Socio-economic inequalities in unmet long-term care needs in Spain

Abstract Europe’s rapidly ageing population places increasing pressure on long-term care (LTC) systems, with inequitable access standing out as a key challenge. While socio-economic disparities in LTC utilisation are well documented, inequalities in unmet needs—the gap between required and received care—are less studied. Using the 2019 European Health Interview Survey for Spain, we categorise unmet needs as fully unmet, partially unmet, or having no unmet needs and quantify the care gap in hours. We assess socio-economic inequalities and inequities in unmet needs, stratified by eligibility for publicly funded LTC and by limitation severity (number of limitations in activities of daily living). We observe that unmet LTC needs disproportionately affect women, individuals living alone, and the oldest old. In addition, we find inequality and inequity, with a disproportionate burden borne by poorer individuals and those with severe limitations. Our decomposition analysis reveals that health status, income, and living arrangement explain most of the observed inequality. Notably, among eligible individuals with more severe limitations, living arrangement emerges as the largest contributor, as having a spouse mitigates inequalities in unmet needs, while living alone exacerbates them. These results highlight the need to reduce inequalities that disproportionally affect the lowest socio-economic strata and to address disparities through more effective resource allocation and targeted policies. By using a continuous measure of unmet LTC need that allows for a more nuanced analysis of its socio-economic determinants, this study contributes to the broader debate on the fairness and efficiency of LTC provision in ageing societies.