Ulrike Famira-Mühlberger (Austrian Institute of Economic Research)

August Österle (Vienna University of Economics and Business)

In contrast to the healthcare system, which is financed by social insurance, long-term care (LTC) is financed by general taxation in Austria. The LTC system in Austria is characterised by a strong reliance on family and other informal care. Persons in need of LTC are supported by a LTC allowance and by the provision of LTC services. While the federal state is responsible for the former, the nine provinces (Bundesländer) are responsible for the provision of the latter. Most services are provided by non-profit organisations and by public bodies (e.g., communities). The provinces are obliged by law to provide care services, but they are largely free to organise them as they see fit, which results in a wide variety of services and conditions across the provinces. Additional support by the federal state is provided for the employment of live-in carers and to informal carers.

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In Austria, the federal government (Ministry of Social Affairs) is responsible for the cash-for-care system (LTC allowance, benefits for informal carers, financial support for 24-hour care) and social insurance coverage for family carers (if eligible). The nine regional governments are responsible for the provision of LTC services (i.e., mobile care, nursing homes, day care, hospice and palliative care, daily assistance, meals on wheels, temporary care, alternative housing and case and care management). The regional governments regulate the conditions for the various LTC services and partly run nursing homes. Some regional governments delegate tasks to regional funds (social assistance associations) or municipalities. Most LTC services are provided by non-profit organisations and public providers. For-profit providers play a minor role.

In addition, there is financial support for those who employ 24-hour carers. The Ministry of Social Affairs regulates the legal framework for 24-hour care and provides most of the funding. In addition, the federal government regulates the professional regulations for qualified nursing staff, while the regional governments regulate those for auxiliary staff (nursing assistants or specialised nursing assistants, home helps, etc.).

The federal government and the nine regional governments coordinate the LTC system in a joint working group (“Arbeitskreis Pflegevorsorge”). While the most important cash benefits (e.g., LTC allowance, benefits for informal carers, financial support for 24-hour care) are organised and available in the same way throughout the country, the organisation, design and conditions of LTC services differ considerably in the nine Länder.

In Austria, LTC is financed by federal taxes, while health care is financed by social insurance contributions. Part of the federal tax revenue is transferred to the provinces (Bundesländer) to enable them to fulfil their responsibilities, including the organisation of LTC services. In 2022, the public sector spent 1,26 % of GDP on LTC allowances and LTC services.

In 1993, Austria introduced a uniform, needs-based but non means-tested LTC allowance (Pflegegeld). There is a legal entitlement to this allowance – irrespective of income and assets and of the cause of the need for care. Depending on the intensity of care required, the LTC allowance is divided into seven levels, ranging from € 192 per month at LTC allowance level 1 to € 2,062 per month at level 7 (2024, yearly adjusted for inflation). Approximately 5.2% of the Austrian population receives the LTC allowance. Financial support for the purchase of LTC services is mostly needs- and means-tested, but conditions vary from province to province. Assets over and above regular income/pension and the LTC allowance are not taken into account when moving to a nursing home – any residual amount is covered by social welfare funds [1].

The Austrian LTC system is characterised by a high importance of informal care [2]. The share of LTC beds in care homes and hospitals per 1,000 population aged 65 and over is slightly above the OECD34 average, but well below other Western European countries (e.g., the Netherlands, Germany) [3]. More than 40% of recipients of LTC allowance are exclusively cared for by relatives [4]. There are several benefits for informal carers, including paid caregiver leave and social insurance coverage. If recipients of the LTC allowance receive LTC services (benefits in-kind), the individual LTC allowance is used to finance these services or the necessary co-payments. Conditions and co-payments vary from province to province.

Private LTC insurance plays a minor role in Austria.

Following the governance structure of the Austrian long-term care system (see above), quality assurance is divided between federal and regional bodies. However, there is no central body for quality assurance and the accreditation of care providers. Instead, providers are contracted at the regional level. There is also no quality rating of providers. Nevertheless, there are some regulations and initiatives at the central level related to quality assurance. The most important of these is the regulation of the long-term care professions. In addition, a competence centre for quality assurance organizes voluntary home visits for recipients of the LTC allowance. The aim of these visits is to provide information and advice to people in need of LTC and their informal carers. These home visits are compulsory for 24-hour live-in care arrangements if they are publicly subsidized (see below). Other voluntary initiatives are a quality certificate for nursing homes and a quality certificate for agencies acting as intermediaries in 24-hour live-in care arrangements. In both cases, however, the number of certifications is rather low.

Public support for LTC provision in Austria uses a combination of cash-for-care provisions (see above) and a range of services [5],[6],[7]. The provision of LTC services can be divided into four main elements: residential care settings, community-based care services, live-in care arrangements and support for informal care provision.

Community-based care is organised and managed in very different ways in different provinces. Across the country, community-based care is dominated by a mix of home nursing and home help services. Other services often include meals on wheels, mobility and visiting services, or palliative care services. Public co-financing arrangements also vary between provinces, but usually take into account both the LTC allowance and the income of the user.

Following regional plans for the development of LTC infrastructure in the 1990s, which gave priority to community-based care arrangements, services were significantly expanded in the 1990s and the early 2000s. By the end of 2022, almost 100,000 people received mobile care services (with public co-financing), which corresponds to 20.9 % of the recipients of the LTC allowance [8]. The provision of community-based care is dominated by non-profit organizations. Both public and for-profit providers only account for smaller shares in community-based care. Apart from the range of publicly co-financed services, community-based care is based on informal care provision and, increasingly since the early 2000s, on live-in care arrangements.

Live-In Care Arrangements

Since the late 1990s, care provided by migrants who live in the household (migrant live-in care) – or 24-hour care, as it is widely known in Austria – has increasingly been used to fill gaps between the traditional arrangements of informal care giving, mobile care services, and residential care. Originally a grey economy of care, regulations in 2007 made self-employment the dominant live-in care arrangement, with migrant care workers rotating in two to more weekly shifts between their Central and Eastern European countries of origin and private households in Austria [9].

By the end of 2022, about 59,000 self-employed live-in care workers were registered, which means that care – according to the dominant arrangement of two care workers rotating in shifts – is provided for about 29,000 care users, which corresponds to 6.2% of the recipients of the LTC allowance. Live-in care is financed from the users’ private sourced (including the LTC allowance), an additional means-tested public benefit specifically addressing the use of live-in care (amounting to a max of € 800 per month) and additional financial support in some provinces.

Support for informal carers includes pension and health insurance coverage (the most important programme in financial terms), various leave options (family hospice leave, full- and part-time care leave options) and a care leave benefit linked to these options, respite care, and consideration of family care in inheritance law [5]. In addition, in mid-2023, Austria introduced a direct cash transfer for informal carers (Angehörigenbonus), amounting to € 125 per month. However, eligibility rules limit these programmes to higher-intensity care. For example, the above-mentioned cash transfer for informal carers is only paid when caring for someone in the long-term care allowance level 4. LTC leave (both full- and part-time) is available for a period of between 1 and 3 months when caring for someone in allowance level 3 and above (or from level 1, in the case of dementia care and when the person being cared for is a child). Family hospice leave (again with a full-time and a part-time option) is available for 3 months, with the possibility of extending to 6 months. Take-up of leave has increased but remains limited, while respite care is often limited by the limited availability of replacement services.

The residential care sector is dominated by so-called Alten- und Pflegeheime, which provide a wide range of nursing, personal and social care. By the end of 2022, 67,576 residents (with public co-financing) – i.e. 14.4% of the recipients of the LTC allowance (470,647 recipients by the end of 2022) – were being cared for in residential care settings [8]. Following the LTC reform in the early 1990s [6], these settings started to emphasize the nursing home character and to focus more explicitly on the population with more extensive care needs. Later, access criteria were more explicitly tightened by requiring minimum levels of care needs (usually allowance level 4), but still taking into account broader social circumstances. The two main providers of residential care are the public sector and the non-profit sector. Homes in the for-profit sector have a much smaller (but growing) market share in Austria and their relative position also varies between the provinces. Except for one provider, multinational companies do not play a major role in this segment. Alternative residential care settings include assisted living arrangements, often in close cooperation with traditional nursing homes, flat-sharing communities, or day care centres.

Assistive technology includes established technologies, such as a wide range of aids. The funding of these aids depends on the specific needs of the individual, but also on the competent social insurance fund. These differ in their more or less restrictive approach to providing these aids and in the co-payment arrangements they apply. New technologies are also influencing the use of more traditional aids. In addition, providers are pioneering the use of specific new technologies or testing them in publicly funded innovation projects. These are, for example, wearables and sensors, mobile applications, or, increasingly, artificial intelligence to support users, providers, and organizations. More specifically, technologies include active and assisted living systems that address, for example, the safety, mobility or physical activities of care users, but also technologies that support the workforce, care management, or the organization and documentation of care work.

Regarding the enabling environment, several initiatives on disability are highly relevant for long-term care, most recently laid down in the National Action Plan on Disability 2022-2030, which aims to implement the UN Convention on the Rights of Persons with Disabilities [10]. As another initiative, in 2023, Vienna will be the first Austrian city to join the WHO Framework for Age-friendly Cities and Communities. The framework addresses issues such as participation, social inclusion, mobility and health, and supports members in identifying and sharing innovative approaches.

The LTC workforce in Austria is highly gendered: 87% of formal carers are women [11]. According to a representative survey, 73% of informal carers are women [2]. While the share of foreign-born workers in the labour market is 22%, it is 33% in the LTC sector – both indicators well above most OECD countries. Although projections show an increase in demand for workforce [10], the proportion of those working in the LTC sector is still low: 1.6% of those in employment work in the LTC sector (slightly below the OECD average). There are 41 formal LTC workers per 1,000 people aged 65 and over in Austria, which is well below the OECD average. Most LTC workers have a medium level of education (72%), only 13% have a high level of education and 16% have a low level of education. Compared to the OECD, the proportion of LTC workers with a medium level of education is higher than the OECD average, and the proportions with high and low levels of education are lower than the OECD average. 67% of all formal LTC workers work in residential care (which is above the OECD average). Those working in residential care earn only 92% of the economy-wide average gross hourly wage, while those working in non-residential care earn 93% – well below those in education and health [11].

In Austria, the LTC sector is experiencing significant labour shortages, leading to high workloads and job dissatisfaction. Recent reforms have included paid scholarships for nursing education, additional leave, and financial bonuses to make LTC jobs more attractive.

There is publicly available data on LTC in Austria. Statistics Austria publishes annual statistics on LTC services, which provide information on the structure and scope of LTC services (service hours, billing days, places, persons cared for, nursing and care staff, expenditure)[13]. The Ministry of Social Affairs publishes an annual report on LTC services, including data on recipients of LTC benefits, financial support for 24-hour care, LTC services in the provinces and other support measures[14]. As the data of the LTC services is not collected uniformly in the individual provinces, comparability is often difficult.

There is also the annual report on the Register of Health Professions 2019, which provides information on the number of health and care workers and their level of qualification[15]. At the beginning of 2024, the website www.pflegereporting.at was established, where existing information and data on care is collated.

However, there is no general access to pseudonymised microdata on LTC beneficiaries or on health services, so there is no publicly available linked health-LTC dataset.

Innovation can take very different forms and follow different paths. New models of care are often initiated by individual providers, provider networks, local or regional authorities, implemented within established care arrangements (e.g., within residential care settings or community-based care arrangements) or as novel programmes. Other initiatives are rooted in more centralised efforts to reform LTC. Two programmes are used as examples:

In 2021, Austria launched the Community Nursing project, with 116 pilot programmes at the beginning of 2024. Community nurses will become the main local contact point for health and care issues, providing information and coordinating services. The aim is to provide low-threshold access and improve outreach. The programme aims at early contact with older people (before the need for LTC arises), supports and advises family carers (before professional services are considered) and emphasises preventive and rehabilitative approaches.

With the COVID-19 pandemic, staff shortages became an even more pressing issue for the LTC system. In response, Austria introduced – among other measures – new educational programmes that open up new pathways into care work. These include upper-secondary educational programmes with a specialisation in care-related qualifications and, as a pilot project, vocational training programmes for assistive professions in LTC. In addition, a new scholarship has been introduced in 2023 to support education and training in care professions. The programme is specifically aimed at people aged 20 and over who are unemployed or on leave of absence. The grant amounts to € 1,400 per month and can be paid for up to 4 years (depending on the duration of the qualification programme).

The Austrian LTC system is based on a comparatively broad coverage of the population with the LTC allowance as a cash benefit for those in need of LTC [16]. The coverage of residential care and community-based care services have been significantly diversified and extended over the last 30 years. However, these expansions have not met the growing need, a deficit that is exacerbated by staff shortages. In recent years, these shortages have meant that some nursing homes have been unable to actually provide all the beds available. Tackling staff shortages has been at the heart of recent reform efforts in LTC. However, given projections of future care needs and the number of care workers retiring in the coming years and decades, significant shortages will persist unless further action is taken [12],[17]. Evidence on the extent to which LTC provision meets LTC needs is still limited for Austria. However, there is evidence of inequalities in the spatial distribution of LTC allowances that cannot be explained by the age and health of the population [18],[19]. Regarding services, regional differences in regulation and governance lead to different patterns of use. Finally, and as outlined above, central coordination, monitoring and quality assurance are limited in Austria mainly due to regional responsibilities for LTC and limited comparability of data on service provision.

As in many other European countries, the Covid-19 pandemic has shed light on health and LTC systems, exacerbating existing deficiencies and raising challenging questions about the balance between public health concerns and individual rights. The lack of support for informal carers, the working arrangements of migrant live-in carers (in relation to the common practice of rotational migration) and the situation of care home residents (with strict limits on social contacts outside the home for public health reasons) together with existing and worsening staff shortages, have been the main challenges identified in the literature [20],[21],[22].

Parts of the LTC system were reformed between 2021 and 2023. The reforms have brought improvements for the LTC profession, LTC education, informal carers and LTC allowance recipients. Specific recent policy changes include the following: LTC trainees receive €600 per month, informal carers receive financial support for the first time (€125 per month, specific conditions apply) and financial support for the provision of 24-hour care has been increased. Where there are company or collective agreements, there is a legal entitlement to carer’s leave. In addition, several measures have been implemented in the areas of training, qualifications and immigration: e.g., easier recognition of foreign LTC training or expansion of the competences of qualified LTC personnel. As part of a pilot project, community nurses have been established in some municipalities. The recent financial equalisation between the federal government and the provinces has increased the resources for the provision of LTC services, but a fundamental reform towards better overall financial management has not materialised [1].

 Famira-Mühlberger U. and Österle A. (2024) Long-term care system profile: Austria. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/austria

Trukeschitz, Birgit, Österle, August, Schneider, Ulrike (2022): Austria’s Long-Term Care System: Challenges and Policy Responses. Journal of Long-Term Care, 88-101. https://doi.org/10.31389/jltc.112

Streicher, G., Famira-Mühlberger, U., Firgo, M. (2022): The Economic Impact of Long-term Care Services, Zeitschrift für Sozialreform (Journal of Social Policy Research), 68, (2), S.211-235.https://doi.org/10.1515/zsr-2022-0009

In German (the most important administrative source on Long-Term Care in Austria):

BMSGPK (2023): Österreichischer Pflegevorsorgebericht 2022. Bundesministerium Soziales, Gesundheit, Pflege und Konsumentenschutz (BMSGPK). https://broschuerenservice.sozialministerium.at/Home/Download?publicationId=704&attachmentName=%C3%96sterreichischer_Pflegevorsorgebericht_2022.pdf

[1] Famira-Mühlberger, Ulrike & Trukeschitz, Birgit (2023): Zur öffentlichen Finanzierung der Langzeitpflege. WIFO-Monatsberichte, 96(12), 857-868. https://www.wifo.ac.at/wwa/pubid/71302

[2] Nagl-Cupal, Martin, Kolland, Franz, Zartler, Ulrike, Mayer, Hanna, Bittner, Marc, Koller, Martina Maria, Parisot, Viktoria & Stöhr, Doreen (2018): Angehörigenpflege in Österreich. Einsicht in die Situation pflegender Angehöriger und in die Entwicklung informeller Pflegenetzwerke. Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz (BMASGK)

[3] OECD (2023a): Health at a Glance 2023: OECD Indicators. OECD Publications. https://doi.org/10.1787/7a7afb35-en

[4] Famira-Mühlberger, Ulrike (2020): Pflegevorsorge in Gemeinden. WIFO Publications. https://www.wifo.ac.at/wwa/pubid/66284

[5] Trukeschitz, Birgit, Österle, August, Schneider, Ulrike (2022): Austria’s Long-Term Care System: Challenges and Policy Responses. Journal of Long-Term Care, 88-101. https://doi.org/10.31389/jltc.112

[6] Österle, August (2021): The Long-Term Care System in Austria. CRC 1342 Social Policy Country Briefs, 12. https://doi.org/10.26092/elib/833

[7] Österle, August (2023): 30 Jahre Pflegepolitik: Ein Blick zurück … und nach vorn. In: Buxbaum, Adi, Filipič, Ursula, Pirklbauer, Sybille, Soukup, Nikolai & Wagner, Norman (Eds.): Soziale Lage und Sozialpolitik in Österreich 2023: Entwicklungen und Perspektiven (pp. 122-136). ÖGB-Verlag. https://api.oegbverlag.at/spid/articles/24_9/pdf

[8] Statistik Austria (2023): Pflegedienstleistungsstatistik 2022. https://www.statistik.at/fileadmin/pages/346/Pflegedienstleistungsstatistik_2022.pdf

[9] Österle, August (2018): Employing Migrant Care Workers for 24-Hour Care in Private Households in Austria. Benefits and Risks for the Long-term Care System. In Christensen, Karen & Pilling, Doria (Eds.), The Routledge Handbook of Social Care Work Around the World (pp. 130-141). Routledge.

[10] BMSGPK (2023): Österreichischer Pflegevorsorgebericht 2022. Bundesministerium Soziales, Gesundheit, Pflege und Konsumentenschutz (BMSGPK). https://broschuerenservice.sozialministerium.at/Home/Download?publicationId=704&attachmentName=%C3%96sterreichischer_Pflegevorsorgebericht_2022.pdf

[11] OECD (2023b): Beyond Applause? Improving Working Conditions in Long-Term Care. OECD Publications. https://doi.org/10.1787/27d33ab3-en

[12] Famira-Mühlberger, Ulrike (2023): Projektionen des öffentlichen Pflegeaufwands bis 2050. WIFO Publications. https://www.wifo.ac.at/wwa/pubid/70673

[13] https://www.statistik.at/statistiken/bevoelkerung-und-soziales/sozialleistungen/betreuungs-und-pflegedienste

[14] https://www.sozialministerium.at/. The 2022 report is available here: https://broschuerenservice.sozialministerium.at/Home/Download?publicationId=704&attachmentName=%C3%96sterreichischer_Pflegevorsorgebericht_2022.pdf

[15] https://goeg.at/JB_Gesundheitsberuferegister

[16] Ranci, Costanzo, Österle, August, Arlotti, Marco & Parma, Andrea (2019): Coverage Versus Generosity: Comparing Eligibility and Need Assessment in Six Cash‐for‐Care Programmes. Social Policy and Administration, 53(4), 551-566. https://doi.org/10.1111/spol.12502.

[17] Jurasovich, Brigitte, Rappold, Elisabeth & Gyimesi, Michael (2023): Pflegepersonalbedarfsprognose Update bis 2050. Aktualisierung der Pflegepersonalbedarfsprognose 2030. Bundesministerium für Soziales, Gesundheit, Pflege und Konsumentenschutz (BMSGPK). https://broschuerenservice.sozialministerium.at/Home/Download?publicationId=707&attachmentName=Pflegepersonalbedarfsprognose_Update_bis_2050.pdf

[18] Famira-Mühlberger, Ulrike, Mayrhuber, Christine & Novotny, Klaus (2022): Gesundheitsleistungen und Pflegegeldbezug. WIFO-Monatsberichte, 95(3), 175-184. https://www.wifo.ac.at/wwa/pubid/69573

[19] Pennerstorfer, Astrid & Österle, August (2023): Take-Up and Distribution of a Universal Cash Benefit: The Case of the Austrian Long-Term Care Allowance. Journal of Social Policy, 1-18. https://doi.org/10.1017/S0047279423000375

[20] Leiblfinger, Michael, Prieler, Veronika, Rogoz, Mădălina & Sekulová, Martina (2021): Confronted with COVID-19: Migrant Live-In Care During the Pandemic. Global Social Policy, 21(3), 490-507. https://doi.org/10.1177/14680181211008340

[21] Leichsenring, Kai, Schmidt, Andrea E. & Staflinger, Heidemarie (2021): Fractures in the Austrian Model of Long-term Care: What Are the Lessons from the First Wave of the COVID-19 Pandemic? Journal of Long-Term Care, 33-42. https://doi.org/10.31389/jltc.54

[22] Rodrigues, Ricardo, Simmons, Cassandra, Schmidt, Andrea E. & Steiber, Nadia (2021): Care in Times of COVID-19: The Impact of the Pandemic on Informal Care in Austria, European Journal of Ageing, 18, 195-205. https://doi.org/10.1007/s10433-021-00611-z

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