Care is a common concern among Europeans. Based on estimates, one in three Europeans have caring responsibilities. Care needs are estimated to increase significantly, especially on the back of ageing population. The majority of care provision relies largely on family and friends. In many EU Member States, in addition to public and for-profit providers, the social economy is increasingly providing care services, offering alternative solutions such as home care and community-based services. They offer innovative models of care provision including ageing with autonomy, increased access in rural areas and integrated services while promoting innovation and advocating for better working conditions. However, they are constrained by challenges including limited sector visibility, staff shortages and the need for better framework conditions. Policymakers and public authorities can play an important role in addressing these barriers to fully unlock the capacity of the social economy to deliver high quality and accessible care services.
Social Economy in Europe
Abstract
Source: Based on (European Commission, 2022[1]).
Rising caring responsibilities and needs in Europe
Care is an essential part of life for many people, whether they are receiving care, providing it or seeking professional care services. One in three Europeans is estimated to have caring responsibilities. Care services span a wide range of different activities from caring for older people or people with disabilities to childcare. As underlined in the 2022 European Care Strategy, access to quality care services has significant implications on living in dignity, upholding human rights, leaving no one behind and providing opportunities for better life and career prospects. (European Commission, 2022[1]). Similarly, the European Child Guarantee underscores the need to tackle social exclusion by guaranteeing access of children in need to free early childhood education and care among other key services (European Commission, n.d.[2]).
Long-term care refers to a range of medical and personal assistance services that support people who are dependent on help for daily living activities. These services include assistance with personal care (e.g. eating, washing, dressing, mobility), basic medical services (e.g. pain management, wound dressing, medication, prevention, health monitoring, palliative care) and instrumental activities of daily care (e.g. managing finances, grocery shopping) (OECD, 2024[3]; OECD, 2005[4]; OECD/Eurostat/WHO, 2017[5]). While ageing may significantly increase dependency, long-term care does not only address the needs of older people but of all people with limitations in physical and cognitive capacities.
Across OECD countries, one in four older people (aged 65 and above) have long-term care needs. The demand for long-term care is projected to increase by almost 30% until 2050 in OECD countries (OECD, 2024[6]). European Union (EU) Member States are no exception. The share of people with long-term care needs is expected to rise from 11.6% in 2020 to 14.1% by 2070 (Belmonte et al., 2023[7]). The EU public expenditure on long-term care is projected to increase from 1.7% of GDP in 2022 to 2.6% of GDP in 2070, which is equivalent to an increase of expenditure by 48% (European Commission, 2024[8]). Similarly, current expenditures on long-term care in the OECD are expected to multiply by 2.5 times by 2050 (OECD, 2024[6]). Across the EU, objectives to promote healthy longevity are hampered by shortages in the health workforce with required skills (OECD/European Commission, 2024[9]).
In many EU Member States, care provision is reliant on “informal” care and family in addition to residential facilities. Around 52 million people are estimated to provide informal care to family members or friends regularly, which corresponds to 80% of long-term care providers (European Commission, 2022[1]). Public spending on long-term care depends significantly on whether care services are more often provided in formal institutional settings or by informal arrangements such as family members. In many southern, central and eastern European Member States, expenditure on formal long-term care services accounts for a smaller share of total spending compared to other countries such as Denmark, the Netherlands, Norway or Sweden (OECD/European Commission, 2024[9]).
Informal long-term care accounts for significant economic value in the EU. The value of hours of care by informal carers is estimated to correspond to 2.5% of GDP. This surpasses the average public expenditure on formal long-term care, which stood at 1.7% in 2019 (European Commission, 2022[1]). Across the OECD, only half of the people over 65 with severe limitations in daily activities receive formal care (OECD, 2023[10]). Notwithstanding, the care sector provides many opportunities for employment and public revenues. Investing in care services is estimated to generate additional tax revenues from jobs created and increased labour market participation, especially by women, reducing public funding requirements for care services (ILO, 2022[11]).
Providing care services, in particular childcare but not only, has important implications for female participation in the labour market. In the EU, 90% of over 9.1 million people working in the care sector are women. Women are also predominantly responsible for unpaid care, with 92% of them in the EU providing care regularly. Around 7.7 million women in Europe are kept away from participating in the labour market due to unpaid care responsibilities, compared to only 450 000 men. This translates into an increased gender employment gap by 11 percentage points, a further gender pay gap of 13% and a gender pension gap of 29%. Recent evidence shows that one-third of women aged 25-49 outside of the labour force indicated care responsibilities as the main reason for not seeking employment in the pre-pandemic 2019, compared to 7.6% of inactive men (European Commission, 2022[1]). Infographic 1.2 summarises some key facts on care employment including childcare and other types of care across EU Member States.
Source: Based on (European Commission, 2022[1]).
As the demand for quality long-term care rises in the EU, these services are often either unaffordable or inaccessible or both. It is estimated that one-third of households with long-term care needs are not able to use home care services due to unaffordability. On average, 26.6% of people aged 65 or over and 39.4% of those aged 75 or over living at home need long-term care. Almost half of people aged 65 or over with care needs have an unmet need for help with personal care or household activities. Similarly, half of children with disabilities are cared for only by their parents (European Commission, 2022[1]).
Affordability of long-term care services is challenging across EU Member States. According to the 2016 European Quality of Life Survey, 9.1% and 27.5% of respondents find cost very difficult and a little difficult respectively as a barrier to accessing long-term care services in the EU (Eurofound, 2016[12]). Challenges around access to long-term care services are echoed across OECD countries. According to the 2024 Risks that Matter Survey, 65% and 61% of respondents worry about accessing good-quality long-term care for themselves or for older family members respectively in the next decade (OECD, 2025[13]). Additionally, care services are unevenly distributed, with significant disparities affecting rural areas and poor households. The lack of affordable and quality care services further exacerbates place-based inequalities and poverty.
Long-term care services are not always comprehensively provided by the public and private sectors. Public authorities often grapple with constraints related to limited financial and human resources, impeding their ability to effectively serve all people with care needs independent of their location. Only half of people aged 65 or above with at least three limitations in activities of daily living receive formal care in OECD countries (OECD, 2023[10]). Such shortcomings in public provision are exacerbated given the increasing demand for care infrastructure and services. Furthermore, serving remote areas or marginalised groups may not be always attractive to private sector care providers due to factors such as low profit margins, long distances or limited public transport options.
Ageing in place with a focus on people-centred, deinstitutionalised and/or community-based care services is increasing in the context of long-term care provision for older people within the EU. These alternatives, often provided by social economy entities, cater to a broader range of needs while offering personalised and flexible support that can adapt to the circumstances of individuals and their families.
Community-based care creates connections to the broader community, which significantly enhances the quality of life for beneficiaries. Such services often involve collaboration among various stakeholders, including local organisations and volunteer networks, to ensure that care is not only accessible but also responsive to community needs (OECD, 2024[14]). Social economy entities interact with and serve vulnerable and marginalised local communities, which may experience difficulties accessing services of public and private providers (OECD, 2024[15]).
Increasing private supply (for-profit and non-profit) for care services
The last three decades have seen an increase in the engagement of private providers, both non-profit and for-profit in the care sector. Non-profit institutions have long supported public providers in some EU Member States, while for-profit entities are emerging, driven by market opportunities and policies promoting choice in care services. There is evidence from countries on the lower quality of for-profit suppliers compared to not-for-profit suppliers, with the former charging higher prices than the latter (OECD, 2024[16]). Although there is an increasing privatisation of services, the balance between profit or non-profit varies by country, while the public sector can still remain the main provider. Non-profit providers are mostly prevalent in Austria, Germany and Greece, while public providers are more active in Czechia, France, and Sweden (European Commission, 2022[17]).
Based on estimates, non-profit institutions represent a significant share of private long-term care services across Europe. They are estimated to account for almost a quarter of the long-term care sector with a market share of 22%, following the public sector (42%) and the private for-profit sector (36%) (European Social Network, 2021[18]). Data on the distribution of providers of care homes for older people by ownership indicates variations in the dominance of public supply by country, with non-profit care home providers making up as much as 80% (Figure 1.1) of private suppliers in some areas. While information on non-profit institutions is limited, it suggests a collaborative landscape where public, commercial, and non-profit providers coexist. This diversity underscores the need for integrated services and multi-stakeholder partnerships to enhance care delivery efficiency.
Note: The data on the supply of long-term care services relate to the latest available year: Austria, Finland and Netherlands (2020); Belgium, Czechia, France and Spain (2019); Greece (2018); Germany (2017).
Source: Based on (European Commission, 2022[17]).
Countries predominantly have residential care services compared to home-based options. Home care and residential care services are more common than semi-residential services such as day care centres. These two types of services are more prevalent both in terms of the number of providers and the market share based on the number of recipients. Home care is often the most prevalent setting for long-term care services, followed by residential services. The promotion of home care as a preferred setting emerges as a policy theme across many EU Member States, in particular in France, Finland, Germany, the Netherlands and Sweden (Figure 1.2) (European Commission, 2022[17]).
Note: The data on where long-term care services are provided relate to the latest available year: Austria and Italy (2018); Belgium, Estonia, Finland and Romania (2020); Czechia, France and Germany (2019); Greece (2017).
Source: Based on (European Commission, 2022[17]).
Available data show that the market share of non-profit providers based on setting varies across EU Member States. Non-profit institutions appear to be active in home care and semi-residential settings while residential care services show more diversity in the concentration of suppliers (Figure 1.3) (European Commission, 2022[17]). Given that home care and residential care services are more prevalent across Member States compared to semi-residential services, the contribution of non-profit institutions could be more pronounced in home care services. Nevertheless, non-profit institutions can still have a significant market share in residential care services, with some Member States, such as Germany, reporting a share as high as 50%.
Note: The data on long-term care settings relate to the latest available year: Austria, Belgium and Ireland (2020); Czechia, France, Germany and Spain (2019).
Source: Based on (European Commission, 2022[17]).
In many EU countries, non-profit organisations providing care services focus on enhanced accessibility and independent living. These factors could explain the high share of social economy entities in providing home-based services in some EU Member States (based on available data). Social economy entities are also found to provide alternative models such as community-based care to maintain autonomy and let people live independently where they prefer. The transition towards person-centred and community-based care has also been mentioned in 2023, in the Council of the European Union “Conclusions on the transition of care systems throughout life towards holistic, person-centred and community-based support models with a gender perspective” (Council of the European Union, 2023[19]). Promoting self-reliant models of long-term care before admitting people to facilities is also important to address increasing pressures on public finances. Improving cost-effectiveness, service provision efficiency and quality can be possible by providing care in the relevant setting.
The Council Recommendation on access to affordable high-quality long-term care, which was adopted by the EU Council in 2022, highlights different roles for the social economy. Social economy entities are identified as important partners for public authorities in the provision of long-term care services. They are also well-positioned among relevant stakeholders to contribute to policy governance in long-term care. By participating in effective co-ordination mechanisms, they can help design, deploy, and monitor policy actions and investments (European Union, 2022[20]). This section looks at the different roles that social economy entities play both as providers and employers of long-term care services for older people.
The social economy as a provider of care services
Across the EU, human health and social care is one of the sectors where the highest number of social economy entities operate. Associations are prevalent in many EU Member States in providing human health and social care, followed by foundations and co-operatives. The same picture holds true when human health activities and residential care and social work activities are differentiated. In many Member States, associations account for almost 50% of social economy entities working in residential care and social work activities. Their share surpasses 85% in some countries such as Belgium, France, Germany, Luxembourg, Netherlands and Romania (European Commission, 2024[21]).
While data on social economy entities’ involvement in care remains limited, some studies highlight the role played by co-operatives The co-operative care model, engaging diverse stakeholders, is mostly prevalent in Italy as well as Greece, Portugal and Spain (Girard, 2014[22]). In Spain, at least 1 000 co-operatives provide care services in residential institutions, day-care centres and as home care, employing 35 000 people. (CECOP, 2022[23]). Italy hosts one of the most prominent co-operative ecosystems for a wide range of care services, spanning from childcare to long-term care for people with disabilities and for older people (Box 1.1). Care services are provided by over 14 000 co-operatives to five million people, employing 400 000 workers in the country. In Emilia Romagna, more than 50% of social care is provided by social co-operatives while in Bologna, social co-operatives provide 87% of care services (Box 1.1).
The social co-operative movement started in Italy during the 1960s and 1970s in response to inadequate care services and funding issues. Over the years, it has expanded significantly across Europe, becoming a major care provider and source of employment. Social co-operatives offer a wide range of care services, including home care, socio-educational support, emergency assistance, nurseries, residential and day centres for both children and adults, foster care support and psychiatric rehabilitation (CECOP, 2022[23]).
Casa Bimbo Tagesmutter is a social co-operative offering childcare and childhood education services using the Montessori method in the South Tyrol region. The co-operative has more than 150 employees operating throughout the province in 24 microstructures, 4 company nurseries, a Montessori nursery school and a Tagesmutter/Tagesvater (babysitting) service. For the vacation periods, special services as the “summer kids” and “school holidays” programmes are offered for children between 3-10 years old.
Spes contra Spem offers residential and socio-cultural integration services for young people, minors at risk and people with disabilities. The social co-operative operates in the municipality of Rome through four family homes, where people with severe disabilities receive support and care. They also provide psychological support services and social integration activities (e.g. music/art therapy laboratory, accompaniment and interventions).
Gabbiano Servizi is a non-profit social co-operative focused on people with disabilities. They offer day and residential services aimed at enhancing autonomy and socialisation targeting adults with psycho-physical disabilities. For students with disabilities, they offer educational-social assistance support services carried out at various reception facilities.
Cadiai Social Co-operative seeks to contribute to Bologna’s community by providing services focused on children, older people, people with disabilities and people in vulnerable situations. Their childcare services include the management of nurseries and kindergartens focused on innovative learning methods, special services to children with autism and a day centre for children and teenagers with disabilities. For adults with disabilities, the co-operative manages residence, day centres and a home care service, offering personal assistance.
Seacoop is a social co-operative operating in Imola and Emilia Romagna. They provide educational and care services to children in 11 different locations. For adults with physical and mental disabilities, the co-operative offers residential and semi-residential services in eight locations, including residences, day centres and socio-occupational centres.
Social economy entities, mostly co-operatives, are active in all types of care services including childcare, care for persons with physical and mental disabilities and care for older people. There are examples such as parent co-operatives, which parents organise to provide care for their children (Box 1.2). These are models where parents have direct involvement and decision-making power over the co-operative's activities. As such, they also can have greater transparency on how their children are cared for.
Parent co-operatives, commonly known as “parent co-ops” provide childcare where families are actively involved in the governance, operations and processes. In Sweden, quality of these co-operatives is developed through a parent-to-staff dialogue, who co-produce the services together. The quality provision of parent co-operatives is driven by the close collaboration between parents and educators, a low child-to-adult ratio and a personalised, play-based curriculum.
Ulvarna’s parent co-operative offers pre-school education in a rural environment in Ulvsby, Karslatd. The preschool provides education services to 20 children led by a professional staff team of four educators. Parents collectively own the centre and are closely involved in its development and direction. The professional staff follows pedagogical and educational goals, aligning their educational offer with municipal kindergartens.
Villa Gorilla parent co-operative is a small-scale preschool based in Stockholm. Villa Gorilla is a staff and parent co-operative as the directive board is composed by both parents and staff. They offer childhood education services in small groups to a total of 26 children between the ages of 1 and 6, focused on creativity and children’s autonomy.
Evidence shows that care for older people is the most common service co-operatives provide in the care sector, while operating in other areas (ILO, 2016[33]). According to a 2016 survey conducted by the International Labour Organization worldwide, co-operatives serve a wide range of populations with diverse profiles including most often their members and other clients. Care for older people emerges within all care services as the most common area of activity for co-operatives. Care for older people is found to have the highest share of responses (over 40%) among other types of care services (ILO, 2016[33]).
Co-operatives’ participation shows a similar distribution as for non-profit institutions in home care, residential care, and semi-residential settings. Care for older people is often provided through care facilities, day care centres or homes. Services are most likely to be provided in co-operative centres or facilities (37.2%), homes (32.6%) or a mix of both (34.9%) (ILO, 2016[33]). This highlights that social economy entities provide care with more flexibility and in diverse settings. Home-based and day care services emerge more often while public providers are prominent in residence-based services. For example, in Spain, six out of ten organisations providing home-based care for older people are part of the social economy. Additionally, co-operatives have emerged as the most significant legal form within the social economy for providing care services in Spain, accounting for 6.3% of the care economy (CEPES, 2023[34]). In France, the social economy accounts for 65% of all private jobs in home-based care services for older people (ESS France, 2022[35]).
Countries with well-developed institutional and legal frameworks for the social economy are increasingly looking into its sectoral contribution in care services. Box 1.3 gives an overview of the share of the social economy in providing care services in Spain based on data published by the Business Confederation of Social Economy (CEPES).
Private providers, whether for-profit or non-profit, are important actors in Spain to provide care services. A 2022 European Commission study found that 29% of long-term care services for older people were offered by public providers, while the rest is covered by for-profit and not-for-profit entities (European Commission, 2022[17]).
The Spanish Business Confederation of Social Economy (CEPES) published detailed information on the contribution of the social economy to care and other social services. Data shows the significant share of the social economy in providing care services in the country with four out of ten entities in care and other social services belonging to the social economy. Table 1.1 summarises the participation of social economy entities in care services in Spain.
The weight of the social economy is particularly pronounced in the non-residential services for older people, along with residential services for persons with intellectual disabilities and mental health issues. Commercial companies account for a higher share of private residential services, especially for older people and disabled persons. Overall, social economy entities account for an important part, 41.3%, of the private supply of care services in the country (CEPES, 2023[34]).
Note: Care services include care services and other social services. All data relate to 2021.
Source: Based on (CEPES, 2023[34]; CEPES, 2022[36]).
The social economy as an employer in the care sector
In addition to being a major provider of care services, the social economy is a major employer of care workers. The care sector employs over 3.3 million people across the EU social economy. Human health and social care are where most employment is concentrated in social economy entities. In many EU Member States, associations are the largest employers within social economy entities in residential care and social work sectors, accounting as much as 97.9% of the workforce in residential care and social work activities in Belgium, 95.5% in Luxembourg, and 92.4% in France. The sector in Italy, on the other hand, is characterised by the prevalence of social co-operatives, which account for almost 79% of employment by social economy entities in the residential care and social work sectors (European Commission, 2024[21]).
Demographic and technological shifts are transforming the care sector and care service delivery. An ageing population drives the demand for long-term care, while increased life expectancy allows more individuals to receive care more independently in their homes and communities. The social economy is exploring digital solutions to enhance access for those in need, including in rural areas.
EU Member States are moving from traditional, formal, residential care models to more independent, home-based care. The social economy plays a major role in this transition by fostering local engagement and innovation. Their person-centred approach promotes intergenerational interactions, diverse roles in care provision, and greater collaboration among health professionals, social workers, and private providers (CEPES, 2023[34]). Social economy entities are also driving the development of new service provision types such as community-based models and intergenerational structures coupled with housing provision.
Accessibility and affordability of care services have important implications on employment, especially of women. Care responsibilities often deter individuals, in particular women, from seeking jobs. Expanding access to affordable care services, in particular childcare, can enhance female workforce participation and help narrow the gender employment gap (OECD, 2023[37]). As social economy entities often focus on providing care services in an accessible manner, they play an important role in helping support the integration of women into the labour force (OECD, 2023[38]).
Public and for-profit providers may tend to focus on urban areas with lower costs due to higher population density and better infrastructure. In contrast, social economy entities are more active in rural care service provisions. For example, in France the social economy accounts for 175 910 jobs in home care for older people. This corresponds to 65% of all private jobs in this sector and 90% of those in rural areas (Observatoire National de l'ESS, 2022[39]). In Spain, social economy entities accounted for 14.2% of all enterprises operating in care and other social services in medium-sized cities and rural areas in 2021, while commercial companies represented only 1.9% (CEPES, 2023[34]).
Given the various challenges within the care sector, the European Care Strategy acknowledges the significance of the social economy in enhancing care provision. The social economy is particularly recognised for 1) contributing to high-quality standards in care delivery and 2) promoting fair working conditions. Care services heavily rely on human interactions, making their quality not only dependent on infrastructure but also on the relationships established between carers and recipients. This two-way dynamic prioritises the well-being of care providers, who often face low wages and high levels of mental and physical fatigue due to the demands of the sector.
The social economy distinguishes itself from public and for-profit care providers through its unique characteristics and innovative solutions. This is achieved through five ways (Infographic 1.3):
1. promoting ageing with autonomy,
2. serving rural and remote areas,
3. providing integrated care by connecting health and social services,
4. using social innovation to improve service delivery, and
5. advocating for better working conditions for care workers.
Promoting ageing with autonomy
Home and community-based care is gaining attention as a means to provide support in more autonomous environments to care recipients. There is an increasing trend among Member States to promote de-institutionalised care settings such as home care compared to residential care. This is driven by increasing demand for care services outpacing the supply, long waiting lists, marked differences across countries for the availability of residential care infrastructure, and fiscal pressures (European Commission: Directorate-General for Employment, Social Affairs and Inclusion, 2021[40]).
The social and local embeddedness of the social economy typically allows it to prioritise communities and tailor social services to local needs. In long-term care, social economy entities are very active in providing de-institutionalised services such as home care through various settings using social innovation. See Box 1.4 for examples of social economy entities providing care services where the people receiving care services can stay in their environment.
The social economy is particularly active in bringing care services to wherever the care-receivers already reside. Such home-based and community-based methods provide the beneficiaries with a chance to have more autonomy and continue independent living as much as possible. Many different social economy entities provide these services across EU Member States:
Germany: Seniorengenossenschaft Riedlingen (Senior Citizen Co-operative Riedlingen) is a registered non-profit association operating in the south-west of Germany, providing both day care and home-based care services to senior citizens in need. It does so by following a self-help structure whereby citizens care for other senior members in their community. The carers in this structure have a “time account” system where they save the hours that they provided working for other citizens, allowing them to use these saved hours to receive care themselves when they become the ones needing care. Saved hours can also be turned into outpayments in cash when requested.
Netherlands: Translating to “neighbourhood care”, Buurtzorg Nederland, a non-profit organisation that delivers home-based care services through community nursing, has emerged among the leading examples of providing holistic and personalised long-term care through the effective use of community resources. Buurtzorg Nederland’s structure is based on self-governing groups of nurses dedicated to specific neighbourhoods that address different care and support needs of individuals in need of help in the community. They also provide training to promote self-care capabilities of beneficiaries to increase autonomy. Buurtzorg Nederland has a client council consisting of care recipients, their family members and/or informal caregivers so they can have a say in the quality of care provided. Buurtzorg Nederland has been long associated with providing higher satisfaction both for care receivers and nurses providing care as well as at lower costs of providing long-term care (KPMG, 2015[41]; Gray, Sarnak and Burgers, 2015[42]).
Portugal: ACAIS (Association of the Support Centre for Older People of São João) is a non-profit organisation serving legally as an entity of public utility. ACAIS operates a day centre and a home support service for older people with a focus on encouraging them to remain in their usual environment, preventing dependency and promoting autonomy. Services provided include personal and housing hygiene care, home monitoring, medication assistance and tele-assistance, and provision of meals among others. ACAIS is committed to promoting strategies for developing autonomy for beneficiaries while facilitating access to community services.
The social economy also provides autonomous modalities of care provision such as community-based or intergenerational settings. In such environments, the care recipient does not only receive services as a beneficiary but also has a say in the quality of the services delivered. They can also sustain lifestyles that are less dependent on an immediate care giver, while their daily and other care needs are attended for. Certain co-operatives, for example, combine care with accommodation to provide intergenerational housing, which offers a space for regular interaction across different generations. Box 1.5 provides an example from France.
Older people may prefer home-based care over institutionalised care, given the numerous benefits it offers. For instance, home care enhances one’s sense of belonging, fosters an environment that promotes independence and autonomy, and is often more cost efficient, especially with rising costs due to limited space in nursing homes.
Les 3 Colonnes, a French social co-operative founded in 2013, enables older people to live in their own homes, while also receiving monthly annuities and care. With over 70% of French retirees owning their homes, the co-operative developed an innovative model in which beneficiaries join the co-operative by selling their property. In exchange, the co-operative provides them with monthly pensions, helping to fund their ongoing support and maintenance needs. Beyond this, Les 3 Colonnes also provides additional services in return, including medical help and care, occupational therapy, entertainment, exercise and nutrition, allowing seniors to remain independent, comfortable and healthy within their own homes.
The financing behind this model is made possible through funding gathered from over 7 000 funders and solidarity partners. Consequently, Les 3 Colonnes own and manage high numbers of properties, currently worth approximately EUR 170 million, which is redistributed to its 600 beneficiaries in the form of monthly annuities. Moreover, following the departure of a resident, the co-operative resells or rents the accommodation which generates profit that can be reinvested for new beneficiaries, creating a self-regenerating model.
By bringing the community into care provision, social economy entities address ageism and isolation among older people. Many social economy entities work to advance social inclusion both across different socio-economic groups and ages. By providing sustainable and independent solutions to long-term care, the social economy places older people not only as mere customers but also beneficiaries and participants of their communities where they can actively engage. This engagement is further facilitated by the social economy’s capacity to mobilise volunteers and other stakeholders to contribute to the community well-being.
The participatory governance model of co-operatives, mutuals and the social economy broadly, allows the inclusion of all care stakeholders. In such models, beneficiaries of care services also have an opportunity to shape how care services are delivered. Inclusion of all stakeholders and participatory decision-making fosters co-ordination across the care chain so workers, beneficiaries and other stakeholders such as families have a say in care delivery (Girard, 2022[50]).
Serving rural and remote areas
Rural areas struggle with shortages of care services. Limited transportation infrastructure, lack of skilled workers and lower population density make it less lucrative for market providers while public providers may not be enough to cover remote regions. The lack of available services increases dependence on informal care services while the availability of residential facilities in rural regions is not uniform across Member States. Against this backdrop, home care and community-based care have more potential especially in rural and remote areas.
The social economy is often a provider of social services in rural areas. Social economy entities operate in rural areas as they are not driven by profit maximisation. They are also more interested in operating in underserved areas to reduce regional disparities in access to services (see Box 1.6 for examples). Social economy entities often complement public and market providers in rural areas given their capacity to hybridise market and non-market resources (e.g. volunteers) and state aid (Girard, 2014[22]).
Many social economy entities are offering care services in rural areas where public and for-profit providers are less prominent. These services provide less dependence on public and institutionalised care, while promoting community engagement and preventing depopulation in rural areas.
Germany: GenoEifel eG is a co-operative operating in the Eifel region in western Germany, which is a rural area suffering from depopulation and limited basic services including public transport. GenoEifel eG provides an intergenerational co-operative model where older people in the community offer childcare before and after kindergarten hours, young people provide babysitting and older people are offered home-based care services including help with transport, household maintenance and shopping. GenoEifel eG represents a sustainable model where older people can benefit from staying in their homes as much as possible while community cohesion in the region is strengthened through intergenerational co-operation.
Italy: The social co-operative Mit Bäuerinnen lernen-wachsen-leben (Learning- growing- living with women farmers) provides childcare and care services for older people in South Tyrol. It uses an innovative model of care whereby older people are offered a flexible semi-residential accompaniment whereby beneficiaries are cared for by host families living in rural areas. This model around social farming emerged in response to concerns over the efficiency of institutional public services. The co-operative offers family-oriented care while actively integrating people in farming life, increasing community engagement.
Netherlands: Zorgcoöperatie Hoogeloon is a care co-operative established by the residents of Hoogeloon, a village in North Brabant with over 2 300 inhabitants, to organise care services for older people in the community. The co-operative provides home-based care services in addition to a day care centre. Zorgcoöperatie Hoogeloon aims to improve the quality of life for older people, people with dementia and people with disabilities through a personalised provision of care in their own setting, thereby preventing forced departures of people from the community.
Spain: COCEDER (Confederation of Rural Development Centres), a non-governmental organisation (NGO) of social action serving public utility, developed the project “Biocuidados (Biocare)” in Spain to provide comprehensive care services in rural areas. The initiative offers personalised care to older people by integrating social, health care, and home support services tailored to the unique challenges of rural living. Through a network of local centres and community co-operatives, Biocuidados aims to ensure that older people in remote regions receive the assistance they need to remain in their homes, stay connected with their communities, and live with dignity. The project was implemented in 18 rural areas.
Providing integrated care by connecting health and social services
Long-term care needs can be complex, often necessitating support from various providers at different levels. Chronic conditions and multiple care needs often lead individuals to seek assistance from both healthcare professionals and social care providers. However, these services do not always work in harmony with one another. A fragmented care system can have significant implications for the quality and cost of service, as well as for the ability to anticipate future health needs. To address this issue, an integrated approach to delivering care services is essential, one that centres around individuals’ needs and adapts to diverse settings (OECD, 2021[56]; OECD/European Commission, 2024[57]).
Social economy entities often adopt more holistic and integrated approaches to long-term care. They have a unique ability to identify and integrate the needs of a diverse range of stakeholders into service delivery design. Collaboration and co-operation are fundamental values for such entities, enabling them to form numerous partnerships with public and private for-profit organisations to address complex societal challenges and facilitate resource access (OECD, 2023[58]). Their collaborative nature and emphasis on well-being enable them to connect various stakeholders, ensuring a seamless continuum of care. By leveraging their local presence and expertise in fostering co-operation, these entities effectively address place-based needs. This empowers them to design and implement care models that seamlessly integrate medical, social, and support services across different sectors and levels. See Box 1.7 for an example of co-operation between a local authority and a foundation to deliver integrated care services for older people in isolated communities from Romania.
Social economy entities operate actively in social services and health care sectors. Their history of building strong collaborations with public authorities as trusted partners places them at an advantage to integrate and connect different care and social services both in home-based and residential settings.
Italy: Auxilium is a social co-operative active in health, social assistance, and educational services. The co-operative provides home-based, semi-residential and residential care services for older people. Auxilium focuses on providing integrated home care with a focus on continuity of services and combining health care with social development in communities. Their home care services in the southern region of Basilicata have become one of the most developed models (known as the Venosa model) of home-based care service provision through successful partnerships between the public and private sectors, which generated high patient satisfaction (such as 90% of users rating the home care service as generally good). In this model, integrated care services are provided under the clinical governance of the local health authorities with a focus on ensuring continuity of care so people with dependency can be treated at their homes instead of hospitalisation.
Romania: The Community Support Foundation (Fundația de Sprijin Comunitar) is a non-profit foundation operating in the eastern region of Bacău County. Their services include providing home-based, day care and residential care services for older people. Its project, titled "A beautiful life and much respect for vulnerable seniors!", co-financed by the Bacău County Council, aims to develop integrated and high-quality services for older people in residential care. The project focuses both on improving the infrastructure and facilities for residential care in the Milly Senior Village in Buhuși, while also increasing the well-being of beneficiaries through outdoor and intergenerational activities.
Spain: ASPAYM Castilla y León is a non-profit association that primarily aims to improve the quality of life for people with disabilities and provide care services for older people. The association’s “Integrated Care in the Rural Milieu” (Atención Integral en el Medio Rural) programme is designed to enhance the quality of life for older people, people with disabilities, and those in situations of dependency residing in rural areas of Castilla y León. Initiated in 2016, the programme offers a comprehensive suite of services tailored to support personal autonomy and well-being within the community including personal assistance, health and accessibility guidance, physiotherapy treatments, socio-sanitary aid and active aging initiatives. The programme is implemented in partnership with local and regional authorities, which provide guidance on selecting rural communities, facilities, and funding.
Mutual societies1 also provide integrated care services connecting social services and health care services given their prominence in these sectors. They are particularly active in providing insurance, health care and social protection services in Belgium and France. Box 1.8 presents an example of a non-profit mutual association providing integrated care services in Belgium.
Solidaris is a non-profit mutual association operating in Belgium with a significant presence in the insurance sector, guided by the principles of solidarity and inclusiveness to promote well-being. In addition to insurance services, Solidaris also has activities around health promotion, mental, physical and social well-being and long-term care. Given their wide footprint on the health and social protection space, serving over 3.2 million members and over 2.1 million main policyholders, Solidaris actively engages in initiatives focused on the integration of care and health services by following a holistic approach centred on providing care based on individual needs:
MASANA project: Masana is an innovative project aiming to integrate home care services and assistance through advanced digital technologies. These include an online case management platform to co-ordinate care services, and digital tools to monitor post-operative patients in their homes. A multidisciplinary team of health care professionals collaborates to deliver comprehensive and personalised care plans, integrating health and care services while family carers are also trained to help manage day-to-day care.
Assistance 2.0 project: This initiative seeks to strengthen the integration and co-ordination of home care and assistance services through digital solutions. A centralised platform helps co-ordinate care provision by managing medical files and facilitating the flow of information between care providers, families and other stakeholders. The project also makes use of monitoring devices and digital assistance to monitor seniors’ daily activities which can send alerts in cases of emergency. Health care professionals collaborate to provide support to seniors through a person-centred approach in care where health and care services are intertwined.
Federation of Home Service Centres (Fédération des Centres de Services à Domicile): The federation represents different structures providing home assistance, care and co-ordination services. It focuses on supporting beneficiaries in their own homes by connecting different professions involved in care provision including health care professionals to provide comprehensive and co-ordinated care. Its services also prioritise the affordability of these services as well as involvement of family carers in the process.
Using social innovation to improve service delivery
While care remains a labour-intensive sector, social innovation and digitalisation are changing how care services are delivered. Innovative technologies are increasingly used in the delivery of long-term care services, enhancing functions such as matching care providers with beneficiaries, removing administrative burdens, workforce planning, and remote monitoring of care recipients for timely interventions. Additionally, platform co-operatives are emerging as models for delivering location-based online care services in many countries. (OECD, 2023[67]).
Social innovation can support care services through digital technologies, including monitoring devices and detection systems. This form of “telecare” offers continuous care and support empowering older people with greater autonomy. By enabling communication during emergencies through button-activated devices or sensors, telecare ensures prompt assistance and promotes independence for users while also preventing situations of insecurity, isolation, or loneliness. See Box 1.9 for an example from Spain on how social innovation can be used to provide better care for older people.
The social economy actively explores alternative models for delivering goods and services, often leading to significant social innovation. Social economy organisations typically experiment place-based solutions to tackle social challenges, drawing on innovative business practices and collaborative partnerships (OECD, 2021[68]). Their emphasis on partnership formation and engagement with support networks further enhances this capacity for experimentation and innovation.
Suara Cooperativa is a social and non-profit co-operative operating in the care sector, offering telecare services for older people by installing devices in the homes of those being cared for, serving more than 82 000 households. Beyond this, Suara also provides home-based care, which supported 18 613 seniors in 2023, enabling older people to continue living in their own homes, as well as several types of residential care to meet diverse needs. For instance, the co-operative operates day centres, serving 308 individuals last year, where different activities designed to improve cognitive functions and physical well-being are carried out. Additionally, Suara manages serviced and sheltered housing – accommodations that allow autonomous older people to remain active and socially engaged within their communities – for more than 300 individuals, as well as assisted living, benefitting 517 seniors by accompanying them through the ageing process in dedicated residential facilities.
In 2023, Suara also launched its own social innovation laboratory, the Social Digital Lab. The laboratory engages with start-ups to pilot test emerging innovations that address various areas of action, including well-being, care, active ageing and preventative health. A prime example is ROB-IN, a prototype robot engineered to support people to age at home, while also enhancing the efficiency of professional caregivers. Furthermore, caregivers can input specific patterns into the robot’s behavior and receive reports on changes in the user’s habits and routines, largely improving the overall quality of care.
As a co-operative, Suara operates on a horizontal and democratic model that values participation. The primary governing body is the general assembly where all 1 574 members have the same right to speak and vote. With the objective of providing high quality care for older people, Suara also partners with external organisations, such as the Connected Homes project with the Ministry of Social Rights, which strives for dependent seniors to feel safe and independent in their own homes by forming an at-home support system with digital technologies, such as voice devices, smartwatches, and sensor networks.
Advocating for better working conditions for care workers
Care jobs are often undervalued and underpaid. Personal care workers in residential care earn 71% of the economy-wide average wage, while the margin is higher for those in non-residential care making only 67% of the average wage (OECD, 2023[10]). The gender pay gap also contributes to lower wages as most workers in care are women. The concentration of migrant workers may limit their ability to demand higher wages, given limited opportunities to change jobs usually due to legal restrictions. Additionally, live-in care providers cannot capitalise on collective bargaining to demand better conditions, which is particularly relevant for live-in foreign-born care workers (OECD, 2023[10]).
Social economy entities often provide pathways to better working conditions for workers including access to benefits, regular hours and long-term contracts. Worker co-operatives, for example, allow workers to jointly demand higher wages and improved employment protection while promoting workers’ rights (ILO, 2018[71]). In Italy, 84% of employees working in social co-operatives providing care had permanent job contracts between 2018-2019. In Portugal, 71% of employees in care co-operatives similarly had open-ended contracts (CECOP, 2022[23]; CECOP, 2021[72]). As profits are reinvested into the activities, social economy entities offer opportunities for training and skills development for their workers. Box 1.10 provides an example of a worker co-operative and social enterprise from Ireland re-investing proceeds into providing better working conditions for carers.
Quality of care services highly depends on the quality of jobs of care workers. Worker co-operatives offer solutions to couple accessible and quality care services with strengthened employment conditions for care workers who often struggle with low renumeration, limited job protection and unstable working hours.
The Great Care Co-op is a worker-owned co-operative and a not-for-profit social enterprise operating as a provider of care services. It provides various home care services including personal care (i.e. hygiene, mobility, medication reminders), respite care, Alzheimer’s and dementia care, chronic illness and palliative care, as well as social support for medical and other appointments.
The co-operative was founded by migrant women who had been advocating for rights and better pay for migrant women working in the care sector in Ireland. The Great Care Co-op is established as a worker co-operative to address low wages, workplace exploitation and discrimination experienced in the home care sector. It provides its services with a vision to create a trusted home care community based on respecting the human rights and dignity of all involved in care while ensuring quality care provision and combatting labour market disadvantages of migrant women engaged in care work.
As a co-operative, the Great Care Co-op relies on its trading income to sustain its operations but does not seek profit maximisation. Instead, it uses its surplus to maintain its business, invest in growing services to members and deliver on its social purpose. The profits also go into providing training for care workers to develop their skills.
Source: (The Great Care Co-op, n.d.[73]).
Social economy entities can also play an important role in advocating for formal and fair employment opportunities for migrant workers. The FairCare initiative by the Association for International Youth Work (Der Verein für internationale Jugendarbeit e.V. (VIJ)) in co-operation with Diakonie Württemberg, a non-profit organisation providing social care services, aims to promote better employment conditions in accordance with labour and social insurance regulations for caregiving staff from Eastern Europe, working in home care for older people and dependent people in Germany. FairCare also helps households find qualified care givers while providing support and advice on legal matters around contract preparation and social security registration (VIJ FairCare, n.d.[74]).
Challenges facing the social economy in care
Working in the long-term care sector is inherently challenging due to demanding physical and emotional labour, low wages, high staff turnover, and limited career progression. Care workers often face stressful conditions, time pressure, and insufficient support, all while providing essential care to vulnerable people. Social economy entities play a vital role in this sector by prioritising social value over profit. However, they face their own challenges, including limited access to sustainable funding and difficulty competing with for-profit providers in schemes where minimum price principle is applied, despite often offering more stable and community-rooted care models.
The COVID-19 pandemic had a considerable impact not only on health care systems but also on the long-term care sector. The share of total COVID-19 deaths among long-term care residents was 34% in 25 countries by April 2022. Older people receiving long-term care services especially in semi-residential and residential settings (e.g. assisted living facilities, nursing homes) were at the highest risk (OECD, 2023[75]). The pandemic also exposed more clearly some structural challenges that constrain the efficiency and effectiveness of delivering care services. Some of these challenges are linked more broadly to the care sector while others are specific to social economy entities.
Challenges affecting long-term care
Lack of co-ordination and limited recognition of the care sector
The long-term care sector is often marked by a lack of co-ordination among health and social services. In most EU Member States, health care is provided by medical professionals while long-term care services are covered by the social sector. Their responsibilities are often split across level of government: national, regional and local (European Union, 2022[76]). Limitations in the integration and co-ordination of health and social services often lead to less recognition and public funding for the latter.
The care sector receives limited recognition during health crises, as evidenced by the COVID-19 pandemic. Numerous residential care facilities in many countries (e.g. Belgium, Germany, the United Kingdom, the United States), experienced significant shortages of masks and other protective equipment, particularly affecting high-risk groups such as older people. These disparities highlighted the care sector's limited visibility compared to the healthcare sector, where public investments primarily centre on hospitals. In contrast, many care facilities play a major role in complementing medical services offered by the healthcare system.
Difficulties in attracting and retaining care workers due to poor working conditions
Care is a labour-intensive sector. Care workers, including both those in the health and social care sectors, accounted for 3% of all employment in the EU in 2022. Their role is expected to rise in significance in the context of the ageing population in Europe. The next decades will witness a higher demand for skilled long-term care workers, as the number of older adults has been growing more than the long-term care workforce. Across the OECD, the number of long-term care workers will need to increase by 13.5 million or by 60% by 2040 to keep the current ratio of workers for every 100 people over the age of 65 (OECD, 2020[77]). At the same time, low pay, temporary contracts and health challenges emerge as important reasons to stop working in care. Indeed, 50% of personal care workers in Europe reported one of the highest levels of health and safety risks at work in 2021 (OECD/European Commission, 2024[9]; European Commission, 2023[78]). A 2024 survey across Europe found that 59.9% of domestic and care workers reported to have considered leaving the sector the past three years, two-thirds of which express low pay as the main reason (Jarrow Insights, 2024[79]).
Care work remains underpaid in the EU. Care workers including carers, nurses and assistant nurses are often paid below the national average wage. Across the OECD, personal care workers have hourly wages that are 12% lower than the average across occupations (OECD, 2023[10]). In EU Member States, social services workers, 69% of whom work in the long-term care, were paid 21% less than the average national hourly earnings in 2018 (Eurofound, 2020[80]). The wages are even lower among private sector providers compared to public providers due to cost-cutting efforts given low profitability. Domestic care work is often the lowest paid compared to other residential modalities and can easily fall outside of regulation (Eurofound, 2020[80]). The consistently lower wages in the face of rising demand for care workers can be attributed to the negative perception of care work as a low-skill job, which often does not impose educational requirements on its workers.
The long-term care sector faces particularly greater challenges regarding working hours. Across the EU, 42% of long-term care workers work part-time, which is higher than the average part-time rate of 19% among the entire workforce (Eurofound, 2020[80]). Part-time work in long-term care is often marked by atypical and irregular hours. This situation negatively impacts job quality for caregivers, subsequently affecting their physical and mental well-being. Carers report experiencing discrimination and verbal and physical abuse more often than other workers. As they perform emotionally demanding tasks, long-term care workers also run a high risk of mental health problems. Carers in the EU are also found to be less informed about physical risks, while they often move or lift people and handle infectious material, exposing them to health and safety challenges (Eurofound, 2020[80]).
Although the social economy strives to improve working conditions, it faces similar challenges in employment within its entities. Many social economy entities may struggle to compete with the public sector when it comes to offering higher wages for care workers. The low recognition of the sector, along with limited career advancement opportunities for care workers, has resulted in staff shortages. This issue is particularly acute in attracting and retaining qualified professionals, such as specialist nurses.
Demographic and technological shifts will also influence future demand for care workers (Cedefop, 2023[81]). For example, the digital transition is likely to change the skill sets required of care professionals. Additionally, improvements in socio-economic conditions tend to lead to a greater reliance on formal care services rather than informal caregivers, resulting in an increased need for formal care workers (European Centre for the Development of Vocational Training, 2023[82]). At the same time, investing in universal childcare and long-term care services are estimated to generate over 13 million jobs by 2030, of which 8 million would be direct jobs in long-term care (ILO, 2022[11]). This job creation potential could be particularly beneficial in rural areas in the context of an ageing population and more pronounced labour shortages.
Care is one of the most gender-segregated sectors
Care services are among the most gender-segregated with the highest share of female employees, reinforcing the stereotype that care is a “female job”. This concentration of women in the care sector also reflects into higher employment levels of women in the social economy as many social economy entities specialise in social services including health and education (OECD, 2023[38]). More generally, women represent 87% of workers in long-term care (OECD, 2023[10]) and up to 90% of the care workforce in the EU Member States (European Commission, 2022[1]).
While women represent over 87% of long-term care employment, the gender pay gap still applies as they earn less than men in the same profession (OECD, 2023[10]). Increased care needs during and following the COVID-19 pandemic also deepened the already precarious work conditions for many care workers, particularly women. These conditions include long working hours as well as physical and mental health and safety risks as women workers may be subject to gender-based violence and harassment. The situation for unpaid care work remains largely the same, while the pandemic intensified the already unequal burden that women bear in caring for others. (ILO, 2024[83]).
Social economy entities tend to perform better in terms of addressing gender pay gaps and providing managerial and leadership opportunities for women (OECD, 2023[38]). Social economy entities tend to enhance wages and improve working conditions for their staff, particularly in the co-operative sector. However, some entities such as associations facing considerable funding challenges, may offer lower salaries compared to other providers (OECD, 2023[38]). Due to their substantial presence in the social care sector, the proportion of female employees in the social economy is often significantly greater than their overall representation in the workforce (OECD, 2024[84]). This phenomenon is largely attributed to the feminisation of care positions.
Limited regulatory oversight on home-based services
Employment in the care sector is physically and mentally demanding, often leading to high turnover rates and challenges in talent retention. The sector struggles with limited access to training and skill development, which directly affects the quality of services provided and, well-being of those receiving care.
The care workforce includes a higher-than-average number of individuals from migrant backgrounds. In OECD countries, 26% of long-term-care workers are foreign born, exceeding the 20% share of foreign-born individuals across all sectors (OECD, 2023[10]). Many of these workers are young and possess high skill levels. However, immigrants frequently find themselves in positions for which they are over-qualified due to limited available opportunities. In many European countries, migrants report being over-qualified more often in the long-term care sector than in other fields (OECD, 2020[77]). For instance, nurses from migrant backgrounds may take on personal caregiving roles instead of utilising their medical qualifications. Additionally, the emigration of skilled health professionals from countries with lower wages to those offering better working conditions may worsen staff shortages in the source countries (e.g. Bulgaria). This creates a challenging cycle that impacts the availability of qualified personnel in the countries of origin.
While undeclared work is less prevalent in long-term care services across EU Member States compared to other sectors, it remains a significant concern, particularly for live-in domestic caregivers. This sector is often staffed by migrant workers, notably in countries such as Croatia, Germany, Greece, Italy and Spain. Given that employers of domestic caregivers are typically private households, live-in care often operates without regulation and occupational protection (Eurofound, 2020[80]). Factors such as labour costs, bureaucratic challenges, and visa regulations contribute to the prevalence of undeclared work. A noticeable trend involves workers from Central and Eastern Europe relocating to Western Europe. It is worth mentioning that care workers in formal settings generally possess higher qualifications, while there is limited oversight of quality in home-based care services.
Due to the prevalent informality in domestic care, service provision frequently lacks regulation. There are no established regulatory systems to guarantee quality control or verify the qualifications of care workers in this sector. As these services remain largely unmonitored by public authorities, care workers may not receive essential benefits such as occupational protection and social security. This is especially crucial given that care jobs often involve higher-than-average physical and mental demands.
Challenges constraining social economy entities in delivering long-term care
Prioritisation of price over service quality in public procurement contracts
Providers of social care services use a mix of different funding modalities to sustain their operations. These mainly include 1) public procurement, 2) reserved contracts, 3) user-centred models (where beneficiaries may receive funding to purchase services on their own), and 4) private investments (EASPD, 2019[85]). While models around reserved contracts allow to value provision of social services provided by social economy entities and non-profit organisations, public procurement is often driven by a competitive bidding process. Since these processes mainly focus on minimum price as the main factor, social economy entities find themselves at a disadvantage compared to for-profit providers. The latter can more readily reduce costs, including those related to staffing, which can negatively impact the quality of services, given that care is a service heavily reliant on human interaction.
Social economy entities and for-profit providers operate under different motivations and approaches in service delivery, resulting in distinct cost structures. Social economy entities are often driven by a social mission to offer accessible, affordable, and high-quality services to their beneficiaries, which can lead to increased operational costs. Moreover, their emphasis on participatory governance and active stakeholder engagement, including communication with family members and informal care givers, adds further expenses that may go unnoticed by public authorities. Effective communication and the engagement of family members in care adds significantly to the quality of services, which is often not included in public tenders.
Adopting a socially responsible public procurement model can enhance the prioritisation of social and economic outcomes in contract awards. Incorporating social clauses in contracts can yield social dividends through procurement efforts (OECD, 2023[86]). Compared to for-profit entities, social economy entities provide a range of advantages that extend beyond care service delivery. These benefits include serving remote and vulnerable communities, fostering local roots for care services that enhance community cohesion, contributing to local development and employment, reinvesting surplus resources into social initiatives to improve service reach and quality, and leveraging social innovation to enhance the accessibility and quality of care services.
High dependence on short-term grant funding
Public funding, subsidies and grants offer short-term funding for social economy entities. This affects their operations and the financial sustainability of their long-term strategies for their care activities. Such short-term funding rarely allows any long-term investment to improve the delivery of care services or to incorporate the digital and green transition into the operations. Therefore, while public support is essential to support the activities of social economy entities working in long-term care, they are also constrained by design for long-term strategic improvements.
One-off funding modalities may also present challenges given the increasing fiscal pressures on long-term care spending. The high fragmentation of budgets (health care vs. social care) and responsibilities around long-term care (national vs. regional and local governments) is another barrier for developing sound and co-ordinated strategies around care (Spasova et al., 2018[87]). The availability of adequate resources has direct implications on the quality of care services, which then have major impacts on the well-being of beneficiaries.
Whether provided by public or private providers, the quality and affordability of care services is critical to sustain the well-being for people with dependencies. Demand is expected to increase pressures on public expenditures for care provision, while persistent staff shortages create barriers for many people in need to access the services they need. Social economy entities are well-positioned as partners to help co-ordinate and deliver comprehensive, socially inclusive and person-centred care.
Improving framework conditions for the social economy can have direct positive impact on their objectives to achieve inclusive and quality care. The EU Council Recommendation on developing framework conditions for the social economy aims to strengthen the role of social economy entities across Europe by creating supportive legal, financial, and policy environments. Importantly, Member States have committed to adopt or update dedicated national strategies for the social economy, or to incorporate social economy priorities into other relevant strategies, ensuring a co-ordinated and coherent approach to unlocking its full potential for inclusive and sustainable growth. These strategies could include elements on the contribution of social economy entities to delivering care services.
Raising the profile of care work with the social economy
National authorities can better communicate on the role of the social economy within their strategies and plans for the care economy. Given their social mission, social economy entities deliver social inclusion and access to social services beyond their roles as providers. They often engage in partnerships with public authorities, private sector actors and civil society organisations to push for improvements in social service delivery in the public agenda. Public investments to increase the efficiency and inclusivity of care services provided in collaboration with social economy entities can be useful modalities of social service delivery while generating social dividends. Some examples of national strategies and plans highlighting the role of the social economy in care services are provided in Box 1.11.
Many EU Member States introduced plans or strategies around care economy or care services. Some programmes were also developed as part of the recovery and resilience plans following the COVID-19 pandemic. Social economy entities, social enterprises and third sector are already identified as important partners to deliver care services in some of these plans. The EU Council Recommendation also invites Member States to acknowledge the role of social economy entities in delivering accessible and high-quality care services.
Italy: The European Commission, through its Recovery and Resilience Facility, supports Member States to promote reforms and investments in their national Recovery and Resilience Plans (RRP). Italy’s RRP includes measures on “social infrastructure, families, communities and the third sector” which focus on social services, disability and social marginality. The Plan includes specific lines of action which are dedicated to older people to help increase autonomy and home-based care and prevent institutionalisation. The measures also focus around ensuring continuity of care services in a co-ordinated manner between health care and social care sectors. Speeding up the implementation of the reform of the third sector is identified as a necessary action to contribute to the measures around providing inclusive social services. EUR 500 million is earmarked to strengthen territorial and proximity social services for older people with dependencies.
Spain: The Strategic Projects for Economic Recovery and Transformation (PERTE) are a public-private collaboration tool to support large-scale projects in Spain. Approved by the Council of Ministers in 2022, the PERTE includes 11 project areas, including one focused on the social and care economy with a budget of EUR 808 million. The PERTE of social and care economy aims to strengthen equality policies and facilitate businesses transition to social economy enterprises, particularly worker co-operatives, with the objective to improve the competitiveness of social economy small and medium enterprises (SMEs). It promotes a people-centred economic model and professionalises the health care and dependency sector, especially from the perspective of ageing. It also aims to promote digital skills in the care sector.
Social economy entities can work with public authorities to develop complementary strategies for care, health care and social inclusion (OECD, 2023[58]). Social economy entities are often at the forefront of communicating to the public and policymakers on how to improve social service delivery, including care for older people (see Box 1.12 for an example from Romania). They do so by capitalising on their social mission and local roots to build trust and credibility, which place them as effective trusted partners to address social issues.
SenioriNET is a federation of NGOs providing medical and social services in Romania. Its main activities focus on promoting the involvement of service provider NGOs for older people in Romania in local, regional, national, European and cross-border policies for the development of services for seniors. It also supports capacity building for service providers as well as raising citizens’ awareness on the importance of developing services for seniors in the community as a means of inclusion and combating poverty.
The “SenioriNET Federation – stronger NGOs to support the elderly in Romania!” project aims to promote coalition and strengthen the voice of NGOs providing services for older people. It is implemented by Caritas Romania Confederation in partnership with Four Change Association, Community Support Foundation and Caritas Metropolitan Greek-Catholic Blaj Association, and is funded by EEA Grants by Iceland, Liechtenstein and Norway through the Active Citizens Fund Romania.
Conducted between 2021-2023, the project builds on the need to increase the capacity of representation for NGOs providing socio-medical services to older people. The ultimate goal is to catalyse systemic changes on the development of social policies for older people and their public funding structure. It aims to do so by increasing the capacity of social and socio-medical service providers to carry out advocacy and increase awareness among citizens local and national authorities and institutions, while strengthening representation of NGOs serving older people in European platforms.
Source: (SenioriNET, n.d.[91]).
Facilitating long-term partnerships with the social economy
Policymakers often use public grants and subsidies to support social economy entities delivering care services, which may not always allow for long-term planning and investments. Public authorities use different working modalities with the private for-profit and not-for-profit providers for care services such as reserving contracts (specifying which types of entities are eligible for contracting), accreditation (assessing and verifying the quality of services provided by an entity), licensing (granting legal permission to offer specific services based on compliance) or authorisation (approving an entity to deliver specific services or participate in public contracts) (European Social Network, 2021[18]).
The different modalities to contract care providers are often combined with various requirements including on the quality of services. Such working modalities could present a more sustainable and long-term oriented co-operation model compared to grant making. By introducing these requirements, they also promote a more focused approach to contracting providers based on the level of quality offered. Box 1.13 presents examples of the use of such mechanisms to work with not-for-profit providers.
To find more sustainable ways to engage providers beyond grant-giving, some Member States resorted to alternative models to promote collaboration between social economy entities, non-profit providers and public authorities (including at the local level).
Hungary: The provision of social care including care for older people is primarily the responsibility of local authorities, which can directly provide services or outsource it to external organisations. Since 2011, only those entities with non-profit status are eligible to take over care services such as residential care from the national and local authorities.
Norway: The public procurement legislation was amended to allow public authorities not to implement the EU Procurement Directive when awarding health and social services contracts to non-profit organisations, so they can be granted contracts without going through a competitive bidding process against for-profit providers.
Spain: Social accordances are commonly used in Spain to have non-profit organisations provide social services. In the Basque Country, for example, the public administrations give priority to non-profit entities when similar conditions around quality and costs exist. Collaboration agreements which are a modality of reserved contracts are used by public authorities to work with non-profit organisations. Renewed every one to two years, these provide stability and continuity for non-profit providers.
As public procurement remains as one of the main modalities to work with social service providers, the quality of services should also be considered among the main criteria when awarding contracts. The emergence of socially responsible procurement practices is crucial to prioritise the inclusion of social clauses in public and private contracts. Social services provided by social economy entities are associated with higher levels of quality and satisfaction among beneficiaries (OECD, 2023[86]).
Prioritising the quality of services for long-term care over costs is necessary given the importance of human interaction in the sector. The quality of care services has direct implications on the accessibility and inclusivity of services as well as individuals’ well-being and community cohesion. The Italian municipality of Castelfranco Veneto, for example, reserves contracts for home care services for persons living with disabilities to type A social co-operatives and their consortia for a 3-year duration. The quality of services is prioritised within the award criteria for these contracts with 60%, while price accounts for 40% (EASPD, 2019[85]).
Encouraging gender diversity among care workers
Countries increasingly push for the recruitment of more men in female-dominated jobs. The feminisation of care jobs and persistent staff shortages associated with a low valuation of care work is a significant challenge to meeting long-term care demands in the EU and beyond (OECD, 2023[38]). Governments work with social economy entities and civil society organisations to organise public campaigns breaking down stereotypes surrounding care work. Although not widely observed in care for older people, there are also examples of national legislation to encourage the recruitment of men in certain sectors such as childcare. Box 1.14 presents examples of such initiatives.
Some countries are carrying out public campaigns to bring more men into care professions to dispel stereotypes and fight against the feminisation of care jobs and responsibilities.
Norway: In 1997, Norway started with the first national action plan to encourage more men to take jobs in childcare, followed by a legislation in 1998 to allow employers to favour male candidates over females in case of equal qualifications. At regional level, country administrations introduced action plans on recruiting more men in childcare while municipalities implemented projects to encourage and pay secondary school boys to work in childcare. These campaigns were successful in attracting more men into childcare, placing Norway among the pioneers in workforce diversity in the childcare sector.
United Kingdom:
The Department of Health and Social Care leads Made with Care campaigns to expand social care workforce the country. They are domestic recruitment campaigns to advertise opportunities in building a career in adult social care. The campaigns also seek to attract more men and younger people who are currently under-represented in the workforce into essential care roles, while showing how rewarding a career in social care can be.
The Men Do Care campaign aimed to encouraged social workers, nurses and other health care professionals to share the benefits that men bring to these professions to break down stereotypes and attract more men professionals to care jobs. The initiative was a joint effort by the University of Central Lancashire and local partners Blackburn with Darwen Council, East Lancashire Hospitals NHS Trust, Lancashire and South Cumbria NHS Foundation Trust and Lancashire County Council.
Setting standards and monitoring the quality of home care services collectively
Quality requirements and controls are increasingly introduced to monitor the quality of services in residential and semi-residential settings, but home-based services present a different picture. Regulatory oversight is the dominant model to improve service quality. Policy measures to monitor quality in long-term care services revolve around three broad groups: 1) setting minimum standards on labour and infrastructure and enforcing compliance, 2) developing standards to streamline care services and monitoring through quality indicators, and 3) using market-based incentives to stimulate quality improvement (OECD/European Union, 2013[97]).
While there are qualifications required to join the care workforce in residential settings, similar surveillance or control mechanisms do not apply to home care services (European Commission, 2019[98]). Many Member States have strong regulations on residential care, while only a few Member States have developed requirements for home care (such as Austria, Belgium, Czechia, Denmark) (Cès and Coster, 2019[99]). The existence of undeclared care workers especially in home-based care services presents additional challenges on monitoring the quality of services provided.
Given that social economy entities are very prominent in the provision of home-based services, they are also reliable partners for regulators to improve quality assurance of home care services. Social economy entities can support policymakers and regulators both by supporting voluntary quality control through standard-setting and accreditation as well as by providing person-centred services driven by a mission to deliver high quality. They can also help bring in the voice of care beneficiaries and their family members to have a say in the quality of services delivered. Their presence in home-based care can help increase the efforts to more effectively and collectively monitor quality of services provided at home. Box 1.15 presents some examples from quality assurance mechanisms for home-based services.
While many Member States already put in place regulations to monitor and improve the quality of care services provided in residential and semi-residential settings, challenges remain to monitor home-based services. Some countries already introduced measures to monitor the quality of care services provided at home.
Austria: The beneficiaries of care subsidies have voluntary or obligatory home visits commissioned by the Ministry of Social Affairs, Health, Care and Consumer Protection. These visits are conducted by qualified nurses free of charge to assess the quality of care provided at home through direct contact with the care recipients. A competence centre for quality assurance in care at home was established within the Social Insurance Institution for the Self-Employed to organise and co-ordinate home visits. A toolkit is also developed for a practical application of quality assurance with a surveying tool and quality indicators to guide the assurance process.
Denmark: The Danish Parliament passed a new elderly care reform in 2024 that focuses on letting beneficiaries determine how to receive care services while promoting holistic and home-based services. Subnational and local authorities are responsible for organising long-term care services as well as defining quality standards and monitoring. The reform also promotes close interaction with family members, local communities and civil society.
Flanders (Belgium): A 2019 decree introduced new regulations that residential and home care services must comply with. The decree aims to improve the quality of elderly care services including home care services with focus on the beneficiaries’ living preferences and care needs. It also highlights the role of local service centres to provide a bridge between local authorities, residents, associations and welfare and care organisations to provide more person-centred and co-ordinated care services. Different stakeholders were consulted during the drafting process including the Flemish Council for Older Persons.
The social economy plays a crucial role in delivering accessible, high-quality, and person-centred care, as recognised in the EU Council Recommendation on developing framework conditions for the social economy. Social economy entities offer unique solutions on long-term care to help people access care services in the setting they prefer, regardless of whether they are placed in rural or urban areas. The social economy's activities in health and social work allows it to propose integrated care services for a more person-centred and comprehensive care system. Social economy entities are also able to leverage social innovation to improve service delivery and respond to complex care needs. Social economy entities, especially many co-operatives, are working towards advancing the working conditions for care workers including their pay, contractual modalities, career progress and training opportunities.
However, long-term care continues to face structural challenges. These include limited visibility of the sector, poor working conditions, gender imbalances, limited supervision especially for home-based services. Challenges are exacerbated for social economy entities as public contracts do not always prioritise service quality and as social economy entities depend highly on short-term grant funding.
Public policy can address these challenges by strengthening the framework conditions around the social economy, enabling it to capitalise on full capacity to deliver care. It's therefore important that Member States take into consideration the role of the social economy in delivering accessible and high-quality care services through long-term and more sustainable partnership modalities with social economy entities. Policies can also promote and incentivise better gender equality in the care workforce. Finally, overseeing the quality of care services through pre-set standards, especially for home-based services, is an important step towards ensuring that everybody can access high-quality services independently of their setting.
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← 1. Mutuals (observed commonly in western European and Nordic countries) are enterprises controlled by their members that provide insurance, social security, and small-scale social services. Their main goal is to meet shared needs, not to make profits or pay returns on capital. Governed by solidarity, members actively participate in decision-making and are the focus of accountability (European Commission, n.d.[103]).