.6.2 Is there a regulated hourly or daily fee for home care services? 1.1.6.3 Is there a regulated hourly, daily, or monthly fee for community care services? 1.1.6.4 Is there a regulated hourly, daily, or monthly fee for care homes and nursing homes? 1.1.6.5 Is there an estimation of the unit cost of service, i.e., the cost per unit of provision of each service? The prices are determined on the basis of the local authorities’ provider’s average long-term costs. The local authority must always impose quality requirements. The quality standards and price requirements for both public and private services must be adopted by the local authority which follows up on the quality and management of the services provided at least once a year. Local authorities must make a clear distinction between their function as a local authority and their function as service providers and have to isolate the costs for home help services and make them transparent. 1.1.7 Financing This section focuses on the sustainability of financing arrangements. Due to population aging, most economies expect an increase their share of the population with higher care needs, pushing the demand for LTC services and hacking the financial sustainability of the system. The section discusses all sources of spending and financing, and how these will be affected by demographic dynamics. It should also cover acts or regulations modifying parameters (like eligibility rules) or setting goals that would affect financial results. Spending 1.1.7.1 Is LTC spending appropriately differentiated from other sources of spending in the government budget? 1.1.7.2 What are the levels of spending in LTC? What is the value of LTC spending in nominal terms, as a percentage of GDP, and as a percentage of total government spending? 1.1.7.3 Is there disaggregated data on spending for different components of LTC? 1.1.7.4 Can spending levels by disaggregated between national and state levels? 1.1.7.5 Can spending levels by disaggregated between regions? 1.1.7.6 What is the share of LTC spending assigned to its administration? I.e., spending for the administration of the system instead of payments to care providers, assistive devices, provision of meals, investment in facilities or other types of capital, etc? 1.1.7.7 Are there regular (annual, biennial, etc.) projections of LTC public spending, financing, and financial gaps? over the short and long terms? 1.1.7.8 If there are projections, are they available for subcategories of LTC spending and financing? LTC spending as a percentage of GDP and as a percentage of total health spending stands as one of the highest across EU countries. According to the 2021 European Commission Ageing Report, Denmark spent 3.5 percent of GDP on long-term care in 2019, almost twice the EU average. Long-term care expenditure was 51.8 percent of overall health expenditure versus an unweighted average of 23.4 percent across the EU27 + Croatia. Spending on LTC as a percent of GDP and as a percent of healthcare spending. Denmark (DK) in red. 70.00 Long-term care spending as % of healthcare NL 60.00 NO 50.00 DK SE 40.00 BE FI 30.00 IE LU IT CZAT LT FR 20.00 MT DE PL SKSI CY ES HU 10.00 LV RO EE BGHR PT EL 0.00 0.00 1.00 2.00 3.00 4.00 5.00 Long-term care spending as % of GDP Source: European Commission (2021b). Projections of LTC spending. With a view to ensuring the sustainability of public finances in the EU, the Economic Policy Committee of the European Commission produces long-term budgetary projections for components of social programs that are particularly affected by population ageing, including long-term care. The model used for the projections of LTC spending is based on assumptions about the characteristics of different age groups in the population including per capita expenditure, health status, need for care and type of care. When over time the (relative) size or features of these groups change, the long-term care expenditure changes in line with the change in those characteristics (European Commission 2021b). Assumptions. The assumptions behind the projections for Denmark in the 2021 European Commission Aging Report include only in-kind benefits (i.e., they exclude cash transfers). The number of potential beneficiaries (indicated as disable people) stands at 379 thousand people. According to the report , 58 thousand receive institutional care and 195 thousand receive home care (European Commission 2021b). However, the report does not contain detailed information about these services. Thus we cannot confirmed that these correspond to the category of aged LTC services that are the target of this report. Based on the assumptions described above and according to the European Commission Aging Report report, LTC expenditure in 2021 was 3.5 percent of GDP in 2019. The projections available up to 2070 are computed under different scenarios assuming changes in demographic, health, policies, and other parameters. Four scenarios assume no change in policies to isolated the effects of ageing, health status and the labour intensity of LTC on expenditure. • The "demographic scenario" aims to isolate the size effect of an ageing population on public expenditure on LTC. • The "base case scenario" focuses on the highly labour-intensive characteristic of the long-term care services by letting in-kind LTC benefits profile grow in line with GDP per hours worked. • The "high life expectancy scenario" assumes that life expectancy in 2070 is higher by two years than in the "base case scenario". • The "healthy ageing scenario" (relative decrease in morbidity) aims to capture the potential impact of assumed improvements in the health (or non-disability) status of the population. Projections of spending in LTC as a percent of GDP in Denmark. Increase in LTC spending as a percent of GDP (in percentage points) in Denmark and EU27 + Croatia. Change Change between between Scenario 2019 2030 2040 2050 2060 2070 2019 and 2019 and 2070 2070 (EU 27 (Denmark) + Croatia) Demographic 3.5 4.7 5.7 6.5 7.2 7.5 4.0 1.2 No policy Base case 3.5 4.6 5.7 6.4 7.1 7.4 3.9 1.4 change High life expectancy 3.5 4.7 6.0 7.0 7.9 8.5 5.0 1.7 Healthy Ageing 3.5 4.5 5.4 5.9 6.4 6.5 3.0 1.0 Shift to formal care 3.5 5.2 6.3 7.0 7.7 8.0 4.5 1.8 Coverage convergence 3.5 4.8 6.0 6.8 7.6 8.2 4.7 2.4 Policy change Cost convergence 3.5 4.7 5.7 6.4 7.1 7.4 3.9 2.3 Cost and coverage convergence 3.5 4.8 6.0 6.8 7.7 8.2 4.7 4.3 AWG combined AWG reference 3.5 4.6 5.6 6.2 6.7 6.9 3.4 1.1 scenarios AWG risk 3.5 4.7 5.8 6.6 7.3 7.7 4.2 3.4 Source: European Commission (2021b). The average projected increase in LTC spending as a percentage of GFP between 2019 and 2070 is 4 percentage points. The biggest increase is expected under the higher life expectancy scenario (5 percentage points). Other four “policy change� generate projections that capture varying assumptions of changing costs and coverage of LTC. • The "shift to formal care scenario" illustrates the impact of a 10-year progressive shift into the formal in-kind service sector of 1 percent per year of dependent population who has so far received only cash benefits or informal care. • The "coverage convergence scenario" assumes an extension of the formal/public coverage of in-kind care (institutional or home care) towards the average EU rate. • The "cost convergence scenario" is meant to capture the potential impact of a convergence in real living standards on LTC spending. • The “cost and coverage convergence scenario� combines the two previous scenarios. The average increase in LTC as a percentage of GDP across the four scenarios is 2.7 percentage points. The cost convergence scenario shows the lowest increase which is in line with the high coverage of LTC in Denmark when compared to other EU countries. Two more scenarios are based on combinations of the eight scenarios described above. • The "AWG reference scenario" combines the assumptions of the "base case scenario" and the "healthy ageing" scenarios. Specifically, it is assumed that half of the projected gains in life expectancy are spent without disability (i.e. demanding care), taking thus an intermediate position between the "demographic" and "healthy ageing" scenarios assumptions. • The "AWG risk scenario" integrates the assumptions of the "AWG reference scenario with those of the "cost and coverage convergence scenario". The expected increase in spending as a percent of GDP under these scenarios between 2019 and 2070 is of 3.4 percentage points (AWG reference scenario) and 4.2 percentage points (AWG risk scenario). Financing 1.1.7.9 What is the government institution tasked with the financial administration of the LTC system? 1.1.7.10 How is LTC financed? 1.1.7.11 How are the sources of financing distributed between a LTC insurance, general taxation, transfers from other public sectors, and government debt? 1.1.7.12 Is there public or private LTC insurance? Or is there a subaccount in the social insurance that applies to LTC? 1.1.7.13 If it exists, either as independent insurance or as a subaccount from social insurance, is LTC insurance mandatory? What is the regulation on the administration and investment of contributions to LTC insurance? 1.1.7.14 What percentage of financing comes from onetime or other type of limited transfers that will need to be replaced? The public system is funded mostly via taxation at the national and municipal levels; regions are not allowed to levy taxes and receive funding for health from the government and the municipalities. Of the total health expenditure in 2015, 83.6 percent came from government sources versus 78.4 percent for the EU. The remaining 16.4 percent of the spending was private; 13.7 percent was out of pocket. These are lower than the EU averages of 21.6 percent and 15.9 percent, respectively (WHO 2020a). 98 Municipalities are responsible for allocating resources; they obtain funding from the national government, local taxes and equalization money from other municipalities. Universal health coverage is ensured via a tax-based, decentralized system. The system provides full coverage, and primary, specialist and hospital care are free of user charges for most services. No co-payments are applied for using long-term home-based care services (cleaning and personal care), although users who choose private providers can purchase additional optional services. Temporary home care (which is not a LTC service) may be subject to co-payment above a defined income levels (WHO 2020a). Care in residential facilities is, subject to fees. Beneficiaries pay rent for the units they inhabit, which can be quite considerable depending on the municipality. The charges are based on the size of the apartment. In addition, residents in nursing homes pay fees to cover the costs of some services such as laundry, meals and medication. Help with personal care and domestic tasks are not subject to fees. Nursing and other care costs are free of charge. During the past decade, however, the Danish Alzheimer Association has challenged this concept as not being particularly specialized to deal with the specific needs of people with Alzheimer’s disease and other forms of dementia. In addition, out-of-pocket payments are required for some outpatient care services such as physiotherapy and psychotherapy, some dental care procedures, some medical devices such as hearing aids and prescription drugs up to a maximum expenditure according to the income of the beneficiary. 1.1.8 Quality regulation, monitoring, and assurance This section explores how quality is regulated, monitored, and assured, for various stakeholders. The subheading “regulation of quality� is focused on how quality is defined in the law and what government institutions are tasked with its regulation. The subheadings “quality monitoring and assurance� discusses two characteristics of quality. First, it discusses the different methods and indicators used to evaluate the quality level of LTC. Examples of methods include surveys from beneficiaries and carers, ratings from beneficiaries, results from inspections, measurements from administrative data, etc. These methods will be used to measure several quality indicators, including the quality of life of the person with care needs, health indicators such as the levels of independence and the speed of deterioration or even improvement of health conditions, the respect of human right, etc. Second, it discusses how quality levels are assured. Assurance may be based on the indicators used to monitor quality. However quality assurance may also rely on other mechanisms (e.g., professional certifications, standards of provision, and market mechanisms). Regulation of quality 1.1.8.1 Is there a specific institution that is responsible for regulating, tracking, and assuring LTC quality? 1.1.8.2 Is there regulation defining legal standards for the provision of LTC that affect its quality? 1.1.8.3 Is there a published institutional methodology to assess LTC quality? 1.1.8.4 Is the regulation of quality established at the national level or is it delegated to subregions? 1.1.8.5 How does the quality regulation for allied services such as health care affect LTC quality? The Danish Institute for Quality and Accreditation in Healthcare oversees safety and quality standards for private hospitals, primary care practices and pharmacies. The municipalities are responsible for service and quality assurance but need to comply with the standards set by national framework legislation. As such, municipalities must ensure full transparency and clear separation between their function as providers and as the authority supervising quality (WHO 2020a). Each year the municipalities determine quality standards for home help, rehabilitation, and training services. These are publicly available, and used in tenders and in audits. The purpose of quality standards is to ensure that citizens get professional, dignified and qualified treatment in the event that they need help and support. Municipal audits include at least one unannounced visit to nursing homes and care homes (Kvist 2018). The transparency reform aims to build a new national and up-to-date platform for collecting health data that will allow good practices and priorities in quality assurance to be identified and promoted. In addition, the national, regional and municipal governments established eight national goals for the health system. The programme aims to improve quality and efficiency by implementing quality improvement teams, enhancing beneficiary involvement and monitoring further performance (WHO 2020a). For general monitoring, municipal governments and the Ministry for Social Affairs and the Interior have developed 23 impact and background indicators as part of the agreement on care for older people. Quality monitoring and assurance 1.1.8.6 What are the methods and indicators used to monitor the performance of the LTC system? 1.1.8.7 Are there surveys measuring the satisfaction of service recipients or the state of carers? 1.1.8.8 Are there indicators of waiting times for people entitled to care, for example, between approval for care and access to care? 1.1.8.9 Are there indicators of changes in needs, accidents, preventable deaths, and other health conditions and health markers of care users? 1.1.8.10 Are there inspections to residential and community care facilities to assess their quality? 1.1.8.11 What indicators used for monitoring quality are used to assure quality? 1.1.8.12 Are there information-related mechanisms for the promotion of quality? These can include education and knowledge management, public reporting, complaints channels, surveys, or others. 1.1.8.13 Can consumers access ratings from individual providers? 1.1.8.14 Are there grievance redress mechanisms for care beneficiaries and are complaints analyzed systematically to assess the quality of LTC? 1.1.8.15 Are there enforcement mechanisms for providers that do not fulfill quality standards? 1.1.8.16 Are there market mechanisms used for the promotion of quality? This can include subsidies, regulation of payment schemes related to performance, public procurement, and others. 1.1.8.17 Are there pay-for-performance mechanisms to promote quality? 1.1.8.18 Are there mechanisms to boost competition on quality? 1.1.8.19 Are there mechanisms based on minimum standards, such as licensing requirements or certifications of carers? 1.1.8.20 Are there educational mechanisms such as specializations or degrees for the personal involved in LTC? Quality monitoring The information on quality standards is used to provide a detailed picture of local services and are intended to be sufficiently objective and transparent to allow users to evaluate the performance of the provider themselves. 23 impact and background indicators developed as part of the agreement on care for older people also provide important information on the state of care. Most indicators are monitored through administrative data and biannual user surveys. Denmark Statistics provides access to Elderly Statistics which contain information about the impact of services, users and referrals for services (home care, rehabilitation, care homes, and rehabilitation), and surveys of user satisfaction, among other. The statistics are a part of a cross-public cooperation, intended to ensure coherent documentation of important areas of municipal service, as well as to increase the comparability of the services provided in the different municipalities. The statistics are used to determine impact targets, frameworks and results requirements for key management initiatives and are comparable from 2008 onwards (Denmark Satistics 2019). Surveys of user satisfaction are available for LTC services. For example, when asked about the quality and stability of their home help, a large majority say they are satisfied or very satisfied. Between 83 and 86 percent said they were satisfied with personal and practical help given to them either in their own home or in a nursing home in 2015. Similarly, 74-85 percent say they are satisfied or very satisfied with the timeliness, stability and uniformity of services. Between 65 and 75 percent are satisfied with the number of different helpers in the services provided (Kvist 2018). Beneficiaries can also access information on the waiting times and performance of hospitals and other providers from general practitioners or from specialized websites maintained by the Ministry of Health, the Danish Health Authority or the administrative regions. Stakeholders also keep track of other indicators of quality such as waiting times for placement in a care home, rates of falls, and prevalence of pressure ulcers. These can be disaggregated by location and sometimes the information is available at the institutional level. There is also data for several indicators that provided a general picture of the state of health and healthcare services that are particularly connected to LTC in Denmark. Amenable mortality, defined as avoidable deaths that could have been prevented by providing appropriate health interventions, at 99 deaths per 100,000 people in 2014, is among the lowest in the EU. This number was 85 for women and 114 for men, both lower than the respective EU averages of 97.5 and 158 deaths (WHO 2020a). In 2015, 4.1 percent of hospitalizations for common chronic conditions (diabetes, hypertension, heart failure, chronic obstructive pulmonary disease and asthma), equivalent to about 600 discharges per 100.000 population could have been avoided. These numbers are among the lowest in the EU, 5.5 percent of preventable hospitalizations for chronic conditions and about 1,000 discharges per 100,000 population. Inpatient average length of stay, 5.1 days for women and 5.8 for men, was also below the rest of the EU (WHO 2020a). The number of bed-days attributable to delays in hospital discharge, which often result from administrative delays or waiting lists for home-based or residential services, was 5 per 1,000 population, also the lowest among countries reporting this data. A high percentage of eligible high-volume surgical procedures is performed as day surgery, including 98.9 percent of cataract surgery, 84.8 percent of inguinal hernia repairs and 54.9 percent of tonsillectomies. Overall, hospital inpatient discharges were 15 per 100 population, about the same as the EU average (WHO 2020a). The average waiting time varies between the 98 municipalities, ranging from 0 in 12 municipalities to 97 days in the municipality of Egedal. 33 municipalities have a shorter waiting period than 2 weeks, and 9 municipalities have a longer average waiting time than prescribed by the guarantee of 2 months (Kvist 2018). Quality assurance Freedom of choice. Beneficiaries have the right to seek treatment anywhere if their administrative region does not provide a service delivered elsewhere. They also have the right to participate in decision-making, to receive personalized services and to complain if they consider services to be suboptimal (WHO 2020a). Inspections. Providers are subject to pre-announced or unannounced inspections from municipal representatives. In addition, officers representing the Danish Health Authority carry out yearly unannounced visits to long-term care facilities. Complains. Beneficiaries have the right to complain if they consider the quality of care or eligibility assessments to be unsatisfactory. Municipal authorities need to respond within four weeks. Appeals can be pursued through the National Social Appeals Board. Municipalities review about 20,000 decisions per year. About 500 are appealed, attesting to the high standards of quality applied by municipalities (WHO 2020a). User satisfaction is routinely collected nationwide. The National Danish Survey of Patient Experiences collects data on the inpatient and outpatient satisfaction with hospital care through questionnaires are sent to beneficiaries a few months after discharge. Regarding long-term care, the quality of user satisfaction is collected every two years from a representative sample of beneficiaries 67 years of age or older. Between 2009 and 2015, 2,286 interviews were carried out with older individuals who received home help in their own homes or in nursing homes. This data are used to inform activities related to providers’ inspection, regulation and accreditation and to provide feedback to practitioners and to inform quality assurance (WHO 2020a). Maximum waiting time. Once a person has been referred to a nursing home, the waiting time must not exceed two months unless the person wants to live in a nursing home of his or her choice or in another municipality, in which case delays could be longer. There are also market mechanisms used for quality assurance. For example, legislation on free choice of provider in 2003 prohibits monopolies in service provision and constrains municipalities to ensure a choice between at least two providers, who compete based on quality and price. Thus, individuals entitled to long-term care have free choice of providers, including residences for older people, gated communities, assisted living units, nursing homes or day-care centers (WHO 2020a). 1.1.9 LTC workforce Policies to support the workforce and requirements. This section covers the regulation that affects the LTC workforce, including the existing requirements for formal LTC workers (e.g., licensing and certificates), the policies and programs available to support formal and informal carers (e.g., training programs, cash transfers, or respite), and formal mechanisms available to understand their needs (e.g., surveys). The size of the LTC workforce is addressed in the Provision level. 1.1.9.1 Is there a certificate system for careers based on education, training, or years of experience? 1.1.9.2 Are there training programs to support formal or informal carers? 1.1.9.3 Are there cash benefits to support formal or informal carers? 1.1.9.4 Is there a paid leave program to support formal or informal carers? 1.1.9.5 Are there respite programs to support formal or informal carers? 1.1.9.6 Are there counseling and mutual support programs for formal or informal carers? 1.1.9.7 Is there online free information to support carers? 1.1.9.8 Are there surveys to assess the needs of formal or informal carers? 1.1.9.9 Is there information to measure and assess the turnover of care workers? 1.1.10 Emigration and immigration Emigration can affect the composition of the household and the availability of familial care. For example, emigration can generate skip households where younger adults emigrate to urban areas for work while older people stay in rural areas to care for grandchildren. Similar dynamics can occur due to international migration. Emigration can also affect the availability of paid carers when there are significant flows of people corresponding to working-age adults. Conversely, immigration can provide an influx of people that in many cases expand to a significant share of the care workforce. This section describes the policies that affect the flows of people capable of providing care. 1.1.10.1 Are there significant migratory flows (rural-urban, across cities, or countries) affecting the demographical composition of the country or the composition of regions inside the country? 1.1.10.2 Are there policies that influence the flows of migrants in the country or in particular regions? 1.1.10.3 Are there policies that target migrant groups that are overrepresented in the LTC sector? 1.1.11 Challenges according to stakeholders This section provides a space to describe the view of stakeholders on the functioning and main challenges for the country’s LTC system. It should discuss the main challenges that the system’s stakeholders would like to incorporate to the political agenda or LTC strategy. The section may feed from surveys and interviews with policy makers, providers, non-profit advocates, carers, and dependent individuals. 1.1.11.1 What are the main issues that stakeholders discuss as a barrier for the development of the LTC system in the country? 1.1.11.2 What are the main issues that the LTC strategy should address moving forward according to its stakeholders? List of key indicators for Section 1.1, Policy domain – Supply perspective. Indicate if the following indicators were identified for the respective economy and described in the sections above. Indicator Related Indicator/1, /2 Check number subheading 1.1.1 1.1.1 List of main legal documents that legislate the LTC sector. � 1.1.2 1.1.1 List of ministries in charge of the LTC sector stewardship. ☒ Main legal document or description of the process determining the 1.1.3 1.1.5 � licensing process for providers. Main legal document or description of the process determining the 1.1.4 1.1.6 ☒ price setting legislation for LTC. Value of LTC public spending. The total national amount spent in 1.1.5 1.1.7 LTC, including public and private, in local currency or as percent of ☒ GDP. Value of LTC spending in local currency or as percent of GDP by type of LTC service. Indicator 1.5 disaggregated by type of LTC 1.1.6 1.1.7 � service. Ideally, the disaggregation should match across key indicators. Value of LTC public spending by financing source. Indicator 1.5 1.1.7 1.1.7 disaggregated by the source of financing, including public, � beneficiaries and their sponsors, donations, and other sources. 1.1.8 1.1.8 Legal document determining the regulation of quality. � 1.1.9 1.1.9 Legal document or process determining the certification of carers. � Legal documents stipulating the benefits or programs for formal 1.1.10 1.1.9 � carers or thorough list of benefits or programs to support them. Legal documents stipulating the benefits or programs for informal 1.1.11 1.1.9 � carers or thorough list of benefits or programs to support them. /1 The population age groups can be defined using the UN age thresholds (15-64 and 65+) or local definitions. /2 Ideally, formal and informal care should be measured using the definition indicated in the definitions sections of the toolkit. Information gaps in Section 1.1, Policy domain – Supply perspective. This section provides a space to describe the information gaps identified during the completion of section 1.1. This country example was prepared as a test for improving the long-term care assessment toolkit and does not comprehend a thorough and accurate assessment of LTC in Denmark. Among other indicators, the assessment would have been enriched by identifying the following information listed in the survey: • A detailed list of the legislation that regulates LTC in the country. • A description of the licensing process for new and existing providers better describing what they are and are not allowed to do. • A description of LTC spending by type service to better understand the share of each service in the total budget. • A discussion of the regulation that determines measurement and assurance of quality and affecting formal and informal carers. • A discussion of literature describing the current national discussion of LTC in the country. 1.2 Demand perspective 1.2.1 Demographic trends Current and future needs for LTC in an economy are to a great extent determined by its age composition, as older- age individuals are more likely to experience needs for support in activities of daily living. The shift in the age distribution of a country's population towards older ages, known as population aging, is typically measured using population age-group ratios, for example, the ratio of people aged 65 and over to the total population. Other important indicators include the old-age dependency ratio (the ratio of people aged 65 and over to the working age population defined as those aged 15 to 64) and the median age of the population. Population ageing is mainly driven by decreasing fertility and increasing longevity, and to a lesser extent by migration in some locations. Thus, an assessment of demand should also look at these factors. 1.2.1.1 How has fertility changed over the last decades? What are the projected changes in fertility? 1.2.1.2 How has life expectancy changed over the last decades? What are the projected changes in life expectancy? 1.2.1.3 How have fertility and life expectancy affected the age distribution of the population? 1.2.1.4 What are the historical and projected trends for the old-age dependency ratio, the share of people aged 65 and over, the share of people aged 85 and over, and the population’s median age ? 1.2.1.5 Are immigration or emigration important factors affecting the age structure of the economy? 1.2.1.6 Are there systematic differences for these indicators across regions? For example, across rural and urban locations? The process of population ageing in Denmark started decades ago. The median age of the Danish population has grown from 31.7 in 1950 to 42.3 in 2020 and it is projected to reach 44.2 in 2050. Likewise, the share of the old age population (typically those aged 65 and above) is expected to keep growing, from 20.2 percent of the total population in 2020 to 24.2 percent in 2050 (UN 2019). Demographic indicators for Romania and EU27. Change Region Sex 1950 1980 2000 2020 2050 2070 2020-70 Denmark Median age 31.7 34.3 38.4 42.3 44.2 44.6 2.3 Average EU27 Median age 29.4 32.5 37.4 43.0 48.4 49.1 6.1 Denmark Share of population aged 65+ 9.0 14.4 14.8 20.2 24.2 26.5 6.3 Average EU27 Share of population aged 65+ 8.2 12.4 14.7 19.9 29.3 30.4 10.6 Denmark Share of population aged 80+ 1.2 2.8 4.0 4.7 9.5 9.6 5.0 Average EU27 Share of population aged 80+ 1.1 2.1 2.9 5.3 10.6 13.4 8.1 Denmark Old-age dependency ratio 13.9 22.2 22.3 31.7 40.4 45.9 14.2 Average EU27 Old-age dependency ratio 12.6 19.1 21.8 30.9 52.0 54.9 23.9 Source: UN (2019). The old-age dependency ratio (the ratio of the population aged 65 and over divided by the working-age population) has also been increasing since the 1950s. The increase in the ratio was of 9.4 percentage points in the period 2000-2020. Based on UN projections the old-age population is expected to reach 40.4 percent of the working population by 2050. Across all indicators in the table above except for the share of its population aged 80+, Denmark is older that the average EU member, however, the rate of ageing will be slower during the next decades. Like other European countries, population ageing is more pronounced in rural areas. Smaller and more remote localities have the highest shares of residents 65 years or older and highest average age; the areas with the highest percentage of older people are Bornholm (27.3 percent), Vest- og Sydsjælland (22.3 percent) and Nordsjælland (21.8 percent). Regarding absolute numbers, most older people reside in larger, more densely populated cities, which compensates for the lower proportion of older individuals. As a result, the larger metropolitan areas must respond to the needs of a larger group of older individuals (WHO 2020a). Life expectancy in Denmark is expected to continue increasing over the next decades. Currently, life expectancy at birth in Denmark stands at 80.7 years, very close to the EU’s average of 80.05 years. As a benchmark, the region’s highest and lowest life expectancy at birth are 74.9 (Bulgaria), and 83.4 (Spain). The same pattern emerges when looking at life expectancy at 65 years of age, which stands at 19.77 for the country that ranks 16th across the EU27. Both measures are projected to increase sharply over the next decades, reaching 85.4 and 22.64 by 2050, respectively. The expected increase in life expectancy is also very close to region’s average increase. Female life expectancy at birth is 3.8 years higher than the equivalent figure for males in Denmark, standing at 83.3 and 79.5 respectively. Likewise, female life expectancy at 65 stands at 21.0 compared to 18.5 years for males. Figures based on EURSTAT (European Commission 2022) slightly differ from those provided by the UN (2019), however, the expected trends and rankings are very close. Fertility rates are higher than the EU average, but they are still below replacement fertility rates. Fertility has bounced up since the 1980s, and it is projected to keep slightly increase from 1.76 in 2020 to 1.80 in 2020 (UN 2019). The country’s historical and projected population growth is characterized by slow but continuous growth. The country’s total population grew from 4.4 to 5.8 million people at an average growth rate slightly above 2 percent between 1950 and 2020. Steady growth is projected to continue although at a slowly declining rate over the next decades, reaching 6.2 millions by 2050 (UN 2019). The expected population growth is due mostly to immigration (WHO 2020a). A positive net migration flow helped maintaining a growing population with rates that varied between 2 and 6 percent of Denmark’s total population. The number of people arriving to Denmark has been consistently higher than the number of people departing from it. The gap between both figures reached a peak in 2015 (78,5 thousand people) and has been decreased since. Although Eurostat does not provide data beyond 2019, the Denmark Statistics website indicates that migratory flows grew during 2021. Denmark, immigration and emigration by year. 100.0 78.5 74.4 80.0 68.4 68.6 64.7 66.5 60.3 60.4 61.4 52.7 56.4 Thousands 60.0 54.4 43.7 43.3 44.4 44.6 40.0 20.0 0.0 20122014 2015 2016 2017 2018 2013 2019 Emigration Immigration Source: European Commission (2022). 1.2.2 Epidemiological profile Although the age structure of a country is a good predictor of LTC needs, the demand of LTC is ultimately defined by the interaction between the environment and the physical and mental capacity of individuals. The main indicator used to approximate the LTC needs of individuals are their limitations in activities of daily living (ADLs) and instrumental ADLs (IADLs). Several other indicators can also be used to approximate the capacity of individuals in a population. These indicators can include measurements of disability, mental health, and other health conditions and health markers. To the extent possible, the description should distinguish the source of the data, as this information is essential to interpret the extrapolation of results. In addition, when possible, it is important to include historical data and projections for the data, as well as a disaggregation by age group and sex. 1.2.2.1 Are there predetermined indicators established by regulation to determine the LTC needs of individuals in the specific country? 1.2.2.2 Is there information about the frequency of limitations in ADLs or IADLs in the population? 1.2.2.3 Is there information about the frequency of limitations by subdomain of ADLs (feeding, dressing, bathing, transferring, toileting, and continence) and IADLs (food preparation, housekeeping, laundry, shopping, long-distance walking, money handling, using the telephone, and taking medications). 1.2.2.4 Is there information on the frequency of other indicators that are typically used to measure the capacity of individuals, A comprehensive list would contain the bullets included below: 1.2.2.5 Cognitive impairments. For example, measurements of sense of time, sense of space, attention span, short-term memory, long-term memory, ability to name objects, ability to repeat sentences, and the abilities to understand, write, read, and copy. 1.2.2.6 Cause of disabilities, including physical and mental indicators. 1.2.2.7 Sensory functional limitations, for example, seeing and hearing. 1.2.2.8 Mental illness. 1.2.2.9 Dementia. 1.2.2.10 Cause of death. 1.2.2.11 Health markers. For example, nutrition, weight loss and loss of appetite, incidence of acute illness in the prior 3 months, neuropsychological problems. 1.2.2.12 Factors that interact with cognitive and physical needs such as loneliness. The proportion of the older-age population self-reporting long-term restrictions in ADLs in Denmark is 41.7 percent versus 47.9 percent in the EU28 (European Commission 2020). The advantage compared to the average EU country persists after controlling by the age distribution of the population. The age standardized share of the population with at least one limitation in ADLs was 3.3 percent in Denmark according to data from EHIS 2 (survey rounds from 2013-2015). In comparison the value was 8.4 percent when looking at the whole EU. According to the same data, the age standardized share of the population with at least one limitation in IADLs was 14.4 percent in Denmark compared to 25.2 percent for the whole EU (Gaertner et al. 2019). Women and individuals with lower education present higher prevalence rates of limitations in ADLs. 33.1 percent of women reported limitations in ADLs in Denmark, compared to 28.8 percent of men. This comparison is not age-standardized hence it does not account for the longer life-expectancy of women. In addition, 36.8 percent of people with lower educational self-reported limitations in ADLs compared to 33.1 percent of those with medium educational level and 26.0 percent of those with higher educational level (Gaertner et al. 2019). Data from 2019 on life expectancy in good self-perceived health at age 65 shows Denmark very close to the average across EU members, 11.3 versus 10.3, respectively. The figure is higher for Danish women (11.8 years) than for men 10.7. Which suggests that the higher prevalence of limitations in ADLs is compensated by a higher life expectancy (European Commission 2022). Noncommunicable diseases are the leading causes of mortality and morbidity. Among people 70 years or older, cardiovascular diseases remain the leading cause of death and loss of disability-adjusted life-years, although Alzheimer’s disease has become the top cause of both for women. The leading determinants of years lived with disability are low back pain, diabetes and age-related hearing loss, whereas the top risk factors associated with disability are mostly behavioural and metabolic, such as smoking, high fasting plasma glucose and high systolic blood pressure (WHO 2020a). Leading causes of death, DALYs, YLDs, and risk factors associated with disability. Measure of death or disability Female Male Alzheimer’s disease Ischaemic heart disease Top determinants of disability- Ischaemic heart disease Chronic obstructive pulmonary disease adjusted life years among people 70 years or older Stroke Stroke 70 years or older Chronic obstructive pulmonary disease Lung cancer Lung cancer Alzheimer’s disease Alzheimer’s disease Ischaemic heart disease Top determinants of years lived with Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease disability among people 70 years or Ischaemic heart disease Stroke older Stroke Lung cancer Lung cancer Diabetes Low-back pain Diabetes Top determinants of years lived with Diabetes Low-back pain disability among people 70 years or Age-related hearing loss Age-related hearing loss older Falls Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease Stroke Smoking Smoking Top risk factors associated with High fasting plasma glucose High fasting plasma glucose disability among people 70 years or High systolic blood pressure High systolic blood pressure older High body-mass index High body mass index High LDL cholesterol Alcohol use Source: WHO (2020). Alcohol consumption remains very high compared with the rest of the EU. The smoking rates were among the highest in the EU at the beginning of the century but they have sharply declined due to aggressive public health campaigns. Lung cancer is the second most frequent cause of death overall, whereas chronic obstructive pulmonary disease is a leading cause of death and disability among both women and men (WHO 2020a). The percentage of people living with dementia in 2012 was 1.53 percent, about the same as the 1.55 percent European average. This translates into 85,562 people, of which 65 percent are women. Among people 60 years and older, the prevalence of dementia in 2018 was about 7 percent, similar to the rest of the EU. The rates of depression for women and men 65 years or older, 7.3 percent and 5.2 percent respectively, were below EU levels (WHO 2020a). 1.2.3 Eligibility Eligibility rules define who is entitled to LTC services and how much they have to pay for the services. Eligibility rules are typically based on the individual’s need levels, age, their (or their family) income levels, wealth or assets, and contributions to LTC or social insurance, among others. 1.2.3.1 What are the main rules determining eligibility for state financed LTC programs? 1.2.3.2 Is eligibility for LTC based to the needs of the person? 1.2.3.3 What is the protocol in place for the assessment of needs related to eligibility? 1.2.3.4 What is the frequency of needs assessments for people receiving services? 1.2.3.5 Is eligibility for LTC programs related to the age of the person? 1.2.3.6 Is eligibility for LTC related to economic conditions (income, assets, wealth) of the person? 1.2.3.7 Are the family of the potential care recipient and their financial condition considered for eligibility? 1.2.3.8 Is the residence composition of the potential care recipient’s household considered for eligibility? 1.2.3.9 Does the national framework for health insurance or pensions affect the eligibility of LTC? 1.2.3.10 Are there programs or outlets with information to communicate the population on the availability of LTC resources and conditions for eligibility? 1.2.3.11 Do users have the right to complain if they consider that their eligibility assessment was unsatisfactory? There are different ways for accessing long-term care. General practitioners can initiate the process. They refer the patient to a social worker for initiating the appropriate paperwork. Nurses or community nurses can contact a general practitioner, a community centre or a private office. Patients in hospital care who need long-term care can be referred to a general practitioner, who receive discharge summaries directly from hospitals and is responsible for following up with beneficiaries. Alternatively, beneficiaries discharged from hospitals can receive follow-up home visits from general practitioners or nurses. These visits take place one week from discharge and repeated at three and eight weeks after discharge if additional support is considered necessary. Each visit lasts about one hour and covers medication review, a general health and functional check-up and needs assessment for follow-up care such as home support or rehabilitation (WHO 2020a). Eligibility for long-term care is based entirely on needs assessment carried out by the municipalities. There are no thresholds or minimum dependence required for in-kind or cash benefits. Access is based on the principle of free and equal access, regardless of income, wealth, age or household situation. Municipalities are responsible for responding to the needs of dependent older people. The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements (WHO 2020a). The needs assessment for long-term care is multidimensional in nature and generally captures a wide range of aspects related to an older person’s situation and well-being. These include an assessment of functional impairments (using the Barthel index), of general welfare and social and family context, material and home conditions and an overview of needs for medication, rehabilitative support and referrals to health providers (WHO 2020a). The assignment of service type and intensity depends on the services provided by each municipality and the discretion of those carrying out the needs assessment. Enabling older people to remain in their homes is strongly emphasized. Standardization of care services. Clients needing formal care are further assessed by a home care manager, and the resulting care plan ends up as a contractual specification for needed services. There exists no predefined classes of dependency, but the applicant will be classified in a continuum of dependency according his/her specific individual needs (Schulz and Berli 2010). Local Government Denmark has published a set of common terms for standardizing the categories of care services and care needs among all municipalities. The Common Language system describes four levels of functional ability, ensuring that beneficiaries receive equal treatment (at least in terms of time allocation) regardless of the municipality in which they reside and the care professional carrying out the assessment. The implementation of the common language is voluntary (WHO 2020a). All older individuals deemed eligible to receive LTC based on their needs are entitled to receive care at no cost for home- based care. This encompassing welfare model enjoys broad public support and older people broadly utilize long-term care without stigma. If the client disagrees with this service allocation, it can be appealed. The municipal shall consider applications for assistance on a case-by-case basis, subject to an assessment of the assistance needed for the tasks that the applicant is unable to perform (Schulz and Berli 2010).. The municipal council shall prepare a plan containing information about the functions covered by the assistance, the object of the assistance, and the period during which assistance is to be provided. The plan shall be completed in cooperation with the applicant and will be returned to the applicant in connection with the decision. For nursing home residents, the plan shall also include information about the overall program for the care and attendance to be provided to the applicant (Schulz and Berli 2010). 1.2.4 Coverage The interaction between the needs of the population, eligibility rules, and the availability of LTC services will result in a level of coverage. Several measures of coverage are important including, a general approximation to coverage (what percentage of older people receive care), the coverage of the demand of care (what percentage of older people with care needs receive care), and the unmet demand (what percentage of older people with care needs does not receive care). All these measures can be further broken by levels of needs and demographic and socioeconomic indicators. It is important to note that coverage indicators may double count users, for example, when the information is based on the sum of people receiving services, as one individual may receive more than one service. For comparability, the assessment should discuss if this issue applies to the data. General coverage 1.2.4.1 Is there administrative or survey data available to quantify the utilization of services by the older-age population? 1.2.4.2 What is the percentage of the older-age population that receives LTC? 1.2.4.3 What is the percentage of the older-age population that receives LTC broken down between formal and informal? 1.2.4.4 Is there information to break down coverage indicators by levels of needs? 1.2.4.5 Is there information to break down coverage indicators by demographic and socioeconomic indicators like sex, age group, income, wealth, education, or location (urban vs rural)? Denmark remains one of the countries with the most comprehensive long-term care systems in the EU, with universal health coverage regardless of contribution and is not tied to membership in any insurance scheme. However, the provision has declined in the past decade. Particularly, the number of people in residential facilities and receiving home care has declined in both absolute and relative numbers in this decade. Policies in the pipeline (see assessment of policy reforms below) are likely to result in more resources in home help. However, as most LTC is provided free of charge and is not dependent on work record, social divisions have not emerged (Kvist 2018). The weekly number of home help hours has gone down. Total home help went down by 18 percent from 656,142 weekly hours in 2010 to 538,950 in 2016 − equal to 6 million fewer hours of home help annually. In particular practical help has gone down by 33 percent, from 135,970 hours in 2010 to 91,691 in 2016 (Kvist 2018). The number of persons receiving home help decreased by 12 percent, from 162,769 in 2011 to 142,865 in 2016. This can only in part be ascribed to elderly people having generally better health and functional capacities (Kvist 2018). The share of the elderly living in nursing homes and care accommodation is falling. From 2010 to 2016, for example, the share of the elderly above 75 years in institutional care fell from 15 percent to 12 percent. The same decline can be noticed for other age groups. There were 1,385 persons on a waiting list for nursing home and care accommodation in 2016, i.e. at a level that has remained stable since 2010 (Kvist 2018). Covered demand and unmet demand (care gap) 1.2.4.6 Is there administrative or survey data available to quantify the utilization of services by the older-age population with LTC needs? 1.2.4.7 What is the percentage of the older-age population with needs that receives LTC? 1.2.4.8 Can measures of coverage for the older-age population with needs be broken down between formal and informal, community and residential care? 1.2.4.9 What is the percentage of the older-age population with needs that do not receive care? 1.2.4.10 Can measures of coverage or unmet needs in the older-age population with needs be broken down by need levels? 1.2.4.11 Can measures of coverage or unmet needs in the older-age population with needs be broken down by socioeconomic indicators? 1.2.4.12 Do people entitled to care based on eligibility criteria receive LTC services, or are services not provided despite eligibility, for example, due to budget constraints, availability of carers, or other reasons? People in need of care and help not receiving any assistance from the municipalities are rare. Thus, the number of people receiving practical and personal help may also be an indicator for the demand of care (Schulz and Berli 2010). 1.2.5 State of the pensions and social assistance programs To a great extent, the development of a pension system and other social assistance programs will affect the performance of the LTC system. For example, the programs available and how well they cover the population will set expectations for the LTC system. In addition, pensions may represent an important source of income for older- age people, defining their ability to pay for LTC services. 1.2.5.1 Is there a public pensions system? 1.2.5.2 Are there other social assistance programs that target or mainly affect the older-age population? 1.2.5.3 When were these programs created? 1.2.5.4 What is the coverage level of these programs? 1.2.5.5 Does the extent of these programs influence what is expected from the LTC system? Denmark has a public pension scheme consisting of a basic pension and a means-tested pension supplement that is paid to the financially most disadvantaged pensioners. There is also a mandatory occupation pension scheme based on lump- sum contributions. In addition, compulsory occupational pension schemes negotiated as part of collective agreements or similar cover about 90 percent of the employed work force (OECD 2019). The public pension scheme is universal and covers the entire Danish population. Entitlement to pension is acquired on the basis of residence in Denmark and is thus not conditional on payment of contributions. The public retirement age is currently 67 years but will be increased gradually to 68 by 2030. Beyond 2030, increases in the retirement age will be linked to increases in life expectancy. A full public old-age pension requires 40 years of residence until 1 July 2025. Thereafter a full public old age pension requires 9/10 years of residence from the age of 15 to the public retirement age. Shorter periods qualify for a pro-rated benefit (OECD 2021). Pension rights with occupational pension schemes are accrued on a what-you-pay-is-what-you-get basis. The longer the working career, the higher the employment rate, the longer contribution record and the higher the contribution level, the greater the pension benefits. 1.2.6 State of the healthcare system This section should discus healthcare and other allied services that cover, support, or interact with LTC services. In some cases, these programs will act as a de facto LTC service covering gaps in the LTC system. This context is more likely to arise in economies with underdeveloped LTC systems that cannot meet the demand for care. However, even in developed systems, there are strong interactions between LTC and healthcare services. The discussion in this section should not be focus on the integration between LTC and healthcare. This assessment is developed in the Policy level. 1.2.6.1 Is there a public healthcare system? 1.2.6.2 When was the public health care system created? 1.2.6.3 What is the coverage level of the health care system? 1.2.6.4 Are there healthcare services that supply to people with LTC needs? The state of health services puts the bar high for LTC in terms of what is expected from the government. Public funding accounted for 84 percent of all health spending (above the EU average of 79 percent), with the remaining spending mostly paid directly out of pocket by households, mainly for pharmaceuticals and dental care. Health spending in Denmark has increased at a moderate rate over the past 10 years. At EUR 3,695 per person in 2017, spending is more than 25 percent higher than the EU average. Health spending accounted for 10.1 percent of Denmark’s GDP in 2017, above the EU average of 9.8 percent (European Commision 2019). Danish residents have universal access to a wide range of health services free of charge. Overall, Danish people report very low unmet needs for medical care. However, unmet needs are higher for services that are less well covered by the public health insurance system such as dental care, particularly for people on low incomes. Financing for the health system is from general proportional income tax for the central budget and proportional income tax at the local level. Out-of-pocket spending is low overall, accounting for only 14 percent of all health spending in 2017 (compared with an EU average of 16 percent), but still plays a major role in paying for medicines, dental services, physiotherapy and glasses. While a significant proportion of the population are covered by some private health insurance (approximately 40 percent by complementary private insurance and 35 percent by duplicate private insurance), spending through voluntary health insurance amounts to less than 3 percent of all health spending. 1.2.7 Intergenerational contract This section discusses how familial traditions and government policies affect the household structure and what is expected from the State in terms of LTC. Many of these elements will be repeated in the Household Structure and Gender Domain. This section should be guided by macro a perspective, discussing how these issues interact with LTC policy while the next sections will be focus on practical considerations, such as provision and gender perspectives. 1.2.7.1 Are there informal familial customs, cultural values, or traditions that affect the organization of LTC? E.g., LTC is expected to be provided by the eldest child, daughters, spouses? 1.2.7.2 Are there policies to support carers that engage or would pursue activities in the labor market but are restricted due to caring responsibilities? 1.2.7.3 Are there policies to support the integration of women into the labor market? In general, social care systems in European Member States can be grouped into three categories: (1) the state responsibility model, (2) the family care model and (3) the subsidiary model. The state responsibility model is characteristic for the Scandinavian countries, including Denmark. From the point of view of the population, personal care is primarily the task of the state (municipality). Nevertheless, a great part of help with practical duties (garden, financial tasks etc.) is provided by members of the family, too (Schulz and Berli 2010). List of key indicators for Section 1.2, Policy domain – Demand perspective. Indicate if the following indicators were identified for the respective economy and described in the sections above. Indicator Related Indicator/1, /2 Check number subheading Current and projected old-age dependency ratio. Ratio between 1.2.1 1.2.1 the old-age population to the working-age population multiplied by ☒ 100. Current and projected ratio of the older-age population to the total 1.2.2 1.2.1 ☒ population. Share of older age population with LTC needs. This indicator can be measured using local regulation or following the indicator used for 1.2.3 1.2.2 the European Commission Ageing Report (European Commission ☒ 2021a) "the population with at least one severe difficulty in ADLs and/or IADLs". 1.2.4 1.2.2 Share of older age population with cognitive impairments. ☒ 1.2.5 1.2.3 Main legal document or process determining eligibility rules. ☒ Percentage of the older age population with needs that receives 1.2.6 1.2.4 � formal LTC. Percentage of the older age population with needs that receives 1.2.7 1.2.4 � informal LTC. Percentage of the older age population with needs that does not 1.2.8 1.2.4 � receive LTC (nor formal or informal care). Percent of the older age population covered by the pension 1.2.9 1.2.5 ☒ system. Percent of the older age population covered by the healthcare 1.2.10 1.2.6 ☒ system. Main policies to support the integration of women into the labor 1.2.11 1.2.7 � market. /1 The population age groups can be defined using the UN age thresholds (15-64 and 65+) or local definitions. /2 Ideally, formal and informal care should be measured using the definition indicated in the definitions sections of the toolkit. Information gaps in Section 1.2, Policy domain – Demand perspective. This section provides a space to describe the information gaps identified during the completion of section 1.2. This country example was prepared as a test for improving the long-term care assessment toolkit and does not comprehend a thorough and accurate assessment of LTC in Denmark. Among other indicators, the assessment would have been enriched by identifying the following information listed in the survey: • A better-developed discussion of LTC needs in the population using data from SHARE or other available databases. • A better-developed discussion about the coverage of LTC services across the older age population and the population with LTC needs, including the type of services received (care mix) and the care gap. • Percent of the older age population covered by the pension system. • Percent of the older age population covered by the healthcare system. • A discussion of policies to support the integration of women into the labor market. 2 Provision domain The Provision domain guides an assessment of practical issues related to LTC, including what programs are available, who provides care, and how the demand for care influences the market. The supply perspective guides an assessment of services and programs available including formal and informal LTC, the availability of facilities, and the LTC labor force. It also discusses the role of each stakeholder in addressing the LTC demand. Last, it covers a discussion of barriers for the development of the market, factors affecting prices, geographical challenges and the effect of migration. The demand perspective guides an assessment of pull factors that drive or limit LTC provision. These include financial restrictions of households, migration, or other local factors. 2.1 Supply perspective 2.1.1 Services and programs available This section surveys the LTC programs available in the country. It provides program disaggregated information on how many people are served, specific eligibility rules, and other characteristics of programs that, although discussed in previous sections, may differ by service. A comprehensive survey would include the provision of home care, daycare, residential care (with and without nursing services), senior housing, independent living communities, assisted living, rehabilitative care, mental care, telecare, respite care, direct payments (cash transfers), meals (nutrition), socialization services, palliative care, assistive devices, home adaptations, preventative visits, and any other programs locally available that cater to older-age people with LTC needs. For comparability, this section should discuss what is the definition of LTC services used for the assessment and how these services are grouped. Overview of the LTC system Before turning into the details of each service type, this section is meant to provide a general description of the LTC services available in the country. 2.1.1.1 What is considered LTC in the country? 2.1.1.2 Is there an official definition of LTC services? 2.1.1.3 What is the distribution of coverage between formal and informal services? 2.1.1.4 What formal services are available and how they compare to each other in size, by number of beneficiaries, budget, etc.? 2.1.1.5 Are there public, private for profit, or private non-profit providers in all services? Denmark has perhaps the most universal LTC system in the world. In 2016 the following were the percentage shares of persons above 65 years of age covered by the system’s four main elements (Kvist 2018). • 8.4 percent received a preventative home visit. • 1.0 percent undertook rehabilitation. • 13.1 percent received home help. • 7.2 percent resided in elderly homes. Updated Figures are available in the Denmark Statistics website on Social benefits for senior citizens (Denmark Statistics 2022). The provision of LTC services is highly decentralized and as such the services available vary from one municipality to another. However, the organization Local Government Denmark has published a set of common terms for standardizing the categories of care services and care needs among all municipalities. The Common Language system describes four levels of functional ability, ensuring that beneficiaries receive equal treatment (at least in terms of time allocation) regardless of the municipality in which they reside and the care professional carrying out the assessment. The implementation of the common language is voluntary. Home care 2.1.1.6 What are the programs that provide LTC care at the residence of the individual? 2.1.1.7 What are the conditions for receiving home care from state-financed programs? Are there specific eligibility rules for home care services? 2.1.1.8 Is there a differentiation between types of home care services based on the needs of the individual? E.g., home care for individuals with higher ADLs, IADLs, etc. 2.1.1.9 Is there a differentiation between partial and permanent home care? Or between day and night care? 2.1.1.10 Is there information of the number of people that receive home care? 2.1.1.11 Can the number of beneficiaries be broken down by type of provider? E.g., public versus private providers, for profit and non-profit providers, etc.? 2.1.1.12 Can the number of beneficiaries be broken down by the need levels of beneficiaries, or their socioeconomic and demographic characteristics? 2.1.1.13 What is the average length of provision? The Danish LTC system classifies homecare into three main categories of services are available to older dependent individuals: • practical assistance consists of help with instrumental activities of daily living tasks such as cleaning, shopping and laundering. • personal care consists of help with activities of daily living tasks such as bathing and getting in and out of bed. • food service or meals on wheels. Home help is given to persons who cannot undertake these activities themselves. The amount of home help is initially decided by a municipal case worker after a home visit and is later also informed by the result of the rehabilitation programme (Kvist 2018). Albeit municipalities have different practices, many municipalities differentiate between five levels of functionality, giving rights to varying amounts and types of home help. Claimants received an average of 5.8 hours of personal care and 0.7 hours of practical help on a weekly basis. In total 538,950 hours of home help weekly was delivered in 2016. In total 146,214 persons were entitled to home help in 2016 (Kvist 2018). Besides the free choice of a private or public provider the elderly can also entitled to appoint a person (including family members) to carry out the caring tasks. Elderly people are offered a choice between at least two different providers of home help, one of which can be a municipal one. In 2016 35.7 percent of home help claimants chose a private provider. The elderly are also entitled to appoint a person to carry out the caring tasks. This person must be approved by the municipality, which acts as employer, sets out the services to be provided, and ensures help is provided in case the person gets ill. The scheme also approves family members but is only relevant for persons under pensionable age (Kvist 2018). Home nursing services are also available for individuals who require temporary care at home after an acute episode or who are chronically or terminally ill. To delay institutionalization, nursing, extensive support and healthcare are, often simultaneously, provided to chronically or terminally ill older people in their homes. In 2018 there were 320 private for-profit home care agencies operating across the country. The average number of hours provided per beneficiary per week varies between one and six, generally increasing with the beneficiary’s age. Entitled clients receive permanent home care free of charge, although temporary home care may be subject to co-payment above a defined income level of about €18,000 for single households and €25,000 for couples (WHO 2020a). Private providers can offer and charge for extra services such as gardening or window cleaning. Food services (considered part of home services) are also charged however the user’s payment cannot exceed €7 per meal or €467 per month (Kvist 2018). Community care 2.1.1.14 What are the programs that provide LTC care in the community? These services may include care centers where the user does not live (e.g., daycare, recreational, and socializing centers) or specialized housing where individuals live but maintain high independence (like senior housing, independent living communities, assisted living). 2.1.1.15 What are the conditions for accessing community care services? Are there specific eligibility rules for community care? 2.1.1.16 Is there a differentiation of services based on the needs of the individual? E.g., community care for individuals with ADLs, with IADLs, food services, etc. 2.1.1.17 Is there information about the number of people that access community care? This could differentiate between public and private provision, professional and volunteer provision, etc. 2.1.1.18 Can the number of beneficiaries be broken down by type of provider? E.g., public versus private providers, for profit and non-profit providers, etc.? 2.1.1.19 Can the number of beneficiaries be broken down by the need levels of beneficiaries, or their socioeconomic and demographic characteristics? Community care consists of day homes and day centres. Both types of facilities are usually attached to nursing homes. Both public and private providers can operate day home and day centres but admission to day home services is subject to needs assessment, whereas day centres are open to all older people, regardless of their functional status. Day homes offer the same services nursing homes would but only during the day, enabling beneficiaries to remain in their homes and retain a strong connection with their local communities. Day centres, in contrast, focus primarily on social and educational activities such as language courses, day trips and social and cultural events. Residential care 2.1.1.20 What are the programs that offer residential LTC? These may include, care homes, assisted living, and nursing homes. 2.1.1.21 What are the conditions for accessing institutional care services? Are there specific eligibility rules for residential care? 2.1.1.22 Is there a differentiation of service based on the needs of the individual? E.g., ADLs or IADLs levels, etc. 2.1.1.23 Is there information about the number of people that reside care facilities? 2.1.1.24 Can the number of beneficiaries be broken down by type of provider? E.g., public versus private providers, for profit and non-profit providers, etc.? 2.1.1.25 Can the number of beneficiaries be broken down by the need levels of beneficiaries, or their socioeconomic and demographic characteristics? There are five types of residential care facilities in the Danish system: • Housing for older people which are dwellings for older people with associated staff and service areas • Nursing homes which are institutions with permanent staff and service areas. • Sheltered housing are connected to institutions for the elderly, with some having permanent staff and service areas and others operating with emergency call arrangements or other arrangements. • General homes for older people which are designed to be suitable for older people and people with disabilities but do not have permanent staff or service areas. • Private care accommodation consists of rental accommodation for persons with extensive needs for service and care, with permanent staff and service areas outside the municipal sector. The number of places in elderly care accommodation was 79,970 in 2016, slightly down from 82,059 in 2010. The average duration of stay in a home for the elderly is 32 months. In 2013 the average age on entering an elderly home was 83.7 years. About 50 percent of residents in nursing homes had one or more chronic diseases and 42 percent in elderly homes had dementia (Kvist 2018). The needs assessment takes into account physical, mental and social aspects, but not the age of the applicant. If the functional capacity of the elderly person is markedly reduced in their existing home and the latter cannot be made suitable, they may be granted a place in a home for the elderly. Beneficiaries can select among the different types of residential care facilities based on their preferences and needs. Beneficiaries choosing to live with their spouse or partner must be offered a facility suitable for two people (Kvist 2018). Financial responsibility. Once beneficiaries have moved into a residential facility, they decide during an assessment process with health practitioners what types of services to receive and which activities they want to participate in. Beneficiaries pay the agreed rent and charges according to the size of the apartment as well as meals and private expenses from their pension. Nursing and other care costs are free of charge. During the past decade, however, the Danish Alzheimer Association has challenged this concept as not being particularly specialized to deal with the specific needs of people with Alzheimer’s disease and other forms of dementia (WHO 2020a). Residents as tenants. Modern nursing home facilities legally consider their residents as tenants and offer them a range of supplementary services such as cleaning and food delivery. This contrasts with the traditional approach to residential care in which a place in an institution implied full service provision to all residents. By 2011, the vast majority of older individuals living in residential care were housed in modern nursing home facilities (WHO 2020a). Private for-profit nursing care remains marginal, although a few non-profit private providers have managed to establish themselves in a primarily publicly operated sector (WHO 2020a). Private non-profit providers have introduced alternative approaches to housing and provision of services to foster self- determination and self-reliance. Noteworthy are initiatives to bridge generational divides by housing students and older people in the same building, proposed by the Danish Deaconess Foundation and senior communal living, recreating the community environment of a small village. Municipalities provide social services for older people (WHO 2020a). The waiting time for residential care must not exceed two months. Free choice of provider, which compels municipalities to ensure a choice between at least two providers, has also been introduced in residential care (WHO 2020a). Deinstitutionalization and quality of residential care. Denmark is the only country in the EU in which the construction of traditional old-age and nursing institutions has been legally banned. Early in the 1980s, the government phased out large institutions with multiple beds in each room and infrastructure for long-term care that resemble hospital environments, replacing them with nursing homes to ensure that users have individual living spaces (WHO 2020a). Informal and familial care The identification of informal and familial care varies across studies. In most cases, the term is used to refer to a non-paid carer. However, a distinction is also made based on the relationship between the carer and the beneficiary to separate familial carers and volunteers from non-profit organizations. Other characteristics used to define informal and familial carers include living arrangements (co-residency with the care recipient) and care intensity (regular, occasional, or routinary care). In some cases, informal or family caregivers are identified as those organizing care delivered by others, even when occurring from geographical distance. In all countries, informal care plays a vital role for the sustainability of the LTC system. In most cases, the informal care force constitutes the lion’s share of LTC provision. Hence, its assessment constitutes a key element to understanding the state of the LTC system in any country. 2.1.1.26 Are informal or familial carers recognized as part of the LTC system? 2.1.1.27 What is the local definition of informal or familial carers? 2.1.1.28 Is there information about the number of people receiving informal care? 2.1.1.29 Can the number of beneficiaries be broken down by type of provider? E.g., public versus private providers, for profit and non-profit providers, etc.? 2.1.1.30 What is the age and gender profile of informal care providers? 2.1.1.31 Are there policies or systems in place to support the informal care force? For example, cash transfers, respite programs, training, information, or emotional support? 2.1.1.32 Does labor force participation affect the availability of informal care? 2.1.1.33 Is there information about historical and projected trends for number of informal carers? The role of informal caregivers in Denmark is reduced compared with most other European countries, especially considering high-intensity hands-on care. In addition, unpaid caregivers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the EU (Kvist 2018). Quality. The 2016 European Quality of Life Survey revealed that 16 percent of the total population provides unpaid care for a relative, neighbor or friend at least once a week. By sex, these numbers are 20 percent of women and 13 percent of men. Unpaid caregivers account for 7 percent of working-age people (18–64 years old) and 18 percent of people 65 years or older (WHO 2020a). Most benefits-in-kind that support the relatives of caredependent people are not run by public authorities but by voluntary organisations. However, municipalities are increasingly working towards involving relatives and voluntary organisations in LTC activities. Many municipalities have a policy that provides a framework for how relatives may be engaged in care activities. All municipalities involve voluntary organisations in organising, for example, activities for the elderly, such as walks and visits (Kvist 2018). Formalization of informal carers. A person can request to a municipality to become a caregiver of a close relative. To be eligible, the municipality ascertains that the alternative to the caregiver is care provided outside home or hiring a full-time caregiver. The potential caregiver must certify that is suitable to provide the needed care, is under pensionable age and that there is an agreement with the beneficiary. If eligible, the caregiver gets employed by the municipality, up to six months, with a prespecified salary calculated based on the national yearly income. Alternatively, municipalities can compensate for lost earnings individuals caring for close relatives with a terminal illness (WHO 2020a). Respite. Unpaid caregivers are entitled to respite from care obligations from a few hours to several days. Respite care can be organized either through temporary placement in a care facility or in the beneficiary’s home with the help of formal caregivers. Respite support is well developed and offered by all municipalities but, since the assessment is local, access to and availability of services varies (WHO 2020a). Training and support. Additional services include training and education programmes, often focused on improving knowledge and ability to provide the needed support and on attaining coping skills, such as self-help and peer groups. Several nongovernmental organizations, especially the DaneAge Association, the Danish Alzheimer Association and Carers Denmark have increased their efforts to raise awareness of the realities of caregiving and their underrecognized needs for support (WHO 2020a). Cash transfers or direct payments Some countries provide cash transfers or vouchers for eligible older people with LTC needs to empower them to hire their own long-term care arrangements. This can be done in the form of an allowance paid directly to the person receiving care or to their informal caregivers (typically a family member). A positive feature of this approach is that it can potentially empower older people and enhance their autonomy. In practice, however, this approach can be quite challenging, particularly for older people with cognitive impairments or without access to information about services are available or what service will better fit their needs. 2.1.1.34 Are there cash transfers or direct payment schemes that can be used to contract paid LTC services or to support informal carers? 2.1.1.35 Are there specific cash transfers for people with LTC needs that allow them to hire their preferred care mix independently? 2.1.1.36 Are there cash transfers to support informal carers? Sometimes these may be assigned to the care user, even though their purpose is to support or compensate the carer. 2.1.1.37 What are the conditions to be eligible for these programs? 2.1.1.38 How many people receive cash transfers? This indicator can differentiate transfers to users and carers if both types of transfers exist. The Act on Active Social Policy guarantees income support in the form of cash benefits for individuals who cannot cover their needs from personal financial resources. About 4,400 older people living in senior centres receive income support to pay their rent. A public transport subsidy is available to older people. This subsidy is funded by municipalities and subject to means-testing (WHO 2020a). Assistive devises, home adaptations, and age-friendly accommodations 2.1.1.39 Are there programs that provide assistive devices, home adaptations, or age-friendly accommodations? 2.1.1.40 What are the conditions to be eligible for these programs? 2.1.1.41 How many individuals benefit from these programs? Prevention 2.1.1.42 Are there prevention programs? Some of these programs may target younger adults and aim at delaying the onset of LTC needs. In some countries, preventative programs may include a system of preventive home visits to assess the health status and functional ability of older adults. In others, these programs comprehend specific services to foster active ageing or rehabilitation services. Disease prevention and health promotion programmes are heavily funded. They are considered by authorities as instrumental to ensure the sustainability of the health system. One of the most successful initiatives to date has been the smoking-cessation and tobacco control policy, which included tobacco-cessation programmes, health warnings on cigarette packaging and public awareness campaigns (WHO 2020a). Municipalities offer the elderly a variety of preventative measures, including preventative home visits and activity offers. Depending on their age and life situation, elderly people are offered a preventative visit that focuses on their functional, psychological, medical, and social resources and challenges. Everyone above 75 years of age is offered a visit. The offer is also made to persons between 65 and 79 years of age who are in a special risk group because they, for example, have lost their spouse, are isolated or have been discharged from hospital. Finally, persons above 80 years are offered a visit on a yearly basis. As of 2016, municipalities can organize public arrangements as an alternative to individual visits for groups that normally decline home visits. In 2016, 93,424 persons received a preventative home visit, down from 122,794 in 2010 (Kvist 2018). The scope and kind of activity offers differ between municipalities and include visit schemes, workshops, education, talks, and sports for the elderly. The offers can be delivered by municipalities themselves, by associations and organisations, and by citizens. Users should have equal responsibility and influence on offers, and if they include elderly people the local elderly council must be consulted. A food service may also be offered – that is, food prepared outside the home and brought to the elderly or to a local elderly centre (Kvist 2018). Other LTC services for users and programs to support carers 2.1.1.43 Are there other services for older people with LTC needs or programs to support carers? These could include: 2.1.1.44 Meals or nutrition (nutrition) 2.1.1.45 Respite 2.1.1.46 Reablement 2.1.1.47 Rehabilitation 2.1.1.48 Palliative care 2.1.1.49 Telecare 2.1.1.50 Other services not covered in the questionnaire Reablement (sometimes mentioned as rehabilitation in the literature) is a key piece of the Danish LTC strategy. In January 2015, a new legislation came into force mandating that all municipalities consider first whether a person applying for home support could instead receive reablement services. In practical terms, when a citizen applies for home help, the municipality must offer a rehabilitation programme prior to assessing the need for home help. The municipality must also offer rehabilitation to alleviate reduced physical function caused by illness, and maintenance training aimed at preventing loss of functional capacity or to maintain or improve such capacities. Older people who are not physically or mentally able to participate in reablement activities can directly access home support (Kvist 2018). The aim of rehabilitation is to make citizens more autonomous and give them a greater sense of independence in everyday life. The goals of the rehabilitation programme are set jointly by the municipality and the elderly, and the programme must be holistic and cross-disciplinary. The programme can be delivered by private providers. The programme contains one or more of the following elements: physical training; a medication review; nutritional intervention; ADL training (training in activities of daily living); physical aids and changes of environment; and measures addressing loneliness (Kvist 2018). The training component is often offered in the form of a 12-week exercise training course, in which the older person together with the care worker identifies and works towards achieving one or more specific goals such as, showering alone or carrying out basic home cleaning activities. In 2016, 11,279 persons above 65 years undertook rehabilitation (Kvist 2018). Meal services. These are locally categorized as home care services and as such we described them in the corresponding section (WHO 2020a). Palliative care. Palliative services are comprehensive and include access to care, medication, physiotherapy, psychological assistance and support with daily activities. These services are provided by general practitioners, municipal home, hospitals and by palliative teams in hospices and palliative units (WHO 2020a). Respite. Respite and flexible care leave of up to six months are available and can be split and shared between people attached to the labour market, e.g. wage earners, self-employed people, and unemployed people, but not persons above pensionable age (Kvist 2018). Telecare. The administrative regions are investing heavily in implementing telemedicine programmes. The goal is to establish pilot projects that can enhance patient communication and treatment and to facilitate contact among practitioners. Pilot projects comprise actions for pre-hospital attention, intra- and inter-hospital care and coordination between hospitals and the beneficiary’s home and in mental health care (WHO 2020a). Allied services 2.1.1.51 Are there other services that are typically not considered aged LTC services, but that cover significant gaps in the demand for LTC in the country? Vaccination. General practitioners, reimbursed by the administrative regions on a fee-for-service basis, carry out vaccination programmes. In 2014, 48 percent of women and 48 percent of men 65 year or older were vaccinated against seasonal influenza (WHO 2020a). Dental care. Private practitioners provide dental care. The health system subsidizes preventive services and some other interventions, the rest being paid for out-of-pocket (WHO 2020a). Eye care. The health system subsidizes visits with ophthalmologists (WHO 2020a). Diagnostic services. The participation rates in screening for breast and colorectal cancer are higher than in the rest of the EU. Other screening programmes include cervical cancer and a primary screening modality of the human papillomavirus. In general, the health system covers diagnostic and laboratory services. Mental health. The health system covers mental health care. Outpatient visits to psychologists and psychotherapists require an out-of-pocket payment (WHO 2020a). Medication. Drug prescriptions at hospitals are free whereas those prescribed by a physician require an out-of-pocket contribution. Beneficiaries exceeding the threshold of medication spending (€470 in 2019) or with assets below a certain amount receive 85 percent reimbursement for all drugs (WHO 2020a). Medical devices. Out-of-pocket payments are required for hearing aids. As of 2016, Denmark had 39 computed tomography devices per million people versus 22 in the rest of the EU. The number of magnetic resonance imaging examinations was 82 per 1000 population (76 for the EU), and the number of computed tomography examinations was 161 per 1000 population (122 for the EU) (WHO 2020a). 2.1.2 Facilities 2.1.2.1 Is there information about the number of facilities including residential and community care centers? 2.1.2.2 Is there information about the capacity of facilities, for example, number of beds or maximum capacity? 2.1.2.3 These numbers should differentiate between residential care and community care centers, but they can be further broken down by type (e.g., care homes and nursing homes for residential care). 2.1.2.4 Numbers can also differentiate public and private, for-profit and not-for-profit, etc. 2.1.2.5 Are there statistics specific for facilities providing palliative care? 2.1.2.6 Are there statistics specific for facilities that focus on users with mental health conditions? 2.1.3 LTC workforce A comprehensive assessment of the LTC workforce encompasses all individuals providing care services to older individuals, including formal and informal carers. The assessment should start by measuring the size of the LTC workforce and the qualifications of carers. It is also important to look at historical trends and projections of the future demand and supply of carers. Importantly, this section is focused on sizing the workforce. Other sections address barriers for its development and the policies supporting it. Capacity of the LTC workforce 2.1.3.1 Is there information about the number of people providing care, including paid-for, volunteer, and familial carers? 2.1.3.2 Is there information about historical and expected trends for the size of the care workforce? 2.1.3.3 Is there information about the demographic composition of the care workforce, including the age, education, and gender of workers? 2.1.3.4 The information above may be available by category of worker. The list below provides examples of typical roles that are central and complement LTC services, however, the nomenclature or the importance of each category would differ across countries. 2.1.3.5 Paid home care assistants. 2.1.3.6 Nurses and nursing assistants (both total and those working especially in LTC). 2.1.3.7 Geriatric nurses (nurses specialized in older people). 2.1.3.8 Medical staff (both total and those working especially in LTC). 2.1.3.9 Geriatric doctors (medical doctors specializing in geriatric medicine). 2.1.3.10 Physiotherapists. 2.1.3.11 Therapists working on different types of impairment, e.g. speech impairment. 2.1.3.12 Social workers working on LTC. 2.1.3.13 Other professionals involved in formal care for older people. 2.1.3.14 Volunteers. 2.1.3.15 Informal and familial carers. Statistics on LTC professionals are available, but the time series was discontinued in 2015 (previously RES10, now RES14). As a result, it will take some years before a new time series can be established (Kvist 2018). Local and central government has for some time attempted to recruit more young people to undertake an education in social and health care − either as a social and health nurse, which takes from 3 years and 10 months to 4 years and 7 months, or as a social and health assistant, which takes 2 years and 2 months. In particular, the social and health assistant track may assist persons who have a marginal place in the labour market to become LTC professionals (Kvist 2018). The employment challenge is very real in Denmark. For LTC itself the challenge is dual: many LTC workers are retiring at the same time as the need for LTC increases (Kvist 2018). 2.1.4 The market structure and the role of stakeholders in provision The goal of this section is to describe who provides what. The LTC system is usually made-up of a combination of stakeholders, including the public sector, private sector for-profit providers, and non-profit organizations (NGOs, religious and civil organizations, etc.). Stakeholders do not necessarily provide care, they can also participate in the market by providing training for carers, information for users, by generating knowledge, or as outlets for complains. The section should also discuss practical issues related to the coordination between private, public, and non-profit stakeholders. 2.1.4.1 Who are the stakeholders that participate in the provision of care in the country? 2.1.4.2 Of those that supply care, what services do they provide and what is their share in the market? 2.1.4.3 Do stakeholders complement each other to build the supply of care? For example, do different stakeholders cater for specific type of needs? Or, do they cover different types of services? 2.1.4.4 Is the voluntary or the private sector attending gaps in the supply of care left by the public sector? 2.1.4.5 Are specific stakeholders attending other types of gaps left by the public or the private sector? 2.1.4.6 Are there stakeholders that do not necessarily provide care but participate in the LTC system through the communication of relevant information to caregivers or care users, training carers, generating knowledge, or by managing complains about quality of care? 2.1.4.7 In what ways are stakeholders poorly integrated for the provision of LTC? 2.1.4.8 Are stakeholders crowding out each other? 2.1.4.9 Are stakeholders impeding the development of a market? 2.1.4.10 Are stakeholders negatively affecting the system of prices or returns of carers? Non-profit actors play mainly a role in advocacy rather than in providing services, although some are active in nursing home care (Danish Deaconess Foundation and OK Foundation) while others are taking a lead role in organizing self-support and peer-support activities in the community (DaneAge Association and Danish Alzheimer Association). The DaneAge Association, a voluntary association with more than 825,000 members, has the most prominent role among civil society organizations. The organization is heavily involved in advocating the rights and well-being of older people and is recognized as a stable partner in the political dialogue (WHO 2020a). Non-profit organizations are also important organizers and promoters of voluntary work, e.g. training volunteers and deploying them in support of long-term care. The number of registered volunteers with the DaneAge Association has risen from 10,000 in 2010 to more than 18,000 in 2018. Since many volunteers are themselves 65 years or older, the organization of volunteering activities can also be seen as an investment in the community by promoting social activity and helping older individuals to stay engaged and active (WHO 2020a). The Elders Help Elders network, a partnership among six older people organizations, is one of the most visible initiatives organizing older people volunteers for supporting other older people throughout Denmark. Most volunteering activities through the network focus on visiting services, mobility support, shopping, practical assistance in the home, sharing meals, exercise, walking, biking and telephone security services. Non-profit organizations also play a crucial role in organizing volunteers in nursing home, hospices and hospitals (WHO 2020a). 2.1.5 Geographical challenges for provision Geography can condition the availability of LTC. For example, aging patterns and the availability of carers and services may differ substantially between localities, particularly between urban and rural areas. These differences can correspond to demographics, geographical barriers in the case of remote or secluded localities, or even economic conditions. Hence an assessment should look at geographical differences in coverage and how existing differences could relate to household and socioeconomic characteristics. It should also discuss how LTC policy is tailored to deal with these issues. 2.1.5.1 Are there differences in the coverage of rural and peripheral areas when compared to urban areas? 2.1.5.2 If there are systematic geographical differences in coverage, do these arise due to geographical conditions that limit physical access to these regions, the availability of resources, systematic economic differences, or other barriers to access? 2.1.6 Migration This section should discuss how migration affect the supply of LTC workers and the development of an LTC market. 2.1.6.1 Is emigration a factor influencing the availability of carers? 2.1.6.2 Is immigration a factor influencing the availability of carers? 2.1.6.3 Are there particular nationalities or groups that systematically contribute to the care workforce? 2.1.6.4 How significant are these groups in the total LTC workforce? 2.1.7 Other supply-side barriers for the development of provision This section covers practical issues that act as barriers for the development of an LTC market, for example, the lack of transparency, the capacity of entitled users to choose among providers, etc. This section is not about the regulation of these issues, as that aspect is covered by the policy domain. The section is about the practical aspects of these and other issues that limit the development of supply. 2.1.7.1 Is there free, open, and easy to access information about prices and the quality of providers? 2.1.7.2 Are there enough providers to assure a minimum level of competition? 2.1.7.3 Are there local challenges that could limit the development of a market? 2.1.7.4 Are there local challenges that limit the development of a LTC workforce? 2.1.7.5 Are there barriers for LTC providers to enter the market? 2.1.8 Prices The Price-setting policy subheading in the Policy domain discusses the regulation determining prices. Instead, this section should cover a discussion supply factors that may affect prices. For example, the availability of carers or entry barriers for providers that may limit competition. List of key indicators for Section 2.1, Provision domain – Supply perspective. Indicate if the following indicators were identified for the respective economy and described in the sections above. Indicator Related Indicator/1, /2 Check number subheading 2.1.1 2.1.1 Official definition of LTC services for older people in the country. � 2.1.2 2.1.1 Share of older age people covered by formal LTC services. ☒ Share of older age people covered by formal LTC services, by type 2.1.3 2.1.1 ☒ of service. 2.1.4 2.1.1 Share of older age people covered by informal LTC services. � Number of facilities including residential and community care 2.1.5 2.1.2 � centers. 2.1.6 2.1.3 Number of formal LTC workers. � /1 The population age groups can be defined using the UN age thresholds (15-64 and 65+) or local definitions. /2 Ideally, formal and informal care should be measured using the definition indicated in the definitions sections of the toolkit. Information gaps in Section 2.1, Provision domain – Supply perspective. This section provides a space to describe the information gaps identified during the completion of section 2.1. This country example was prepared as a test for improving the long-term care assessment toolkit and does not comprehend a thorough and accurate assessment of LTC in Denmark. Among other indicators, the assessment would have been enriched by identifying the following information listed in the survey: • A discussion of the local definitions of LTC services, beneficiaries, and other concepts that affect the reach of long-term care. • A better decomposition of the population covered by formal and informal LTC services. • The composition of the market, including the share of public and private providers. • A better-developed discussion about the facilities available for the provision of LTC and of the size and qualities of the care workforce. • A discussion of the effects of migration on the capacity of the workforce. • Information about the unit cost of LTC services. • A discission about the main supply-side barriers for the development of LTC provision, i.e., what are the main barriers that shape the national conversation about LTC. 2.2 Demand perspective 2.2.1 Poverty and inequality This section discusses the capacity of demand to sustain paid-for care provision. I.e., are financial restrictions a factor deterring individuals from hiring care? In addition, it discusses the effect of socioeconomic inequalities in access to care. In other words, are certain demographic groups more restricted from access to care due to lower incomes, education levels, institutional disparities, etc.? 2.2.1.1 To what extent are financial restrictions a factor limiting access to care? 2.2.1.2 Is there information on the willingness to pay for care services? 2.2.1.3 What is the socioeconomic profile of the older population? What is their income level in comparison to the rest of the population? 2.2.1.4 What are the main income sources for the elderly? E.g., savings, assets, transfers, pension, etc. 2.2.1.5 Are there last resort programs for older-age individuals with needs that can’t access LTC care due to financial constraints? 2.2.1.6 Is high inequality a factor limiting access to formal care? Are there significant differences in access to paid-for care for individuals or households with different levels of income? 2.2.1.7 Are there sub-demographics that are in disadvantage to access LTC or that show significant differences in access to LTC services? Although access is equal and mainly provided free of charge, waiting times and distance reduce the take-up of healthcare and result in unmet need. However, the share of people with self-declared unmet need for healthcare services due to financial barriers, waiting times or travelling distance (1.2% in 2015) is considerable lower than in the EU28 (3.2%) (Kvist 2018). List of key indicators for Section 2.2, Provision domain – Demand perspective. Indicate if the following indicators were identified for the respective economy and described in the sections above. Indicator Related Indicator/1, /2 Check number subheading Share of the older age population that cannot access health 2.1.1 2.2.1 ☒ services due to financial restrictions. 2.1.2 2.2.1 Share of the older age population below the national poverty line. � Share of the older age population covered by mean tested or other 2.1.3 2.2.1 � cash transfer programs targeting poorer individuals or households. /1 The population age groups can be defined using the UN age thresholds (15-64 and 65+) or local definitions. /2 Ideally, formal and informal care should be measured using the definition indicated in the definitions sections of the toolkit. Information gaps in Section 2.2, Provision domain – Demand perspective. This section provides a space to describe the information gaps identified during the completion of section 2.2. This country example was prepared as a test for improving the long-term care assessment toolkit and does not comprehend a thorough and accurate assessment of LTC in Denmark. Among other indicators, the assessment would have been enriched by identifying the following information listed in the survey: • A better-developed discussion about the extent to which demand-side barriers affect access to LTC, particularly for those aspects that relate to the financial capacity of individuals. 3 Household structure and gender domain The Household structure and gender domain guides an assessment of the interaction between the characteristics of households, gender dynamics, and LTC. The supply perspective discusses how the household composition, residence patterns, and migration interact with the supply of LTC, particularly through the availability of familial care. The section also discusses gender inequalities in familial care provision and how these inequalities translate into economic outcomes (labor force participation, education, and income). The demand perspective guides an assessment of how gender interacts with LTC needs, access and satisfaction with care. 3.1 Supply perspective 3.1.1 Household composition and residence patterns 3.1.1.1 Does the household composition affect the supply of familial care? 3.1.1.2 Has the average size of households changed over the last decades? 3.1.1.3 What is the composition of households with older people? 3.1.1.4 What is the percentage of households with a single older age person? Households are on average smaller than in the EU, however, the share of single households of people older than 65 years rose from 14.1 percent in 2008 to 18.2 percent in 2018, which is above the EU average of 14.5, in 2016. The average household size is 2 persons, below the EU average (2.3 persons) and slightly under the 2008 average of 2.2 persons (WHO 2020a). 3.1.2 Migration Effect of migration on the availability of familial care. 3.1.2.1 Does emigration (rural-urban or international) affect the composition of households and the supply of familial care? Migration plays a substantial role for the population dynamics of Denmark. A positive net migration flow has helped maintaining a growing population with rates that varied between 2 and 6 percent of Denmark’s total population. The inflow does not only helps slowing down the rate of population ageing, but it may also provide workers that could join the LTC workforce. Nevertheless, we could find information or have identified a study discussing the contribution of migration to the pool of formal carers or the availability of informal care. 3.1.3 Expectations of gender roles in LTC provision 3.1.3.1 Are there familial traditions that affect the distribution of care labor among household members by sex? Only 2 percent of Danish individuals surveyed in SHARE W1 indicated that care is totally or mainly family's responsibility. This is the lowest value across surveyed countries. In other regions the figure ranges from 5.2 percent (Netherland) to 65.6 percent (Greece). Consequently, the role of informal caregivers is reduced compared with most other European countries, especially considering high-intensity hands-on care (Börsch-Supan 2022). A traditional explanation for this is the generous provision of social services which has unburdened the family and managed to relieve women of some of their care responsibilities for older parents. Relative to other European countries, Nordic economies (including Denmark) have achieved a measure of gender equality in informal caregiving and display smaller gender care gaps. Legislation in these countries tends to treat women and men equally for employment (Rostgaard et al. 2022). There have been efforts to increase the participation of men in the LTC workforce. The Ministry for Gender Equality supported projects in 2014 to enhance knowledge and possibilities for recruiting more men for the care professions in 2014. 3.1.4 Economic outcomes This section discusses how LTC provision affects economic outcomes, typically through gender inequalities. For example, local traditions may assign uneven expectations of care responsibilities between men and women, limiting female economic opportunities such as education, income, labor force participation, and access to pensions or healthcare. These issues may compound on each other. For example, reduced LFP will decrease labor income for carers, but it can also reduce their education opportunities, affecting their professional opportunities, expected income, or their likelihood of accessing pensions. 3.1.4.1 How does LTC provision interact with labor force participation? 3.1.4.2 What are the labor force participation rates disaggregated by sex and age? 3.1.4.3 How does familial care affect carers from accessing education? 3.1.4.4 What is the impact of familial LTC provision on time poverty? 3.1.4.5 Does familial care impact the likelihood of accessing pensions? Looking across countries, Denmark scores relatively well on gender equality indicators, for example, the country ranks third on the UNPD gender inequality index (UN 2022). Moreover, today the country has one of the lowest gaps in labor participation. The labor force participation rate of males in Denmark is 8 percent points higher than that of females. This is the fifth lowest gap in labor force participation among high income countries with data available in the UNDP gender inequality index (UN 2022). Labor force participation by sex and age group in 2021. 100 92.5 91.6 87.5 86.8 90 83.5 80.2 79.7 80 70.9 70 60.9 59.9 60 Percent 50 40 30 20 14.8 10 5.4 0 15-24 25-34 35-44 45-54 55-64 65+ Male Female Source: ILO (2021). Ever since the 1950s, there has been an emphasis on increasing women’s participation in the labour market; a key measure to achieve this goal was transforming unpaid care work into paid employment. Today, Denmark works with a dual earner– carer model, whereby the assumption is that both paid work and unpaid care are equally shared between the genders, but this is more successful in long-term than in childcare policy: most parental leave is used by mothers, contributing in part to a gender pay gap of around 16 per cent (Rummery 2021). Over the past years the extent of home help has gone down at the same time as the population is ageing. Thus, one might expect an insufficient provision of formal care, which in turn could hinder female labour market participation. However, when examining the employment rates of women of middle age, i.e. the group most susceptible to suffer from the reduced scope of formal care, one finds no such empirical support – either over time or compared with the situation in other countries (Kvist 2018). List of key indicators for Section 3.1, Household structure and gender domain – Supply perspective. Indicate if the following indicators were identified for the respective economy and described in the sections above. Indicator Related Indicator/1, /2 Check number subheading Percent of multi-generational households. Multigenerational households are defined as including two or more adult generations 3.1.1 Section 3.1.1 � or a skipped generation, which consists of grandparents and their grandchildren younger than 25. 3.1.2 Section 3.1.1 Percent of single older age adult households. ☒ 3.1.3 Section 3.1.4 Labor force participation disaggregated by sex and age. ☒ 3.1.4 Section 3.1.4 Educational attainment rates disaggregated by sex and age. � Percent of the older age population covered by the pension system 3.1.5 Section 3.1.4 disaggregated by sex. Coverage defined as the proportion of the � elderly receiving some kind of pension income. /1 The population age groups can be defined using the UN age thresholds (15-64 and 65+) or local definitions. /2 Ideally, formal and informal care should be measured using the definition indicated in the definitions sections of the toolkit. Information gaps in Section 3.1, Household structure and gender domain – Supply perspective. This section provides a space to describe the information gaps identified during the completion of section 3.1. This country example was prepared as a test for improving the long-term care assessment toolkit and does not comprehend a thorough and accurate assessment of LTC in Denmark. Among other indicators, the assessment would have been enriched by identifying the following information listed in the survey: • A more better-developed discussion of how living arrangements affect the demand for LTC. 3.2 Demand perspective 3.2.1 Gender differences in LTC needs and access 3.2.1.1 Are there differences in needs by sex? 3.2.1.2 Are there differences in care received by sex? 3.2.1.3 Are there differences in satisfaction experienced by care users disaggregated by sex? 3.2.1.4 Are there differences in income or location of households that affect the availability of LTC by sex? 3.2.1.5 Pensions can be an important or sometimes the main source of income for older-age people. However, pensions are usually tied to labor force participation. Due to LTC provision and gender roles, there may be significant differences in access to old-age pensions by sex. How do these differences interact with LTC in the specific economy? Women present higher prevalence rates of limitations in ADLs. 33.1 percent of women reported limitations in ADLs in Denmark, compared to 28.8 percent of men. This comparison is not age-standardized hence it does not account for the longer life-expectancy of women. Moreover, men have a lower life expectancy, engage more often in lifestyle-related risk behaviors and report more financial challenges to access care (Gaertner et al. 2019). There are sex differences in the provision of services by sex. 38.2 percent of women 65 or older received a referral to home care, compared to 27.0 percent of men. Similarly, in 2018, 20.6 percent of women 75 or older received a preventive home visit, compared to 18.3 percent of men. Men received on average 20 minutes more of care at home than women. The lower utilization reported by men may be partly explained by their lower life expectancy and residence patterns. Men are more like lo live with a partner or relatives while there are more women living alone (WHO 2020a). The data is consistent with statistics of access to healthcare disaggregated by gender that show that men are more likely to indicate health care-related unmet needs due to financial constrains than women (WHO 2020a). List of key indicators for Section 3.2, Household structure and gender domain – Demand perspective. Indicate if the following indicators were identified for the respective economy and described in the sections above. Indicator Related Indicator/1, /2 Check number subheading Share of older age population with LTC needs disaggregated by sex. The population with LTC needs can be measured using local regulation or, for comparability purposes, based on the indicator 3.2.1 Section 3.2.1 ☒ used for the European Commission Ageing Report "the population with at least one severe difficulty in ADLs and/or IADLs, disaggregated by sex"./3 3.2.2 Section 3.2.1 Satisfaction with LTC provision disaggregated by sex. � /1 The population age groups can be defined using the UN age thresholds (15-64 and 65+) or local definitions. /2 Ideally, formal and informal care should be measured using the definition indicated in the definitions sections of the toolkit. /3 European Commission (2021). Information gaps in Section 3.2, Household structure and gender domain – Demand perspective. This section provides a space to describe the information gaps identified during the completion of section 3.2. This country example was prepared as a test for improving the long-term care assessment toolkit and does not comprehend a thorough and accurate assessment of LTC in Denmark. Among other indicators, the assessment would have been enriched by identifying the following information listed in the survey: • A discussion of satisfaction with LTC services disaggregated by sex. Definitions Accreditation. A voluntary or compulsory method to regulate the market entry and standards of any service provider. Service requirements are defined by specific regulations and compliance is assessed by inspection (European Commission and OECD 2013). Access (accessibility). Describes the degree to which an environment, service or product allows access by as many people as possible (WHO 2015). Activities of daily living (ADLs). The basic activities necessary for daily life, such as bathing or showering, dressing, eating, getting in or out of bed or chairs, using the toilet, and getting around inside the home (WHO 2015). Active ageing. The process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age (WHO 2015). Aging. At the biological level, aging results from the impact of the accumulation of a wide variety of molecular and cellular damage over time. This leads to a gradual decrease in physical and mental capacity, a growing risk of disease, and ultimately death. These changes are neither linear nor consistent, and they are only loosely associated with a person’s age in years. The diversity seen in older age is not random. Beyond biological changes, aging is often associated with other life transitions such as retirement, relocation to more appropriate housing, and the death of friends and partners (WHO 2015). Assessment for care. A systematic process to collect information on care needs of older persons, based on a set of predefined concepts and data categorization to guide care planning. Clinicians or trained professionals typically use assessment to evaluate the physical, cognitive, and functional care needs of older persons and rank their levels of impairment (Asian Development Bank 2020). Assistive devises. Any device designed, made or adapted to help a person perform a particular task; products may be generally available or specially designed for people with specific losses of capacity; assistive health technology is a subset of assistive technologies, the primary purpose of which is to maintain or improve an individual’s functioning and well-being (WHO 2015). Carer (or caregiver). A person who provides care and support to someone else; such support may include: helping with self-care, household tasks, mobility, social participation and meaningful activities; offering information, advice and emotional support, as well as engaging in advocacy, providing support for decision making and peer support, and helping with advance care planning; offering respite services; and engaging in activities to foster intrinsic capacity (WHO 2015). Carers are typically distinguished by their level of professionalization and remuneration. Professionalization is commonly understood as a carer that received professional training while paid care relates to the receipt of a remuneration for the service provided. The matrix below shows how these categories separate typologies of carers (Figure 3). Figure 3. Classification of caregivers. REMUNERATION PAID UNPAID FORMAL Voluntary PROFESSIONALIZATION Care worker care professional INFORMAL Live-in carers Informal / & personal family assistants caregivers Source: WHO (2022). It is important to understand how these typologies cover the LTC market, however, it is unlikely that countries will have even basic information about the care workforce for all these categories. Moreover, in many publications, the terms professional and paid carer are used indiscriminately. Problems for the categorization of carers also arise from cultural differences across countries. For example, the word “carer� has a different meaning across countries or across sub-groups within the same country. Given the lack of an internationally applied definition, assessment should include, to the extent of possible, a precise description of how the groups discussed are defined and identified." Carer (care worker). Care workers provide long-term care services within the context of an employment contract, receive a wage and social benefits and are often professionally trained for care work (WHO 2022). Carer (voluntary carer). Voluntary care professionals provide care within the context of a formalized agreement with a care provider, and are often professionally trained for care work but do not receive remuneration (WHO 2022). Carer (live-in carers and personal assistants). Live-in carers and personal assistants are members of the family or the community who provide regular support, within the context of a formal or an informal agreement with the family or the State. They are paid, and often have only sporadic training on specific care tasks (WHO 2022). Carer (informal / familial carers). Informal caregivers are usually family members or members of one's close social circle (e.g. friends, neighbours, colleagues) who provide support in the context of a personal or social relationship, without any remuneration and without being professionally trained for care work (WHO 2022). Care dependence. Care dependence arises when functional ability has fallen to a point where an individual is no longer able to undertake the basic tasks that are necessary for daily life without assistance (WHO 2015). Care needs. LTC needs among older adults is typically assessed through the measurement of functional status—namely, a person’s ability to perform activities of daily living (ADLs, such as bathing, dressing, and using the toilet) or instrumental activities of daily living (IADLs, such as shopping, preparing meals, performing housework, and managing medications). The measurement of ADLs has been relatively more consistent across different countries than the measurement of IADLs. Greater variability in IADLs could be driven by cultural and geographical variations in those activities that are considered instrumental to daily living Differences in survey questions (wording, types of scales used, etc.) and survey methodology could also impact the comparability of ADL/IADL based disability measures. Therefore, cross-country comparison of disability measures based on activity limitations is challenging (Glinskaya, Feng, and Suarez 2022). Case management. A collaborative process of planning services to meet an individual’s health needs through communication with the individual and their service providers and coordination of resources (WHO 2015). Centralization. The degree of centralization refers to the distribution of responsibilities for long-term care organization, provision and funding between local, regional and national administrative levels (WHO 2022). Community care. Services and support to help people with care needs to live as independently as possible in their communities (Asian Development Bank 2020). Comprehensive geriatric assessment. A multidimensional assessment of an older person that includes medical, physical, cognitive, social and spiritual components; may also include the use of standardized assessment instruments and an interdisciplinary team to support the process (WHO 2015). Typically, a care assessment is part of the assessment for eligibility of LTC benefits. Dementia. A loss of brain function that affects mental function related to memory impairment, low level of consciousness and executive function. The most common form of dementia is Alzheimer’s disease (European Commission and OECD 2013). Dependency ratio. The ratio of dependent people (older persons and children) to working-age people (aged 15–64). May be split into old-age dependency ratios and child dependency ratios (UN 2019). Disability. An umbrella term for impairments, activity limitations and participation restrictions, denoting the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors) (WHO 2015). Environment. All the factors in the extrinsic world that form the context of an individual’s life; these include home, communities and the broader society; within these environments are a range of factors, including the built environment, people and their relationships, attitudes and values, health and social policies, systems and services (environmental and personal factors) (WHO 2015). Frailty (or frail older person). Extreme vulnerability to endogenous and exogenous stressors that exposes an individual to a higher risk of negative health related outcomes (WHO 2015). Functional ability. The health-related attributes that enable people to be and to do what they have reason to value (WHO 2022). Geriatrics. The branch of medicine specializing in the health and illnesses of older age and their appropriate care and services (WHO 2015). Gerontology. the study of the social, psychological and biological aspects of ageing (WHO 2015). Health. A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity (WHO 2015). Health characteristics. underlying age-related changes, health-related behaviors, physiological risk factors (for example, high blood pressure), diseases, injuries, changes to homeostasis, and broader geriatric syndromes; the interaction among these health characteristics will ultimately determine the intrinsic capacity of an individual (WHO 2015). Health condition. an umbrella term for acute or chronic disease, disorder, injury or trauma (WHO 2015). Healthy Ageing. The process of developing and maintaining the functional ability that enables wellbeing in older age (WHO 2015). Impairment. A loss or abnormality in body structure or physiological function (including mental functions); in the WHO 2015 Aging Report, abnormality is used strictly to refer to a significant variation from established statistical norms (that is, deviation from a population mean within measured standard norms) (WHO 2015). Instrumental activities of daily living (IADLs). activities that facilitate independent living, such as using the telephone, taking medications, managing money, shopping for groceries, preparing meals and using a map (WHO 2015). Integrated health services. integrated health services are managed and delivered in a way that ensures people receive a continuum of services including health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care at different levels and sites within the health system, and that care is provided according to their needs throughout their life course (WHO 2015). Informal care. There is no international definition of informal care that applies to all existing systems. The term usually refers to unpaid care provided by a family member, friend, neighbor or volunteer (World Health Organization 2015). In some cases, there will be a differentiation between paid informal and paid formal caregivers that will respond to the level of training of the caregiver or the possession of some type of certification. Informal caregivers can be involved in providing "hands-on" care or – also a very significant role – in organizing care delivered by others, sometimes from a distance (WHO 2018). Intrinsic capacity. the composite of all the physical and mental capacities that an individual can draw on (WHO 2015). In-kind benefits. Are those provided to long-term care recipients as goods, commodities, or services, rather than money. They may include care provided by nurses, psychologists, social workers and physiotherapists, domestic help or assistance, or special aids and equipment. They might also include assistance to family caregivers such as respite care (European Commission and OECD 2013). LTC services and benefits (at home). In its data, the OECD groups three types of services under home care, including (1) services provided to people with functional restrictions who mainly reside in their own home, such as personal care; (2) the use of institutions on a temporary basis to support continued living at home – such as in the case of community care and day care centres and in the case of respite care; (3) specially designed, assisted or adapted living arrangements for persons who require help on a regular basis while guaranteeing a high degree of autonomy and self-control (European Commission and OECD 2013). In the toolkit we allocate these services to separated categories, as some of their characteristics, for example prices, differ substantially from each other. LTC services and benefits (residential). Refers to nursing and residential care facilities (other than hospitals) which provide accommodation and long-term care as a package to people requiring ongoing health and nursing care due to chronic impairments and a reduced degree of independence in activities of daily living (ADL). These establishments provide residential care combined with either nursing, supervision or other types of personal care as required by the residents. LTC institutions include specially designed institutions where the predominant service component is long-term care and the services are provided for people with moderate to severe functional restrictions (European Commission and OECD 2013). LTC services and benefits (cash or cash-for-care). Include cash transfers to the care recipient, the household or the family caregiver, to pay for, purchase or obtain care services. Cash benefits can also include payments directed to carers (European Commission and OECD 2013). LTC services and benefits (rehabilitation). a set of measures aimed at individuals who have experienced or are likely to experience disability to assist them in achieving and maintaining optimal functioning when interacting with their environments (European Commission and OECD 2013). LTC services and benefits (palliative care). Palliative care aims to improve the quality of life of people experiencing a significant decline in their intrinsic capacity and who have a limited life prognosis; it also aims to help patients and their families by preventing or relieving physical, psychosocial or spiritual suffering (WHO 2015). LTC services and benefits (assistive devises and technologies). any device designed, made or adapted to help a person perform a particular task; products may be generally available or specially designed for people with specific losses of capacity; assistive health technology is a subset of assistive technologies, the primary purpose of which is to maintain or improve an individual’s functioning and well-being (WHO 2015). LTC services and benefits (home modifications). Conversions or adaptations made to the permanent physical features of the home environment to improve safety, physical accessibility and comfort (WHO 2015). Long-Term Care. Long-term care is defined as all activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity (WHO 2015). Long-term care systems. Is defined as a range of services required by persons with a reduced degree of functional capacity, physical or cognitive, and who are consequently dependent for an extended period of time on help with basic activities of daily living (ADL). This personal care component is frequently provided in combination with help with basic medical services such as nursing care (help with wound dressing, pain management, medication, health monitoring), as well as prevention, rehabilitation or services of palliative care. Long-term care services can also be combined with lower-level care related to domestic help or help with instrumental activities of daily living (IADL) (European Commission and OECD 2013). Older-age population. Although people of any age can become dependent on others, LTC needs usually increase with and typically at a much faster pace for those considered the older-age population, typically those aged 65+. However the threshold for the jump in dependency rates may vary across countries. The association of 65 years old as the threshold for old age has a historical background (Sanderson and Scherbov 2015). There is also a focal point with age 65 as a threshold for retirement (Coile 2015). Following the literature and to maintain comparability, we use 65 years of age as the threshold for older age across the different sections of the toolkit. However, we acknowledge that some countries will have different regulatory (e.g. eligibility rules) and biological (e.g. dependency rates) patterns that may suggest other thresholds. Out-of-pocket expenditure. Payments for goods or services that include (i) direct payments, such as payments for goods or services that are not covered by any form of insurance; (ii) cost sharing – that is a provision of health insurance or third-party payment that requires the individual who is covered to pay part of the cost of the health care received; and (iii) informal payments, such as unofficial payments for goods and services, that should be fully funded from pooled revenue (WHO 2015). People-centered services. An approach to care that consciously adopts the perspectives of individuals, families and communities, and sees them as participants as well as beneficiaries of health care and long-term-care systems that respond to their needs and preferences in humane and holistic ways; ensuring that people-centered care is delivered requires that people have the education and support they need to make decisions and participate in their own care; it is organized around the health needs and expectations of people rather than diseases (WHO 2015).. Population aging. a shift in the population structure whereby the proportion of people in older age groups increases (WHO 2015). Quality. Refers to effectiveness and care safety, patient-centredness and responsiveness and care co-ordinaton which relate to technical quality as well as experience that LTC users will have and the way care is harmonised across setting. Structural quality refers to staffing and management, care environment, and information and communication technology (ICT) and nonICT assistive technologies that are instrumental to LTC quality (European Commission and OECD 2013). Citations Asian Development Bank. 2020. Country Diagnostic Study on Long-Term Care in Indonesia. Börsch-Supan, Axel. 2022. “Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 1. Release Version: 8.0.0. SHARE-ERIC. Data Set.� 2022. https://doi.org/10.6103/SHARE.w1.800. Coile, Courtney C. 2015. “Economic Determinants of Workers’ Retirement Decisions.� Journal of Economic Surveys 29 (4): 830–53. https://doi.org/10.1111/joes.12115. Denmark Satistics. 2019. “Documentation of Statistics for Elderly - Indicators 2019.� https://www.dst.dk/Site/Dst/SingleFiles/GetArchiveFile.aspx?fi=91072100033&fo=0&ext=kvaldel. Denmark Statistics. 2022. “Social Benefits for Senior Citizens.� 2022. https://www.dst.dk/en/Statistik/emner/sociale-forhold/social-stoette/sociale-ydelser-til-aeldre. European Commision. 2019. “State of Health in the EU. Denmark. Country Health Profile 2019.� https://www.oecd-ilibrary.org/docserver/5eede1c6- en.pdf?expires=1651846608&id=id&accname=guest&checksum=9712F711A6BFA659C6793D0308538583 . European Commission. 2020. “ECHI Data Tool.� 2020. https://webgate.ec.europa.eu/dyna/echi/. ———. 2021a. “Long-Term Care Report Trends, Challenges and Opportunities in an Ageing Society . Volume 2.� Vol. Volume 2. Luxembourg. https://doi.org/10.2767/677726. ———. 2021b. The 2021 Ageing Report. Luxembourg. https://doi.org/10.2765/84455. ———. 2022. “EUROSTAT.� 2022. https://ec.europa.eu/eurostat/data/database. European Commission, and OECD. 2013. A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care. OECD Publishing. https://doi.org/https://doi.org/10.1787/2074319x. Gaertner, Beate, Markus A Busch, Christa Scheidt-Nave, and Judith Fuchs. 2019. “Limitations in Activities of Daily Living in Old Age in Germany and the EU - Results from the European Health Interview Survey (EHIS) 2.� Journal of Health Monitoring 4 (4): 48–56. https://doi.org/10.25646/6226.2. Glinskaya, Elena, Zhanlian Feng, and Guadalupe Suarez. 2022. “Understanding the ‘State of Play’ of Long-Term Care Provision in Low- and Middle-Income Countries.� International Social Security Review 75 (3–4): 71– 101. https://doi.org/https://doi.org/10.1111/issr.12308. ILO. 2021. “ILOSTAT.� 2021. https://ilostat.ilo.org/data/#. Kvist, Jon. 2018. “ESPN Thematic Report on Challenges in Long -Term Care. Denmark.� https://ec.europa.eu/social/main.jsp?catId=1135&intPageId=3589. OECD. 2019. “Pensions at a Glance 2019. Denmark.� https://doi.org/http://dx.doi.org/10.1787/888934042960. ———. 2021. Pensions at a Glance 2021. OECD Pensions at a Glance. OECD. https://doi.org/10.1787/ca401ebd- en. Roostgard, T., and M. Langins. 2022. “COVID-19 and the Long-Term Care System in Denmark.� In LTCcovid International Living Report on COVID-19 and Long-Term Care. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://doi.org/https://doi.org/10.21953/lse.mlre15e0u6s6. Rostgaard, Tine, Frode Jacobsen, Teppo Kröger, and Elin Peterson. 2022. “Revisiting the Nordic Long-Term Care Model for Older People—Still Equal?� European Journal of Ageing 19 (2): 201–10. https://doi.org/10.1007/s10433-022-00703-4. Rummery, Kirstein. 2021. “Gender Equality and the Governance of Long -Term Care Policy: New Comparative Models and Paradigms.� Journal of International and Comparative Social Policy 37 (1): 16–33. https://doi.org/DOI: 10.1017/ics.2020.16. Sanderson, Warren, and Sergei Scherbov. 2015. “Are We Overly Dependent on Conventional Dependency Ratios?� Population and Development Review 41 (4): 687–708. https://doi.org/10.1111/j.1728- 4457.2015.00091.x. Schulz, Erika, and Diw Berli. 2010. The Long-Term Care System in Denamark. UN. 2019. “World Population Prospects 2019, Online Edition.� United Nations, Department of Economic and Social Affairs, Population Division. 2019. https://population.un.org/wpp/Download/Standard/Population/. ———. 2022. “UN Gender Inequality Index.� 2022. https://hdr.undp.org/en/content/human-development-index- hdi. WHO. 2015. World Report on Ageing and Health. Geneva: World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. ———. 2020a. “Denmark. Country Case Study on the Integrated Delivery of Long-Term Care.� ———. 2020b. “Romania - Country Case Study on the Integrated Delivery of Long-Term Care.� Copenhagen. https://www.euro.who.int/en/countries/romania/publications/romania-country-case-study-on-the- integrated-delivery-of-long-term-care-2020. ———. 2022. “Rebuilding for Sustainability and Resilience: Strengthening the Integrated Delivery of Long -Term Care in the European Region.� Copenhagen: WHO Regional Office for Europe. https://apps.who.int/iris/handle/10665/353912.