1. XXXIV Simposio Análisis Económico A double sample selection model for unmet needs, formal care and informal caregiving hours of dependent people in Spain Cristina Vilaplana Prieto (UMU, FEDEA) Sergi Jiménez-Martín (UPF, FEDEA) Valencia, December 2009

2. XXXIV Simposio Análisis Económico Motivation Factors affecting the supply of informal caregivers  Average household size:  1998  3.23 people  2007  2.74 people (Continuous Household Budget Survey, INE)  Number of children per woman  1975  2.803 children  2008  1.458 children (Basic Demographic Indicators, INE)  Divorce rate (per 100 mariages)  1980  4.7%  2007  63.92% (Social Indicators, INE)  Female labor participation  1987  31.83%  2008  60.13% (Active Population Survey, INE)

3. XXXIV Simposio Análisis Económico Motivación Factors affecting the demand of care  Number of elder people living alone:  1998  784.283 (1.98% of population)  2005  1.420.578 (3.18% population) (Continuous Household Budget Survey, INE)  Percentage of mentally ill people among those receiving informal care  1994  19.2%  2004  39.6% (Informal Support Survey, 1994 y 2004)  Population projections

4. XXXIV Simposio Análisis Económico Motivation Preferences of elder people and informal caregivers  Opinion about the participation of Public Sector in long-term care  Preference for the place for receiving care in case of need

5. XXXIV Simposio Análisis Económico Motivation  Previous research has concentrated on: causes and consequences of unmet needs (UNs) (Allen, 1994; Tennstedt et al., 1994; Desai et al., 2001; Sands et al., 2006 ).  Consequences of UNs: Always negative  Morbility rate  Degree of severity of disabilities Downfalls and accidents  Use of emergendy departments  Physician visits  Hospital stays  Institutionalization rate  Health expenditure (Allen and Moor, 1997) (Komisar et al., 2005; ) (Long et al., 2005) Limiations of previous studies :  Do not take into accout the characteristics of informal caregivers network  Omission of principal caregiver opinion

6. XXXIV Simposio Análisis Económico Motivation  Reliability of informal caregivers’ reports as a valid instrument for measuring the number of informal hours and the type of services received (Williams et al., 1997 ; Albert et al., 2004 )  Spanish literature about UNs: scarce

7. XXXIV Simposio Análisis Económico Questions  To what extent personal social services for dependent people (Home Care and Day Centres) are able to satisfy dependent’s needs  What is the effect of formal unmet needs over informal caregiving hours?  Which factors are associated to the emergence of personal unmet needs?

8. XXXIV Simposio Análisis Económico Data  Informal Support Survey (IMSERSO, 1994 & 2004)  Method: household interview  Who answers: informal caregivers (relatives, friends, neighbours) of older people (60 years and older), who may be co-resident or not  Sample: N=1.665 in 1994, N=1.504 in 2004  Ceuta, Melilla and La Rioja excluded  Conclusions can not be applied to:  Institutionalized dependent people  Individuals who only receive formal care  Innovative approach for determining the dependency degree  Application of the Ranking Scale of Dependency (R. D. 504/2007, de 20 de abril)

9. XXXIV Simposio Análisis Económico Descriptive statistics  Classification in three dependency degrees:  Moderate: needs help for DLA one a day  Severe: needs help two or three times per day  Great: needs help for DLA several times per day  Two levels of supervision inside each degree: Level 1: can perform the activity by himself Level 2: requires some degree of support  Compare the survey questionnaire with the official one  47 tasks grouped in 10 activities (+ an additional activity for mentally ill/cognitive disabled)  25-49: Moderate; 50-74: Severe; 75-100: Great

10. XXXIV Simposio Análisis Económico Descriptive statistics  Slight increase in the percentaje of no-dependent people as a consequence of  healthy life expectancy  High degree of consistency between the classification obtained form Informal Support Survey (1994, 2004) and the Disabilities, Deficiencies and Health Status Survey (1999)

11. XXXIV Simposio Análisis Económico Definition of Unmet Needs (UN)  Not satisfied (Quantity, quality) Unmet needs Problem  Rejected Accepted Dependent (or informal caregiver) applies for public formal care Satisfied Home Care Day Centre

12. XXXIV Simposio Análisis Económico Descriptive statistics Relation betwen FC and UN according to dependency degree Comparison 1994/2004 Decrease in 2004 Higher for great dep. Slight increase in 2004

13. XXXIV Simposio Análisis Económico Double sample selection model Relation between FC and UNs:  difference between the amount of services offered and the conditions required to be awarded.  difference between the expected benefit from formal care and the current provision of services. are unobsevable

14. XXXIV Simposio Análisis Económico Double sample selection model In the hours equation we must take into account Define an equation for each subsample where we include the selectivity terms to correct the double selection problem (Tunali, 1986): ’s: Selectivity terms

15. XXXIV Simposio Análisis Económico Explanatory variables  Carerecipient’s characteristics Gender, sex, marital status, level of education, dwelling arrangements, degree of dependency, pathologies, type of benefit received, monthly household income  Caregiver’s characteristics Gender, sex, level of education, marital status, number of caregiving years, permanent caregiver, wilful caregiver, kinship dependent-caregiver, good relation with dependent before the onset of caregiving tasks  Informal network: Secondary caregivers, kinship primary-secondary caregiver, children living at household  Formal care Private formal care Social services: Home Care (coverage index, time devoted to personal care, hours/week, cost/hour, copayment), Day Centre (coverage index, % psycogeriatric places, copayment)  Identification of equations Not included in FC equation Not included in UN equation Underlined not included in Hours equation Size of muncipality

16. XXXIV Simposio Análisis Económico Bivariate probit model: Results  Correlation coefficient  Negative Dependent people who receive FC are less prone to suffer UN Bigger effect in 2004  Marginal effects for binary variables  using the sample mean and the sample median Pathologies Almost constant for dementia  osteoarticular problems

17. XXXIV Simposio Análisis Económico Bivariate probit model: Results  Great dependent:  FC=0&UN=1 by 47.01% in 1994 and 22.10% in 2004.  Moderate dependent: Lower decrease in the FC=0&UN=1 than GD Differences between dependency degrees have shortened.  Severe or Great dependent:  FC=1&UN=1 by 12.54% and 25.18% in 1994 and has raised to 22.33% and 35.44, respectively, in 2004  higher probability of both receiving FC and considering it is unsatisfactory.  Moderate dependency: If they receive FC, lower prob. of not being satisfied

18. XXXIV Simposio Análisis Económico Bivariate probit model: Results  Higher coverage index of Home Care/Day Centre  FC=0&UN=1 &  FC=1&UN=1 In 2004, the negative effect over:  FC=0&UN=1 is higher for Day Centre  FC=1&UN=1 is higher for Home Care

19. XXXIV Simposio Análisis Económico Bivariate probit model: Results  Home Care includes personal care and houseworking More time devoted to personal care:  FC=1&UN=1  High variability across regions:  Maximum: Navarra 80%  Minimum: Extremadura 20%  More hours/month  FC=0&UN=1  FC=1&UN=1  High variability across regions:  Maximum: Galicia 25.14 hours/month  Minimum: Andalucía 8 hours/month

20. XXXIV Simposio Análisis Económico Bivariate probit model: Results  Cost/hour & copayment:  FC=1&UN=1 and  FC=0&UN=1  Cost/hour:  Maximum: Navarra 22.32 €/hour  Minimum: Extremadura 6.18 €/hour  Copayment Home Care  Maximum: 21% Galicia  Copayment Day Centre  Maximum: 40% Galicia

21. XXXIV Simposio Análisis Económico Informal hours: Selectivity terms  1994:  22>0,  42<0  FC=1&UN=1more IH than FC=0&UN=1  2004:   21<0: FC=0&UN=1 more IH than FC=0&UN=0   31>0: FC=1&UN=0 less IH than FC=1&UN=1   42<0: FC=1&UN=1more IH than FC=0&UN=1 FC=0 UN=0 FC=0 UN=1 < FC=1 UN=1 < > FC=1 UN=0

22. XXXIV Simposio Análisis Económico Informal Caregiving Hours: Results  Higher coefficients for FC=1&UN=1 as compared to FC=0&UN=1.

23. XXXIV Simposio Análisis Económico Informal Caregiving Hours: Results  For the same dependency degree, informal caregivers devote more hours in 2004 than in 1994. For example, a level 2 great dependent with FC and UN implied an increase of 4.65 hours/week in 1994 and 5.64 hours/week in 2004..

24. XXXIV Simposio Análisis Económico Informal Caregiving Hours: Results  The distance in caregiving hours between moderate (level 2) and great dependence (level 2) has increased between both waves:  2.76 hours/week in 1994  3.62 hours/week in 2004.

25. XXXIV Simposio Análisis Económico Informal Caregiving Hours: Results  Difference between with/without UN FC=0&UN=0 vs. FC=0&UN=1 1994  1.09 more hour/week 2004  1.68 more hour/week FC=1&UN=1 vs. FC=1&UN=0 1994  1.70 more hour/week 2004  2.01 more hour/week

26. XXXIV Simposio Análisis Económico Predicted number of IC hours  Wives provide more care than daughters for the national average  Significant differences by Autonomous Communities related to the provision of social services

27. XXXIV Simposio Análisis Económico Conclusions  Negative relationship between FC & UN  1994: self-selection in UNs equation  2004:  Significant self-selection in both equations  Selection in UN eq higher than in FC eq  Evidence against Substitution Model (FC   IC)  Dependent’s variables not considered in conditions required for receiving FC in 2004  Significant effect over Informal Hours  Consequences of UNs extended to informal caregiver’s life  Home Care: formal caregivers should...  Assume that althoug IC is available, dependent people do not want to overburden family members  Homogenisation of the % of time devoted to houseworking and personal care across Autonomous Communities

28. XXXIV Simposio Análisis Económico Future research  New Law of Dependency  Individual Care Program (art. 29): “ the modes of intervention that are most suitable to their needs from among the services and financial benefits foreseen”  Consideration of insufficient coverage : “The services in the Catalogue shall be of a priority nature and shall be provided through the Social Services Network by the respective Autonomous Communities or subsidised private centres or services” (art. 14.2)  Is there a significant reduction in the percentaje of UNs?  Are some UNs more important than others?  What is more important in terms of dependent’s quality of life: the elimination of a moderate UN or the reduction of a severe one?

29. XXXIV Simposio Análisis Económico THANKS FOR YOUR ATTENTION