France already faces challenges in ensuring sufficient and quality long-term care, notably at home, which might be further compounded as population ageing increases demand for care. Increasing the supply of care and its quality will require improving the working conditions of care workers and support for informal carers. Defining a core national care offer could contribute to more equal access to long-term care across the country. Long-term care expenditures will also weigh on public spending. Increasing preventive care would support healthy ageing and help limit cost increases. Increasing funding from greater contributions from older people while strengthening the targeting of public support for long-term care to older people with severe needs and low incomes could better limit poverty risks, fiscal costs and negative economic impacts. Strengthening data availability and internal control would enhance the monitoring of spending. Refined support for informal carers would support their ability to work and GDP.
OECD Economic Surveys: France 2026
Abstract
Demand among older persons for long-term care (LTC) – that is, for assistance with everyday activities (Box 2.1) – is increasing in France, as throughout OECD countries, as the population ages and household structures change. The population has been ageing over the past three decades, as the birth rate declined and life expectancy increased (Figure 2.1, Panels A and B). This trend is set to accelerate as the baby boomer generation reaches advanced ages, rapidly increasing the share of the population over 80, who have the highest care needs. By 2025, 22% of the population was aged 65 or over, which will increase to 26% by 2040, slightly more than in the average OECD country (Panel C).
As the population ages, the share of older people with care needs is projected to increase from 4% to 5% by 2050, similar to the OECD average (Figure 2.1, Panel D). Demand for formal LTC is also increasing due to changing household structures, with people less likely to be married and more likely to have fewer children than in the past (HCEFA, 2024[1]).
Note: Panels A and C: mid-year population data. For France it covers metropolitan France and overseas departments, Mayotte is included since 2014. Panel D: United Kingdom: data for England only.
Source: OECD Historical population and projected population database; OECD Health Statistics database; Eurostat and OECD (2024[2]).
Long-term care (LTC) services help people live as independently and safely as possible when they can no longer perform everyday activities on their own (OECD, 2024[2]). People require services around:
1. Activities of daily living, which are a set of personal care tasks, such as bathing and dressing.
2. Instrumental activities of daily living, which are tasks necessary for someone to be able to live independently in the community. They include shopping, housekeeping, and preparing food.
3. Maintaining social activity or supporting with cognitive impairment or other behavioural limitations.
Key forms of public support for home-based LTC are:
The means- and needs-tested personalised autonomy allowance (allocation personnalisée d’autonomie).
Non-means-tested tax credits, which reach 50% of the costs of home-based non-medical services up to an annual limit of EUR 12 000.
The treatment of older people with severe needs as 1.5 people in the calculation of joint taxation. This reduces the household’s tax liability and represents a form of tax benefit.
For institutional care, social housing assistance (Aide sociale à l'hébergement, ASH) supports older people unable to pay for the accommodation portion of institutional care. It can be recoverable from their estate and adult children can also be legally required to contribute.
LTC is financed by national and local authorities. The National Solidarity Fund for Autonomy (CNSA, Caisse nationale de solidarité pour l’autonomie) provided 64% of LTC financing in 2023, followed by departments (17%), the health insurance social security branch (15%), and the State (5%) (Gouvernement, 2025[3]).
The CNSA receives almost 90% of its revenues from social contributions, as well as the pension levy (contribution additionnelle de solidarité pour l’autonomie), and the solidarity contribution for autonomy (contribution de solidarité pour l’autonomie), payable as part of the solidarity day (journée de solidarité, a worked public holiday) (CNSA, 2025[4]). Health insurance is financed primarily through social contributions. Departmental resources stem from taxes on property transactions and central government transfers.
Similarly to other OECD countries, France is facing challenges in providing care that meets the population’s needs. Around two-thirds of people in France worry about accessing good-quality LTC for themselves and for older family members over the next decade (OECD, 2023[5]). Four in ten people aged 65 and over with at least three limitations in activities of daily living have unmet care needs (OECD, 2023[6]). As around 80% of these people receive care, these unmet needs suggest gaps in the adequacy or amount of care provided. Additionally, scandals regarding the mistreatment of residents in institutional care in recent years have raised concerns about the quality of care. These developments have highlighted the need to address staff shortages, ensure adequate training and education, and reinforce regulation and monitoring, including around the financialisation of LTC services (see Chapter 1).
Several factors contribute to unmet care needs and the quality of care. Almost one in two recipients did not use their full entitlement to the personalised autonomy allowance in 2017, on average leaving around one third unused (Drees, 2024[7]). Some reasons for this under-consumption include not wanting support, the complexity of the system (with many actors and mechanisms), elevated out-of-pocket costs, and shortages of care professionals (HCFEA, 2024[8]; Revil and Gucher, 2025[9]). Shortages of care workers are also impacting the quality of care as well as the working conditions of care professionals. The way LTC is financed, with local authorities contributing to a share of LTC spending, is also resulting in different levels of direct support across the country and citizens perceive that treatment is unequal (Libault, Perruchon and Farnault, 2022[10]).
The LTC system is also facing growing demand for home-based services. LTC at home typically better aligns with the preferences of older people, uses human resources more effectively, and is less expensive for low and moderate levels of need (OECD, 2025[11]; Cheneau, Sicsic and Rapp, 2025[12]). Estimates across 17 OECD countries suggest that shifting 10% of LTC spending from institutional to home-based care could reduce spending by 4.9% in five years following the shift (OECD, 2025[11]). While home-based care can lower public spending, it can also have other spillovers, such as on informal carers, including on their health or ability to work, or the need for strong coordination and communication within the LTC and health systems. Such spillovers require wide-ranging policy responses and coherently aligned incentives. Around 39% of older people receiving care in LTC institutions have severe needs. While this is above the share of 29% across the OECD, it still suggests significant room for older people with low or moderate needs to receive care at home (OECD, 2024[2]). Around 60% of people who receive care do so at home, compared to 69% in the OECD.
Population ageing and reducing unmet care needs will lead to increasing LTC expenditure, at the same time as the country faces fiscal constraints (Cour des comptes, 2025[13]) (see Chapter 1). While significant reforms have been undertaken regarding health and pension policies over recent years, reforms on LTC have been more limited and represent a key uncertainty for the medium to long term. Growth in public LTC expenditure due to ageing is projected at around 2% per year on average until 2050, below the average of 2.6% in OECD countries (OECD, 2024[2]). Public spending on LTC is projected to increase from 1.9% of GDP in 2022 to 2.4% of GDP by 2050 (EC, 2024[14]), a significant amount to finance. At the same time, improving the quality of LTC would raise spending, although quantifying the fiscal cost of such reforms would require further analysis.
France is undertaking significant reforms to its LTC system to address these challenges and improve quality, geographical equity, and efficiency. In 2021, it created an autonomy branch within the social security system, recognising the loss of autonomy as a social risk, and aiming to provide universal and solidarity-based coverage in the case of loss of independence (Vachey, Allot and Scotté, 2020[15]; CNSA, 2025[4]). The National Solidarity Fund for Autonomy (CNSA) was designated to manage this branch, with responsibilities for financing, steering policy, and coordinating actors. Despite some progress, further reforms to develop the branch’s role have been limited. In 2024, the government published the ‘Ageing well’ law (loi “Bien vieillir”), aiming to build a society that is adapted to the challenges of ageing, with an emphasis on preventing loss of independence and combatting social isolation. This law provides for a conference on autonomy at least every three years with various stakeholders to define guidelines and discuss political measures to be put in place.
This chapter is divided into two sections, presenting a combined package of reforms, which is needed to boost the quality of LTC alongside greater efficiency. The first discusses how to improve the quality of LTC services by updating long-term care needs assessments, boosting working conditions, and refining support for informal carers. The second section analyses how to better target financial support for LTC, mitigating costs through reinforcing prevention and the capacity to monitor spending and increasing sources of funding.
Receiving sufficient care for physical and non-physical difficulties is key to enabling more older people to stay longer at home. Several factors can support this including comprehensive needs assessments, access to sufficient care across the country, a sizeable and skilled care workforce, and well-supported informal carers.
2.2.1. Increasing the comprehensiveness of long-term care needs assessments
France’s long-term care needs assessment, conducted to determine eligibility for an older person to benefit from the personalised autonomy allowance (Allocation personnalisée d’autonomie), is ranked by the OECD as being of medium comprehensiveness (Table 2.1). Comprehensive assessments help prevent people’s abilities from declining by addressing risks beyond basic care, including social isolation, self-neglect, malnutrition, and psychological distress. A total of 13 out of 29 OECD countries have needs assessments ranked as highly comprehensive, attained through a holistic approach including cognitive, behavioural and social limitations.
France’s care needs assessment that determines public support poorly accounts for non-physical difficulties, whose recognition will become increasingly important as the LTC system moves towards home care. While a medical-social team can assess a person’s loss of autonomy and needs using several tools, only the AGGIR (autonomy gerontology iso-resource group) grid determines an older person’s eligibility for and amount of the personalised autonomy allowance. The AGGIR grid includes six bodily activities (i.e. dressing, eating) and only two mental activities (consistency and orientation) (HCFEA, 2023[17]). However, people with restrictions based on the two mental activities alone are almost always ineligible for the personalised autonomy allowance, which impacts 14% of all people aged 75 and over in ordinary housing (HCFEA, 2024[8]). In addition, even if seven additional domestic and social activities are considered when drawing up the care plan, maximum levels of the personalised autonomy allowance are determined by the initial eligibility criteria only. In practice, this often limits the ability to provide support for these activities.
Broadening the eligibility criteria in the AGGIR grid that determines the initial needs assessment for support to people also suffering from cognitive, behavioural, and social limitations would help ensure an appropriate amount of the personalised autonomy allowance and provision of care. One option is to extend support to people with at least two severe or absolute limitations among any of the eight activities in the current assessment, which is estimated to increase the number of beneficiaries by around 295 000 (HCFEA, 2025[18]). This would cost around EUR 1.4 billion or 0.05% of GDP. France could follow the example of other OECD countries to better include cognitive, behavioural and social limitations (Llena-Nozal, Araki and Killmeier, 2025[16]). For example, Slovenia’s 2023 Long-Term Care Act introduced newly defined care categories and an updated assessment tool, which evaluates LTC needs based on eight criteria, including cognitive and communication abilities, behaviour, and mental health. Australia is majorly reforming its Aged Care system, which includes introducing a streamlined, nationwide needs assessment system, which assesses a wide range of factors, such as carer profiles, health, social and psychological needs, cognition, behaviour, home safety, and financial and legal aspects. Germany recognises dementia as a condition requiring significant support.
The care needs assessment is complex, not fit-for-purpose, and outdated, with no major changes since 2008. The tool’s complexity leads to results that are difficult to understand for beneficiaries and professionals (HCFEA, 2024[8]). The needs assessment was originally designed to assess a person’s condition, not to determine the level of assistance that could be financed (HCFEA, 2023[17]). It is also poorly suited to assessing home care needs, even though this is what the majority of the personalised autonomy allowance supports (HCFEA, 2023[17]; CNSA, 2025[4]). Updating the tool to more accurately assess home care needs, while making it simpler and more transparent, could help ensure that older people receive the care they need.
Despite the nationwide needs assessment, departmental practices in allocating the personalised autonomy allowance differ (HCFEA, 2023[19]). Departmental medical and social teams appear to reinterpret guidelines to determine independence levels (IPP, 2023[20]; Gramain, Billaud and Xing, 2015[21]), which may also be linked to challenges discussed in the following section. This results in different assessments across departments, in part by considering different environmental factors (IPP, 2023[20]). Training in assessment and interpretation of the Social Action and Families Code can also lead to departmental differences in assessment (IPP, 2023[20]). Ensuring that an updated needs assessment is implemented in the same way across the country through improved guidelines and training will help ensure sufficient care and reduce regional differences.
2.2.2. Ensuring equal access to long-term care across the country
Different departmental practices due to unequal financial capacities likely lead to a gap between estimated and actual LTC needs (IPP, 2023[20]), undermining the quality and equity of support. The amount of the personalised autonomy allowance, a key form of public support, which partly covers the cost of professional non-medical assistance, differs across departments. The governance of France’s LTC system is mostly decentralised, with roles for both national and local authorities, as in around two-thirds of OECD countries (Table 2.2). Local authorities, notably departments, are the principal funder of the personalised autonomy allowance and have the ability to set its amount within nationally-set minimum and maximum levels. Annual spending per recipient averaged EUR 5 220 across departments in 2023, ranging from EUR 3 900 to 9 300, which could result from significant variations in individuals’ resources, health and isolation across departments. Geographical inequality also results in inefficient public spending as insufficient non-medical assistance, funded by departments, can increase the use of nursing care, which is more costly and funded through national health insurance (HCFEA, 2023[19]).
Note: The governance of a country’s LTC system is defined as decentralised if one of three aspects of its governance – benefits, services, and eligibility – is not centrally managed. For Canada, data for Ontario only for integration of LTC with primary care and hospitals. The United Kingdom is classified as decentralised: Scotland, Wales, Northern Ireland, and England have different laws and governance systems, but each is centralised in each region.
Source: Llena-Nozal, Barszczewski and Rauet-Tejeda (2025[22]).
Departments can be limited in their ability to provide the personalised autonomy allowance and those with more resources appear to be more generous in terms of eligibility and care provision (IPP, 2023[20]). Departments’ resources include revenues from property transactions, which can limit their spending during economic downturns, as they cannot go into debt to fund operating expenditure (see Chapter 1). Additionally, departments do not all face the same spending pressures. Firstly, the share of possible recipients ranges from 4% to 40% of a department’s population (HCFEA, 2023[19]). Secondly, some face higher spending on their other policy responsibilities, such as child welfare services or minimum income benefits (RSA), which will weigh on their ability to provide the personalised autonomy allowance.
The government has taken steps to reduce territorial inequalities. In 2022, the introduction of the national minimum hourly tariff for home-care services funded by the personalised autonomy allowance helped reduce territorial inequalities, with the increase financed by the CNSA. Its introduction increased the value of about 71% of home-care hours financed by departments under the personalised autonomy allowance and the disability compensation benefit (Prestation de compensation du handicap, PCH). However, many members of the Age Council have noted that the tariff is insufficient to cover the costs of delivering home care (HCFEA, 2022[23]). Other critiques include that the annual adjustments to the tariff based on inflation do not keep up with changes in costs, which are largely due to wage increases.
Defining a core offer of support financed through the personalised autonomy allowance, which would require increasing transfers from the CNSA to departments, could guarantee a universal minimum of care. This would also reduce dependence on cyclical revenues on property transactions and further clarify the roles of the CNSA and departments. Its scope could range from raising the minimum level of the personalised autonomy allowance to extending support to a universal social security benefit for LTC (Cour des comptes, 2025[24]; CESE, 2024[25]). Such a change would still allow departments to complement a minimum nationally-defined level of support with additional services, reduce out-of-pocket costs (see below), and guarantee a regional network of medical and social services.
A pilot programme aiming at altering the financing of LTC institutions, i.e. residential care, could also support territorial equity. In 2025, in nearly a quarter of departments, regional health agencies (Agences régionale de santé) received an additional allocation, with an aim of financing the total budget of institutions. Previously, regional health agencies only financed care services of LTC institutions, while departments financed assistance and support services, which could vary across the country. This pilot aims to reduce the fragmentation of health services within LTC and inequalities between departments, increase simplicity and transparency, strengthen the financial stability of establishments, and strengthen the role of regional health agencies and national health insurance in financing medico-social establishments. Evaluating this pilot and continuing to affirm the role of regional health agencies in managing nursing homes could help reinforce the role of each actor and efficiency. Ensuring strong communication between home-care and institutional-care providers and avoiding misaligned incentives that would discourage transfers between settings will be key.
Greater coordination across actors could also help reduce regional inequalities. A departmental public service for independence (SPDA) is aiming to facilitate care pathways for older people by improving coordination between the many actors providing LTC services, among other objectives. The available offer of LTC services is not always clear, information is scattered and difficult to understand, and recipients often receive services from many providers who do not coordinate well (Or et al., 2023[26]; Libault, Perruchon and Farnault, 2022[10]). Providers often work in silos, which can cause breaks in care (Cour des comptes, 2025[24]). Such a service could help provide more of a single offer of support. In 2024 the CNSA piloted this public service in 18 departments and is now rolling out the programme nationwide. Providing this service with precise objectives for service quality as well as for reducing regional inequalities in the levels of assistance and provision will help boost the quality and equity of LTC services (HCFEA, 2025[27]).
2.2.3. Increasing the attractiveness of the care and nursing professions
France, like many OECD countries, faces persistent care worker shortages. Shortages are especially acute for personal care workers (aide soignante), who represent 75% of France’s LTC workforce (OECD, 2023[6]). Personal care workers provide routine support, such as bathing or dressing. Nurses largely make up the remainder of the workforce. Low pay and poor working conditions in the highly female-dominated sector, partly driven by tight public budgets and limited social recognition, constrain the supply of LTC workers. France has no staffing ratio requirements, unlike 19 OECD countries, which typically support working conditions, reduce burnout, and provide better outcomes for care recipients (Llena-Nozal, Barszczewski and Rauet-Tejeda, 2025[22]). Nevertheless, introducing staffing ratio requirements is likely infeasible under current shortages.
Labour shortages are set to worsen as the ageing population boosts demand while the working-age population shrinks. The number of 20-64-year-olds is projected to fall by 2% between 2023-2033 then 3% between 2033-43, similar to the OECD average (OECD, 2023[6]). At the same time, assuming unchanged shares of formal-care use and staffing ratios, LTC workers would need to increase from 1.3% of total employment in 2023 to 1.6% in 2033 and 1.9% in 2043 (OECD, 2023[6]). Another estimate suggests that around 150 000-200 000 additional workers will be required by 2050 (Drees, 2026[28]). France has implemented some measures aiming to tackle staffing shortages, such as those resulting from the Health Summit (Ségur de la Santé) launched in 2020, which helped increase salaries, staffing, and working conditions, and through the 2020-24 Plan to promote the attractiveness of careers in old age care (Plan de mobilisation nationale en faveur de l’attractivité des métiers du grand âge). Nevertheless, these trends underline the need for stronger policies to address unmet needs and labour shortages (OECD, 2023[6]), especially as national projections foresee shortages (Drees, 2024[29]; France Stratégie & Dares, 2022[30]).
Even though France has increased remuneration since the onset of the pandemic, LTC wages remain low. Numerous measures have helped increase salaries in recent years, including the increase in salaries and change in the pay scale for personal care workers following the Health Summit, and the introduction of the national minimum hourly tariff for home-care services in 2022. Despite these increases, in 2023, personal care workers earned around 88% of median net monthly earnings in the public sector and around 57% in the private sector. While comparable cross-country data on personal care workers and private nurses are limited, remuneration of hospital nurses can provide an indication of relative salaries across countries. In France, hospital nurses earn around the average wage, compared to around 120% of the average wage across the OECD. Their salaries are also below the OECD average on a purchasing power basis. With around 80% of LTC services publicly financed, increasing public spending to improve job quality, including wages, is essential to attracting workers and reducing shortages. Evaluating the increase in attractiveness from recent measures would help determine further changes.
Policies that reduce discrimination against women and challenge gender stereotypes would support women in the LTC sector, which represented 94% of care workers in France, compared with 87% across the OECD in 2021 (OECD, 2023[6]). Despite gradual shifts in traditional gender roles, care work is still often viewed as women’s work, which leads to undervaluing the working conditions needed to attract and retain staff. OECD analysis using data from the OECD Survey of Adult Skills (PIAAC) finds that the gender hourly wage difference among LTC workers in similar jobs and with similar characteristics is significant and estimated at 8% across the OECD, contributing to the sector’s lower wages (OECD, 2023[6]).
Supporting education, training and working conditions
France has a relatively well-qualified LTC workforce although greater opportunities for career progression and training could enhance job attractiveness. Only 6% of workers did not have at least an upper secondary qualification in 2019, compared with 22% in the OECD. France requires some mandatory training, as in 13 other OECD countries (Llena-Nozal, Barszczewski and Rauet-Tejeda, 2025[22]). Nevertheless, expanding training and the use of digital tools could improve opportunities for career and salary progression, reduce physical and mental risks, and support higher quality care (OECD, 2023[6]). For example, training can make LTC work less straining by teaching workers proper techniques for lifting people or caring for people with dementia. France has recently increased the number of training places and renovated facilities and the impact of these measures on training rates will need to be followed closely. Taking full advantage of digital technologies hinges on sufficient digital skills, an area where France lags the OECD average.
Recognising prior personal-care experience in the form of course credits for education and training programmes could support career development (OECD, 2023[6]). In Sweden, Switzerland, the United Kingdom, and the United States, experience can replace parts of vocational training programmes, while in Switzerland, it can replace entire programmes. Portugal has a national system to register qualifications in social services built up through training or experience.
In France, as across OECD countries, insufficient social recognition reduces the attractiveness of the LTC profession. Public campaigns can help change the image of LTC work, attract more men and contribute to workers feeling more valued (OECD, 2023[6]). France’s “Prendre soin” campaign aims to reinforce the attractiveness and recruitment of workers in the care and social sectors (Gouvernement, 2025[31]). A website and social media presence aim to introduce people to these careers, facilitate job searches, and offer information on career paths and retraining. The campaign targets young people and adults seeking a career change. Evaluating the campaign’s impact would support its effectiveness.
Ensuring the fair treatment of migrant workers
Migrant workers are overrepresented in the LTC sector and may face greater risks of unfair treatment. Around 15% of declared LTC workers had a migrant background compared to 12% of all workers in 2021 (OECD, 2023[6]), while the available evidence suggests that most undeclared workers are migrants (Eurofound, 2025[32]). While below the OECD average, the share has risen by around 4 percentage points between 2011 and 2021. While France has highly protective labour laws, ensuring fair working conditions for migrant care workers, which both protects their rights and maintains care quality, can have specific challenges. For example, a higher share of migrant workers provides live-in care, an area where labour regulations are difficult to enforce. Continuing to develop ways to monitor the employment conditions of private live-in carers, in particular working hours, rest periods, and remuneration for hours on call, could help to ensure better treatment. France could also simplify the recognition of foreign qualifications, with nursing degrees from third countries outside of the European Union, Switzerland, and Quebec (Canada) generally not recognised in France (OECD, 2025[33]). For example, in Germany, an equivalence assessment evaluates nursing and medical diplomas against German standards to establish if it is equivalent.
2.2.4. Refining support for informal carers
Informal carers play a central role in providing LTC, supporting older people’s preferences to stay at home, and helping contain costs. They include family members, friends, and neighbours who provide care because of a close relationship, regardless of any financial or in-kind compensation. Out of the share of older people receiving care in France, around 44% receive informal care or a combination of informal and formal care, compared to 46% across the OECD (Figure 2.2, Panel A). In France, around 15% of people aged 50 and over provide informal care on a weekly basis, compared with 13% across the OECD, with a slightly higher share of care being provided by women than men, although below the OECD average (Panel B).
The number of informal carers risks falling due to population ageing. The contribution of informal carers of older people in France is estimated at 0.5%-0.9% of GDP in 2019 (EUR 12 to 21 billion) (Roy, 2019[34]). While France has strengthened support for informal carers, it remains limited, as in many OECD countries. For example, for an older person with moderate needs and a median income, public support would cover 57% of formal care costs. However, if the person relied on informal care, public support would amount to only 27% of what formal care would cost (OECD, 2024[2]).
Note: Panel A: ADL stands for activities of daily living while IADL stands for instrumental activities of daily living (see Box 2.1). Informal care is received from family and friends; formal care is delivered by paid carers. Panel B: The average represents the 25 OECD countries for which data are available. The definition of informal carers differs between surveys (see Rocard and Llena-Nozal (2022[35])). Canada: data refer to those aged 15 years old or over. United Kingdom: data for England only.
Source: Rocard and Llena-Nozal (2022[35]).
Public support can reduce the negative impacts on carers’ health and labour market outcomes. Lower labour supply and skill losses are estimated to cost almost 0.4% of GDP in western European countries (Barszczewski et al., 2025[36]). France is supporting the protection of informal carers through the Acting for Carers national strategy (Agir pour les Aidants). Informal carers can receive an indirect cash benefit (conditional on an agreement with the care recipient), similar to in around two-thirds of OECD countries (Rocard and Llena-Nozal, 2022[35]). Paid leave of up to 21 days helps carers combine paid employment and care, which is generous compared to other countries. Unpaid leave from employment to care for an older dependent can be taken for up to three months, renewable once. Workers with a carer’s status (“proche aidant”) can convert leave entitlements into reduced working hours. France is among the 70% of OECD countries that provide some form of social security coverage to informal carers (Rocard and Llena-Nozal, 2022[35]). Since 2023, the old-age insurance for carers (assurance vieillesse des aidants, AVA) enables carers to accrue pension entitlements (CNSA, 2025[4]). Extending coverage to spouses, who are eligible for public support in all OECD countries except France and the United States, would better support many informal carers whose care responsibilities often constrain their ability to work.
Providing an assessment of the needs of informal carers during a recipient’s needs assessment could better support gender equality. Potential informal care provided by spouses appears to be taken into account when developing care plans. One study finds that for identical care needs, male recipients living with their wives received on average EUR 54 less per year in care benefits (around 10% of the average total care provision of EUR 550) than female recipients living with their husbands. This suggests an expectation that wives provide more care on average (Drees, 2020[37]). More generally, people living with a spouse also received around EUR 130 less per year (24% less on average) than those living alone. Introducing an assessment for informal carers could help incorporate their perspectives on home care while raising awareness on available support (Rocard and Llena-Nozal, 2022[35]). Informal carers’ assessments occur in England, the Netherlands, and in some Swedish municipalities.
In the face of increasing LTC expenditures, further policies are needed to ensure fiscal sustainability, in addition to addressing the current gaps in unmet needs. Non-mutually exclusive options outlined in this section that could be implemented simultaneously include adjusting the targeting of LTC benefits, promoting healthy ageing to reduce the costs of LTC, and seeking additional sources of funding.
2.3.1. Increasing the targeting of public support for long-term care
As France faces fiscal constraints limiting its ability to move towards universal public support for LTC, targeting can limit negative economic impacts and poverty risks. Targeting support to people with severe needs and those the least able to afford care can yield one of the largest reductions in the risk of poverty. It also limits the need for significant care from family or friends, which improves their ability to work, increasing GDP and government revenues (see above).
France reduces the poverty risk associated with LTC costs less effectively than some other OECD countries given the amount of public spending as a share of GDP (OECD, 2024[2]). France provides support in the form of the means and needs-tested personalised autonomy allowance, non-means tested tax credits, and reduced tax liabilities for people with severe needs (see Box 2.1). More targeted needs and means testing could better reduce the risk of poverty while limiting public spending.
Strengthening targeting for home care based on needs
Out-of-pocket costs for older people in home-based care can be equivalent to the median income of people aged over 65 for someone with severe needs, while these decline to around 50% of income for someone with moderate needs, and are minimal for someone with low needs (Figure 2.3, Panel A). Unlike in most OECD countries, the share of LTC costs covered by public funding declines as needs increase (Panel B): public support covers 76% of costs for someone with low needs (needing 6.5 hours per week) but only 45% of costs for those with severe needs (needing 41.25 hours per week). One reason for this is the cap on the maximum number of care hours financed by the personalised autonomy allowance, a feature also observed in Korea and Slovenia. As a result, in 2026, a person cared for at home evaluated as being in the highest needs category (GIR 1) could receive up to EUR 2 080 per month, equivalent to about 19.2 hours of care per week at the minimum hourly rate of EUR 25 (see the discussion below on public support for institutional care). Greater targeting of public support by needs could more effectively reduce poverty risks, meet care needs, and reduce the need for informal care.
Home care for older people with low, moderate and severe needs, with median income and zero wealth
Note: Low, moderate, and severe needs correspond to 6.5, 22.5 and 41.25 hours of care per week. An older person with severe needs receiving LTC at home is assumed to live with a spouse who can provide 24-hour supervision, help with taking medicines, and manage finances, but cannot provide other activities of daily living or instrumental activities of daily living care. Care recipients’ needs are described in OECD (2024[2]). GBR: England only.
Source: OECD (2024[2]) based on the Long-Term Care Social Protection questionnaire, the OECD Income Distribution database, and the OECD Wealth Distribution database.
Strengthening income-based targeting
While public support for home-based care is overall progressive (Drees, 2024[38]), further refinements could better minimise poverty risks and maximise the efficiency of public spending on LTC. Income testing, also used in Spain and the United Kingdom (England), helps increase the effectiveness of spending (OECD, 2024[2]). France lowers public support and requires greater personal contributions to the personalised autonomy allowance according to recipients’ incomes (Figure 2.4, Panel A). However, there appears scope to better support the lowest income earners. The threshold at which care recipients must contribute to the personalised autonomy allowance is below the relative poverty line. In 2025 this threshold was a monthly income of EUR 918, which is adjusted each year based on an indexation reference for social benefits (Majoration pour Tierce Personne, MTP). Raising the minimum income threshold for contributions to at least the relative poverty line, which occurs in the Flanders region of Belgium, could help reduce the risk of poverty. Contributions to the personalised autonomy allowance increase up to an income of EUR 3 382, around 150% of median income, after which contributions are capped at 90% of the allowance. Maintaining a small share of the allowance for high income earners maintains the universality of support.
Two other forms of support, tax credits for home care and reduced tax liabilities for people with severe needs, limit the progressivity of support. OECD analysis suggests that out-of-pocket costs for a low-income earner (20th percentile) and a median-income earner with moderate needs are around 45% of income, only slightly below those for a high-income earner (54%) (Figure 2.4, Panel B). Non-means-tested tax credits for home care cover 50% of the costs of home-based non-medical services, up to EUR 12 000 per year. Reduced tax liabilities for people with severe needs, who are counted as 1.5 people in the calculation of joint taxation, principally benefit high-income earners due to higher taxes paid. Combined with the personalised autonomy allowance, a person earning an income above EUR 3 382 could receive a maximum of EUR 2 046 per month in public support if they are classified as having the most severe needs (GIR 1), while contributing only EUR 921 (Gouvernement, 2025[3]). Strengthening targeting could help limit public spending and allow for higher support for severe-needs and low-income recipients.
Note: Panel A illustrates how public support as a share of the highest possible amount of public support changes across income levels and incorporates the personalised autonomy allowance and the tax credit. Low, moderate and severe needs correspond to 6.5, 22.5 and 41.25 hours of care per week. Panel A: Expressed as a share of median income among the population aged over 65. Panel B: Low, median and high income refer to the upper boundary of the 20th, 50th and 80th percentile of the income distribution among the population aged over 65. Descriptions of care recipients’ needs are available in OECD (2024[2]). GBR: England only.
Source: OECD (2024[2]), based on the Long-Term Care Social Protection questionnaire, the OECD Income Distribution database, and the OECD Wealth Distribution database.
In residential LTC institutions, out-of-pocket costs as a share of income vary across income levels, suggesting scope for greater fairness. Median income earners with severe needs can face out-of-pocket costs that are greater than their incomes (Figure 2.5). This does not necessarily mean that needs go unmet, as costs already include board and lodging, leaving few additional costs. Older people unable to pay for the accommodation portion of institutional care can receive social housing assistance (Aide sociale à l'hébergement, ASH), recoverable from their estate, and adult children can also be legally required to contribute. Low-income earners may receive housing support (aide personnalisée au logement, APL). Out-of-pocket costs for high-income earners fall to 68% of their income and for low-income earners, this declines to 22% due to threshold effects in access to public support. Making the co-payment more equal across income levels could increase fairness and reduce public spending.
Further incorporating a person’s assets as well as their income in means-testing, while allowing for deferred payments in the case of illiquid assets, could contribute to better targeted social protection and enhanced equity (OECD, 2024[2]; Oliveira Hashiguchi and Llena-Nozal, 2020[39]). While targeting care to those unable to afford it can minimise poverty risks, taxable income may be an imperfect measure of older people’s resources and ability to contribute. More than half of OECD countries and subnational areas for certain OECD countries use some form of wealth-testing to determine eligibility for LTC support, primarily in institutional settings (OECD, 2024[2]). France does not include wealth to determine eligibility for LTC support. However, it does include a notional income based on a flat-rate return applied to certain non-productive assets (for example, vacant property, notably excluding the main residence, or uninvested capital, excluding life insurance holdings). Additionally, wealth is included to determine eligibility for social housing assistance in institutional care (see above).
Average out-of-pocket costs of institutional care for someone with severe needs after receiving public support
Note: Low, median and high income refer to the upper boundary of the 20th, 50th and 80th percentile of the income distribution among the population aged over 65. Descriptions of care recipients’ needs are available in Annex A of OECD (2024[2]).
Source: OECD (2024[2]) and OECD analyses based on the Long-Term Care Social Protection questionnaire, the OECD Income Distribution database, and the OECD Wealth Distribution database.
While including assets within means testing could incentivise more efficient use of public resources and reallocate spending towards those most in need, it needs careful design. Firstly, low thresholds may lead to unintended consequences, such as strategic behaviour to fall below the threshold, and may discourage savings. To prevent this, some countries have introduced progressive wealth-testing. For example, in Spain, 5% of the value of wealth excluding the primary residence is added to older people’s income to determine their public support. In England, support for older people with moderate and severe needs decreases gradually between wealth of GBP 14 250 and GBP 23 500. Secondly, means testing could also take account of assets and income over previous financial years, reducing incentives to lower assets through bequests, as in New Zealand and the United States. Thirdly, to avoid the risk of high care costs for long-term users and reduce incentives for delaying receiving care, France could consider a lifetime cap on user contributions. Lastly, in the case of illiquid assets, the development of reverse mortgages in France provides one option. Deferred payment agreements are another option to allow care recipients to postpone contributions to their care (Llena-Nozal, Araki and Killmeier, 2025[16]). Contributions could be recoverable from a person’s estate, as is done for financial support that helps cover the accommodation cost of institutional care (aide sociale à l’hébergement).
2.3.2. Limiting rising costs though healthy ageing and greater preventive care
Investing in healthy ageing
While population ageing will challenge the LTC system, the extent depends on how people’s health evolves as they age. While people in France are living longer, they are also spending more time in less than full health. At age 60, people in France spend 6.2 years in less than full health, compared with 5.7 years in the average OECD country (Figure 2.6, Panel A). However, healthy ageing, i.e. living all additional years of life due to higher life expectancy in good health, could limit the projected increase in older people with severe needs from 0.7% of the population in 2022 to 0.9% by 2050, instead of 1.6% if current trends continue (Panel B). Investing in healthy ageing helps improve people’s quality of life, delaying, reducing, or outright preventing chronic diseases (OECD, 2025[11]). Helping people to age independently at home and delay a transfer to a LTC facility can help meet the preferences of older people and be more cost effective, with home-based care generally less expensive for people with low and moderate needs than care in facilities. OECD calculations show that an increase in the ratio of spending on long-term care at home over long-term care in facilities by 10% can lead to a decrease in the overall long-term care spending by 4.9% (OECD, 2025[11]). Several measures are strengthening prevention for loss of autonomy including the 2022-2026 national fall prevention plan, the MaPrimeAdapt’ programme, supporting older people to adapt their housing, the 2024 ‘Ageing well’ law (loi “Bien vieillir”), and the ‘Mon Bilan Prévention’, prevention assessment at key age points. Nevertheless, there remains scope for further expansion, based on evaluations of existing programmes.
Note: Panel A: OECD and EU are simple averages; Panel B: Healthy ageing assumes that all additional years of life due to higher life expectancy are lived in good health. The figure includes an unweighted OECD average. United Kingdom: data for England only.
Source: World Health Organisation; OECD (2024[2]).
Continuing to adapt health systems for older people could better meet their more complex and different needs while reducing costs. Adapting health systems can shift care to settings that offer better value for money and better care, such as in primary and intermediate care facilities or in a person’s home. It can also shorten or replace hospital stays for older people, which are expensive and can be stressful for older people and expose them to risks. In France, insufficient medical and social support for older people has led to additional health costs, in particular an increase in hospitalisations (HCFEA, 2025[18]; Penneau and Or, 2023[40]). France is making progress in offering more coordinated care that is closer to people’s homes. For example, France is one of 22 OECD countries that predominantly offers hospital-type care in a patient’s home or LTC facility to outright replace or shorten inpatient stays (OECD, 2025[11]). France is also one of 20 OECD countries with an Integrated Care Programme, which formalises coordination among workers and incentivises better continuity of care by changing how professionals are paid (OECD, 2025[11]). Nevertheless, efforts to adapt the health system should continue.
France could continue to better identify older people at risk. Since 2025, France has been rolling out the World Health Organisation’s Integrated Care for Older People (ICOPE) programme, integrating screening tools into Mon Espace Santé and training health professionals to support the programme, aiming to reach around 2 million older people by 2027. Ensuring the programme reaches all older people, including those less able to access digital tools, and that it is followed up with interventions will be key. Targeted interventions, such as preventative home visits, which are offered in 16 OECD countries, can also improve health outcomes, reduce hospitalisations, and delay admissions to long-term care facilities, although these are only optional in France. Implementing widespread preventive visits could improve outcomes and help limit spending pressures: preventive home visits in Norway were found to reduce admissions to long-term care facilities by 7%, hospital admissions among those aged 80 and above by the same rate, the average number of hospital days by 11%, and mortality of those aged 80 and above by 4% (OECD, 2025[11]).
France could extend rehabilitation after health shocks to better support recovery. France, as in most OECD countries, has measures for rehabilitation and reablement in place; however, it does not offer some services that are commonly available across countries, such as occupational therapy, speech and language therapy, cognitive therapy, and mental health therapy (OECD, 2025[11]). Increasing the offer of rehabilitation services could better support individuals to maintain or regain certain functions and translate into lower consumption of high-cost care.
Increased data and information on prevention and healthy ageing could help to target efforts. Many local and national actors are involved in preventing loss of autonomy, which often act alone, and services are unequal across the country (Cour des comptes, 2021[41]). This can make it difficult to understand the scope, content and results of all efforts. Continuing to better define actors’ roles and better availability of data through an integrated IT system (see Section 2.3.4), could greatly support older people to age healthily.
Boosting prevention
Investment in preventive care remains low, as across the OECD. France currently spends around 0.27% of GDP on prevention, slightly below 0.3% in the average OECD country (Figure 2.7). Prevention is closely associated with vaccination or screening campaigns and characterised by a health approach that takes little account of living conditions and habits (Cour des comptes, 2021[41]). Only around 0.03% of GDP is spent on information, education, or counselling programmes, and 0.03% on early disease detection compared to 0.06% and 0.04% of GDP in 21 OECD countries. This limits the scale and scope of programmes and the impact they have in leading to tangible effects. A 2026 reform aims to create a pathway to provide reimbursed preventive care to patients with early-stage chronic diseases, such as adapted physical activity, dietary support and regular comprehensive check-ups. Increasing spending on preventive care for both older people and across the population could help lower health spending: OECD estimations show that a 10% increase in spending on prevention was associated with a decrease in the share of people with chronic conditions and lower health spending of almost 1% in France and 0.9% in the OECD after a period of five years (OECD, 2025[11]). While behavioural changes earlier in life can lead to larger benefits, prevention and promoting healthy behaviours at older ages can still improve healthy ageing and reduce health expenditures (OECD, 2025[11]).
Alcohol consumption and smoking rates, particularly for women, are well above the OECD average (OECD, 2023[42]). Diseases associated with excessive use of alcohol across the population are estimated to lower French GDP by 1.4% over 2020-50 (OECD, 2021[43]). France has implemented numerous measures to support reduced alcohol consumption, although compared to some OECD countries, France maintains lower levels of tax on alcohol, particularly on wine (OECD, 2024[44]; 2021[43]; 2017[45]). France has also strengthened its tobacco control policy through policies such as increasing the price of tobacco products, plain packaging, a yearly cessation campaign, and the reimbursement of nicotine replacement products. OECD estimates suggest that the implementation of these policies over 2023-2050 will return EUR 4 for each euro invested, avoid around 4 million cases of chronic diseases, and increase labour productivity and participation in the labour market by the equivalent of 19 800 additional workers per year (Devaux et al., 2023[46]). Reinforcing prevention efforts to reduce alcohol consumption and continuing efforts to reduce tobacco consumption will help limit the burden of chronic diseases and offers cost-effective returns (OECD, 2025[11]).
The share of the population that is overweight or obese is relatively low in France, although there is significant room for people to eat healthier. Only 20% of the adult population consume five or more portions of fruit and vegetables per day, above the OECD average of 15% (OECD, 2023[42]). Increasing prevention efforts to support healthy eating would support health outcomes and the economy: Overall, overweight is estimated to reduce GDP in France by 2.7% on average over 2020-2050 period (OECD, 2019[47]).
Only one in five older people meets daily physical activity guidelines, below the OECD average of over one in four. Physical activity is key to healthy ageing, for example it can reduce the incidence of falls among older people by 38% and reduce cognitive decline (OECD, 2025[11]). France is undertaking interventions to support physical activity. For example, maisons sport-santé organise information and awareness sessions and provide guidance and personalised support from health and sports professionals for sustainable practice of physical activity and sport (OECD/WHO, 2023[48]). However, additional spending on prevention and measures targeted at older people could lead to further gains. For example, Japan facilitates a community-led sports course that helps older people increase physical activity while also building social networks.
Spending on prevention by health function, 2024 or latest available
Note: OECD26 is the non-weighted average of the 26 OECD countries for which the spending on prevention components is available.
Source: OECD Health Statistics database.
Increasing use of digital tools to support healthy ageing and productivity
Technology has the potential to improve worker productivity, promote efficiency, and potentially reduce the costs of long-term care at home (OECD, 2025[11]). For example, in Denmark, a digital training tool for physical activities at home (“DigiRehab”) contributed to efficiently monitoring care recipients’ physical ability while also reducing home care needs (OECD, 2025[11]). In Finland, the telecare scheme, “Remote Care”, helped long-term care workers reduce travel time. Greater financial support for assistive technology could better support its adoption. France provides public funding to cover medication dispensers although further coverage could be extended to promote rehabilitation or exercise (OECD, 2025[11]). Norway, the Slovak Republic, and Sweden also cover location trackers with public funding. Other examples of publicly funded digital tools for people living at home include home security alerts and remote monitoring, which are available in Canada (New Brunswick), Luxembourg, and New Zealand (OECD, 2025[11]). France’s ‘Dare AI’ programme and sectoral AI Ambassadors initiatives will help accelerate the economy-wide adoption of AI and digital transformation tools. Expanding training for digital skills for LTC workers will also be key (see above).
2.3.3. Reinforcing the capacity to monitor spending
One of the objectives of the National Solidarity Fund for Autonomy (CNSA), the manager of the autonomy social security branch, is to ensure the efficient management of resources (CNSA, 2022[49]). The CNSA’s spending has increased since it became the manager of the social security branch in 2021, although the results on better planning and use of resources are patchy (Cour des comptes, 2025[24]). The CNSA lacks structured projections for LTC spending needs beyond 2030 and the tools to project and analyse long-term financing needs in depth (Cour des comptes, 2025[24]). Multi-year projections for needs and their financing should be extended to allow for greater financial and administrative planning. For example, the New Zealand Treasury produces long-term fiscal projections every four years.
The CNSA needs stronger data collection to be able to strengthen its oversight of the system and improve control on the quality and effectiveness of spending. The CNSA uses many information systems, which is complex. Collected data is insufficient, focusing on supply, with little data on users and needs (Cour des comptes, 2025[24]). More data are needed to produce a more detailed analysis of future needs, their timing, the effects of organisational or pricing choices, and the required investments in prevention and early detection (Cour des comptes, 2025[24]). Efforts over the past 10 years have tried to harmonise information systems. Some features have been deployed but are not operational for all departments. One key challenge is the diverse systems used by actors. Improving data availability through a shared information system is key for the CNSA to effectively manage the branch and harmonise practices (HCFEA, 2025[18]). Spain, a country with decentralised LTC governance, has managed to improve data availability. While regions often have their own IT system, as in France, Spain created a centralised IT system where regions must share a minimum amount of data on beneficiaries and spending with the national government. The central government only reimburses regions for LTC spending once this data is received. The development of a regulatory text to establish a national information system for LTC needs assessments is underway.
Continuing to develop the CNSA’s internal control tools will help better ensure the accountability of spending. The CNSA finances almost half of departments’ spending although it has limited ability to monitor if allowances and funding are allocated in line with regulations (Cour des Comptes, 2025[50]). The number of CNSA staff dedicated to internal control is insufficient to ensure risk management of all stakeholders (Cour des comptes, 2025[24]). The CNSA’s human resources are set to increase by 50% between 2022 and 2026. Taking stock of whether the CNSA has the appropriate resources for their responsibilities, as planned, will help ensure it can fully achieve their objectives. Strengthening internal control procedures, developing a structured anti-fraud policy and increasing controls on the effective use of certain benefits will also play a key role (Igas / IGF, 2025[51]).
2.3.4. Increasing sources of funding
Appropriately funding LTC in the face of population ageing remains a challenge in France (Cour des comptes, 2025[13]). Changes to the financing structure of the autonomy social security branch have been relatively limited since its creation. However, in 2026, the government created a financial contribution for autonomy by increasing the rate of the Contribution sociale généralisée (CSG), a broad-based social tax, on certain capital incomes. This contribution is expected to generate around EUR 1.4-1.5 billion of revenues per year for the branch, whose deficit is now projected to ease to around EUR 200-400 million per year until 2028. Financing needs will continue to build over the coming decades. Increasing funding through a rise in social security contributions or taxes would be a challenge: only around 27% of people in France would be willing to pay an additional 2% of their income in taxes or social contributions to benefit from better provision and access to LTC, below 34% of people in the average OECD country (OECD, 2023[5]). Shifting additional resources from the current working-age population to older people might have implications for intergenerational equity and compound the existing inequalities in income and wealth across generations (see Chapter 1 and OECD (2025[52])). In France, older people have among the highest relative standards of living compared to the working-age population in the OECD. Old-age poverty is low: France is one of 18 out of 32 OECD countries which report lower poverty rates for people over 65 compared to children.
An older person contributes less to the financing of LTC than someone of working age (see Chapter 1). They face lower rates for the Contribution sociale généralisée (CSG), which finances the social security system, and benefit from reduced social security contributions (see Chapter 1), which finance around 88% of the autonomy social security branch. Aligning older people’s CSG and social security contributions with those of workers would also help increase funding for rising LTC expenditure.
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