Population ageing is taking place all over the world and leading everywhere to an increase of care needs. One of the great challenges for humankind in the twenty-first century is finding ways to deal with this development. Countries face this challenge from very different starting points. Some have developed sets of care policies, while others have very limited support structures. Some nations put their trust in informal care. Others have a legacy of institutional care, but very limited home-based care services. There is variation even among those countries where publicly funded home care is available: some welfare states provide both personal and practical care, while others offer help in only one of these two domains. Socio-emotional support is most often left to informal networks. Whatever the starting point, care needs are growing across the globe, and it is not self-evident in any country that this increase will be met adequately. Care poverty is a real risk everywhere already, and it will be even more so in the future.

In order to build policies and practices that are able to counteract the growing risks of unmet care needs, it is first necessary to understand the phenomenon thoroughly. Currently, knowledge of unmet care needs is fragmented, and the accumulation of understanding has been slow. This is partly due to the amount of variation in the definitions and methods used for research on unmet care needs and partly due to the separation of this literature from that on social inequalities and social policy. That is why this book has aimed to gather together existing knowledge on the issue, building bridges between different strands of research literature.

Besides describing the state of the art, this book has also suggested a new conceptual framework. It has introduced the concept of care poverty that applies approaches from poverty research, drawing attention to the characterisation of unmet care needs as deprivation and inequality. The book suggests that the notion of care poverty could introduce a more societal approach and thus help research focus its attention on social inequalities, long-term care policies, and their manifold connections with the lack of adequate care.

In existing research, the prevalence of unmet needs—that is, care poverty rates—is the issue that has received the most attention. Yet despite the growing volume of literature, the picture remains blurry as it has been difficult to summarise findings from different studies due to a multiplicity of definitions and operationalisations of unmet needs. Often, datasets used for study are local or regional, not nationally representative. Reliable international datasets simply do not exist. Longitudinal data are rare, as well. All of this makes it very difficult for analyses to grasp the connections between care poverty and societal or policy changes.

To help deal with the fragmentation of research, the book introduced a specific framework consisting of three care poverty domains and two measurement approaches. So far, research has concentrated on the domains of personal and practical care poverty. These have proven to be very different and rather independent from each other. Their rates are often dissimilar, with the first being more dominant in some countries and the second in others. Research into socio-emotional care poverty is still largely missing despite its importance, which is why loneliness studies have been used here as a sort of proxy for analysis of the lack of social and emotional support.

In this book, the two measurement methods widely used in unmet needs studies are called ‘the absolute approach’ and ‘the relative approach’ and the issues they measure are called absolute and relative care poverty. While the notions of absolute and relative care poverty follow the concepts of absolute poverty and relative poverty, their meaning is not entirely analogous. Absolute care poverty stands for the complete absence of any informal or formal support for long-term care needs. It thus recalls absolute poverty, which is usually defined as the severe deprivation of basic needs such as food and shelter (UN, 1996).

Relative care poverty is not based on comparing the level of need satisfaction in a certain group to the whole population, so it differs from the approach of relative poverty. When it comes to care, such a comparison would be irrelevant: while everyone needs food and shelter, not all in the population have care needs. Care poverty should be analysed among those who have care needs, not among the total population. Relative care poverty nonetheless takes people’s expectations and normative social environments into consideration. Measurements following the relative approach are based on self-reports from older people (or the views of proxy respondents) that depend on local and national norms and values, reflecting conceptions about what is generally understood as the inadequate coverage of care needs in specific cultural contexts.

The care poverty framework proved especially helpful in reviewing the findings of earlier studies on the factors of unmet needs. Different domains of care poverty were found to have somewhat different predictors, although some factors were significant in all domains. Living alone is one such superfactor, together with health status and the number of functional limitations. Income level, too, is a significant factor in most domains—especially when measured with the relative approach. Perhaps surprisingly, gender, ethnicity, and education level proved to predict care poverty only rarely, once other variables were controlled.

Earlier studies showed that unmet needs have a number of negative consequences for older people. Adverse consequences follow especially from personal care poverty and, as the meaning of the term entails, cause the well-being of older people to deteriorate in a serious manner. A lack of assistance with basic personal care tasks such as bathing and toileting makes life substandard and undignified. Depression and other problems with emotional well-being are also among the consequences of inadequate care. Some studies even indicate an augmented mortality rate. Furthermore, the evidence shows that care poverty often leads to disproportionate use of health care and residential social care, creating unnecessary costs for social and health care systems.

The book argues that care poverty is a dimension of social inequality per se. The existence of care poverty creates a contrast between those who receive adequate care for their needs and those who are left without such support. Care is a basic human need. It is a necessary component of well-being and human dignity, so deprivation of such support indicates a major social inequality . The lack of adequate care does not merely reflect other dimensions of inequality such as poverty, gender inequality , or ethnic inequality. Instead, care poverty is a social phenomenon and a type of inequality in itself.

Although it is necessary to understand care poverty as an issue in its own right, lack of adequate support is certainly connected to other social inequalities . Intersectional analysis shows that different dimensions of inequality are interlinked, often amplifying each other’s negative impacts (Williams, 2021). Income inequalities, especially, are often closely related to care poverty. This is not surprising as economic resources greatly enhance the capacity to purchase for-profit care and pay user fees for public care services. At the same time, poverty alone does not necessarily lead to care poverty. This is both because informal care resources can compensate for the lack of formal care and because care policies can bring new opportunities to people in low-income groups.

Due to language and attitudinal barriers, racial and ethnic minorities have additional difficulties in accessing formal care. These could include when information about services is available only in the majority language, or when minority groups are uncritically thought ‘to look after their own’ and prefer informal care to formal services (e.g., Ahmed & Jones, 2008). However, the unmet needs literature suggests that it is possible to reduce ethnic inequalities in care poverty through universal or targeted social policies. Universal programmes cover everyone, and as low-income and minority ethnic groups often overlap, targeted support for minorities or low-income population may also have a sizeable positive impact.

The empirical finding that gender is not a factor of care poverty was unexpected. Based on the wealth of feminist literature on care, we know that care is a thoroughly gendered social issue and that women are largely overrepresented among informal carers , formal care workers, and migrant care workers. As well, they form the clear majority of the very old population and, thus, of care users. But still, gender does not feature in the reviewed studies as a predictor of unmet long-term care needs .

Like we saw in Chap. 7, statistical methods can sometimes ‘adjust away’ the importance of a major factor. Statistics show that older people at particular risk of care poverty live alone, have low incomes, experience poor health, and have several functional limitations. But they do not highlight the fact that these people are overwhelmingly women. It is women who more often live alone in their old age, have low pension incomes due to disturbed careers, and have poorer health and functional capability due to their longer life expectancy. For example, our Finnish DACO (Daily Life and Care in Old Age) survey dataset from 2020 shows gender as nonsignificant for care poverty; at the same time, the same dataset shows that 78% of all older people in care poverty are women. Care poverty is thus a gender issue that impacts women in particular.

Social inequalities and care poverty are closely interrelated overall, placing those with limited social and economic resources at particular risk for care poverty. A recent qualitative study from Finland shows how care poverty is often intertwined with deep social disadvantage and social inequalities , sometimes resulting from life-long marginality (Sihto & Van Aerschot, 2021). At the same time, care poverty is not simply a reflection of poverty or other inequalities. It is a specific dimension of social inequality in itself, dividing people into haves and have-nots, those with and those without adequate support for their care needs.

Lessons for Care Policies

A key argument of this book has been that it is necessary to understand the lack of adequate care within its societal and policy contexts rather than as resulting from certain characteristics of older individuals. Care needs and ways to meet them are societally structured. So, too, is care poverty. Long-term care policies are a central element of these structural conditions. Policies can have a major role in alleviating care poverty, but they may also exacerbate the problem if they are not carefully planned and implemented.

Unfortunately, the knowledge base for drawing policy lessons is still rather weak. Some, but not many, studies of unmet care needs discuss the policy implications of their findings. Consequently, drawing firm policy conclusions and formulating specific policy recommendations is not yet possible. Comparative policy analyses and longitudinal studies—which both are essential for understanding the impact of social or policy changes and different policy models for care poverty—are particularly in short supply.

However, some preliminary conclusions can still be drawn. First, Europe-wide studies of unmet needs show that care poverty is most pervasive in a number of Eastern European countries. Though the reliability of the datasets still leaves room for improvement, demanding caution when interpreting results, this finding is not unexpected. Formal home care as well as support for informal carers are both limited in these nations. If care is unavailable from either formal or informal sources, widespread care poverty is the logical result. However, not all countries in the region are in the same situation; nations such as Slovenia and the Baltic states indicate noticeably more positive results.

Northern Europe, especially Scandinavia and the Netherlands, does well in the first comparative studies. Sweden, for example, displays very low levels of care poverty. These countries are known for their developed formal care provisions. The current state of the art suggests that universal care systems that also offer home-based services and target them to older people with the highest needs are the most efficient policy choice for eradicating care poverty. On the other hand, evidence on Medicaid from the United States demonstrates that a means-tested long-term care system can also substantially mitigate care poverty—though it will not be able to eliminate all unmet care needs.

Southern Europe is generally known as a family care regime, which is characterised by a lack of extensive formal care provisions and an expected abundance of informal care (e.g., Simoni & Trifiletti, 2004). While EUROFAMCARE and Eurobarometer data show high rates of care poverty for Italy and Greece, the EHIS dataset does not locate the highest rates of care poverty in Southern Europe (save for Malta). Live-in migrant care and perhaps also family care are more available in these countries than in many parts of Eastern Europe. Some Southern European countries also provide cash-for-care schemes that help finance migrant and informal care (Bettio et al., 2006; Da Roit, 2007; Da Roit & Le Bihan, 2011).

In general, familialistic social policies are connected to a traditional gender division of labour and a strong male-breadwinner ideology, contributing to low levels of female employment (e.g., Esping-Andersen, 1999; Leitner, 2014). The first EHIS findings raise the question of whether familialism could possibly work better at decreasing care poverty than in reaching gender equality targets. However, comparative evidence is both contradictory at the moment and only preliminary. Consequently, conclusions can be drawn only when more knowledge is available. Familialism comes in many shapes and forms, so further research on care poverty will also have to distinguish between, for example, familialism by default, prescribed familialism, and supported familialism (Saraceno, 2016).

The COVID-19 pandemic brought the problems of long-term care to light and public debate. The pandemic hit older people hard, and care homes, in particular, saw a massive amount of deaths—many of these due to inefficient responses to the pandemic (e.g., Thompson et al., 2020; Alacevich et al., 2021; Morciano et al., 2021). In addition to pandemic-specific problems such as the lack of personal protective equipment, several long-standing issues characterise current care provisions in many countries. These include insufficient staffing levels, substandard working conditions, problems with staff recruitment and retention, and deficient opportunities for older people to exercise influence and choice over their care arrangements (e.g., SOU, 2020; Wee & Yap, 2020; Werner et al., 2020). All these issues are relevant to care poverty, amplifying its risks.

The pandemic made clear that lack of adequate care—that is, care poverty—is a serious problem in many residential care settings. Research on unmet needs in residential care is nevertheless still limited, and that is why this book has focused on care poverty in home-based settings. During the COVID-19 pandemic, home care was overshadowed by the attention paid to care home deaths. However, issues such as inadequate staffing, insufficient quality, and limited access have characterised also home care provisions for a long time in many countries; these problems were then accentuated under the exceptionally demanding conditions of the pandemic (e.g., Sterling et al., 2020). Infections and deaths have taken place not just in residential settings, but also in home care. Many of the long-term deficiencies of home care systems derive from inadequate resourcing, which elevates the obvious policy conclusion: in many countries, substantial investments are needed in home care (e.g., Grabowski, 2021). Strengthening the capacity of home care to meet the needs of older people has been an urgent challenge during the pandemic. It will remain a key issue in the post-pandemic world.

Lessons for Research

Recent years have seen a development in social policy research where researchers are increasingly directing attention to not only the inputs and outputs of policies, but also their outcomes. This book aims to support this trend by highlighting care poverty as a critical outcome indicator of care policies. The book has made an inventory of the current state of knowledge on unmet long-term care needs and suggested a new conceptual framework for this research. A key argument has been that we must understand the lack of adequate care not only as a problem at the individual level, but also as a social issue—the roots of which are embedded in the structures of society.

Keming Yang’s (2019) recent book on loneliness is centred around a similar main argument. While literature on loneliness has grown substantially in recent decades, it almost always, according to Yang, depicts loneliness as an individual psychological problem rather than a societal issue. The mission of Yang’s book is to show that loneliness is indeed a social issue. In a very similar way, the main goal of this book is to argue that unmet care needs should be understood as a societal and social policy issue. While the objectives of these two books are almost identical, Yang succeeds more in presenting evidence for his argument. In his book, he shows that loneliness varies between cultures and societies, social classes, and ethnic groups. Major societal events, such as mass immigrations, large-scale social conflicts, and economic crises, prove to increase loneliness.

Unfortunately, this book has not been able to validate its argument the same way. While Yang had access to reliable international longitudinal data on loneliness, such sources are not available on care poverty. In order to analyse the impact of different policy models on care poverty, high-quality international data are needed. And in order to analyse the impact of societal disruptions and policy changes, time series data are needed. A critical challenge for the research community is thus to build reliable international datasets that can be used for comparative and longitudinal analysis of unmet care needs. This requires surveys that include specific questions on the adequacy of care, that are repeated regularly, and that collect large enough samples of older people with care needs.

Having specific questions on the in/adequacy of care means following ‘the relative approach’ in measuring care poverty. The benefits of this approach outweigh those of ‘the absolute approach’. While the absolute approach might at first seem more objective, as it is not based on older people’s self-evaluations of the adequacy of their care, it is actually also based on self-reports. It is still the older respondents who need to report whether they received informal or formal care. As it is far from self-evident what actually constitutes informal care (and sometimes even formal care), the subjective interpretative element is present in ‘absolute’ measurements. Above all, the absolute approach seriously underestimates the spread of care poverty because it assumes everyone who receives any support from either formal or informal sources has their care needs met. This is a groundless assumption.

It is questionable whether absolute care poverty actually represents a more serious situation than relative care poverty. Using SHARE data and thus the absolute approach, Laferrère and Van der Bosch (2015, p. 340) observed that ‘the prevalence of unmet need falls with the [rising] level of need’. In other words, the absolute care poverty rate was not highest among people with the most needs; instead, it was highest among those whose needs were less extensive. As well, LaPlante et al. (2004, p. S101) argued that those who receive no help at all despite having care needs—that is, those who are in absolute care poverty—have only a low level of needs in that they mostly need help with IADLs only. Adverse consequences, as well, have been identified as less likely among those who do not receive any help than among those who receive at least some assistance (Freedman & Spillman, 2014).

The term ‘absolute’ signifies a severe deprivation. But the aforementioned findings suggest that the needs of people in absolute care poverty are less extensive than those in relative care poverty. Even if their needs remain fully unmet, their situation is probably less severe than those who receive some (but not adequate) support for their high needs. Relative care poverty thus probably denotes a more serious deprivation than absolute care poverty. This perception is supported by the observation that adverse consequences seem to occur more typically among those in relative care poverty than those in absolute care poverty. The evidence is still too limited to give a final answer to the question of which type of care poverty represents a more serious deprivation. Nevertheless, ambiguities around the nature of absolute care poverty are another reason to avoid the use of the absolute measurement approach.

While the studies mentioned above pay attention to the extent of needs, this is exceptional. In most studies on unmet needs, variations in the level of people’s needs are not taken into account. Studies regularly measure the number of functional limitations but not their scope. However, how much and how often help is needed is of crucial importance in daily life and can also be expected to have a connection with the risk of care poverty. Research on this topic is nevertheless still very thin. In future research, especially when collecting larger international datasets, researchers should take variation in the extent of care needs into account, besides directing attention to differences between different care poverty domains and measurement approaches.


Like food, water, and shelter, care is a basic human need. No human being can survive without it. Everyone is fully dependent on care at the beginning of their lives. Most of us will also need it at the end of our lives. Leaving a person without necessary care means leaving a human being without human dignity, inflicting physical, mental, and social suffering on them. As we saw in Chap. 1, care poverty can even have fatal consequences.

Currently, no nation appears to be free of care poverty. This casts a deep shadow over even the most advanced welfare states, making care poverty a global plight. It is not possible to abolish all misery from the world, but leaving vulnerable older people without the care that they need raises serious questions about the legitimacy of the social order. In democratic societies, in particular, governments are expected to help people meet their basic needs and to protect their human rights. To rephrase Nelson Mandela’s words on poverty from Chap. 2, it could be said that overcoming care poverty is both an act of justice and the protection of a fundamental human right to dignity and a decent life. Care poverty is not natural but man-made. It can thus be overcome and eradicated by the actions of human beings.