The main findings in this study are the different patterns of LTC that were identified. Countries characterized by closer alignment between old age related expenditure and elderly needs are those where the needs of the very old population seem to be properly met by the level of expenditure in the LTC sector and on social benefits. This pattern characterizes both Nordic and Western European countries. The majority of Nordic countries having higher levels of formal care are supply oriented systems, with a strong state responsibility for providing formal care . This model of welfare also includes Denmark, where a varied range of adapted dwellings for older people have been developed in the last decades .
Western European countries mainly fulfil the needs of the elderly through social protection schemes based on cash for care, which are seen offering LTC services that are less expensive than traditional provision; these countries can be therefore defined as consumer choice oriented [21, 22]. The cash programmes, both in tax funded and insurance based LTC systems, aim to give households choice over care decisions, fostering and supporting family care, developing care markets, and containing costs . Three main types of programmes can be distinguished:
personal budgets and consumer-directed employment of care assistants;
payments to the person who needs care and can spend it as she/he likes, but has to acquire sufficient care;
payments to informal caregivers as income support .
Also in some Nordic systems, cash for care schemes have been introduced to reform policies that were seen as too supply oriented, costly and unresponsive. This is the case of the Personal Budget for Care and Nursing in the Netherlands, the Care Wage in Norway, and the Attendance Allowances and the Care Leave in Sweden. These programs were all introduced to bring some flexibility into the LTC system. In Sweden, the employment of payments for care interventions, coupled with a reform policy that restricted care services to highly dependent elderly with limited family support, lowered the proportion of older people who received home care. This might explain the linear dynamic trend that emerged in the analysis [1, 22].
The dynamic of both France and the United Kingdom is towards increasing resources addressed to the elderly and a surging amount of formal care. Since the mid 1990s France has undergone a process of reforming LTC, aiming to increase the number of recipients on the basis of a universal principle, and growing attention has been paid to elderly care after creating the "Plan for frail elderly people" in 2004 . The United Kingdom has also faced some reforms of the LTC system in recent years, increasing the proportion of older dependent people who receive intensive home care packages .
Mediterranean and Central-South Eastern countries show less alignment between old age related expenditure and elderly needs. In addition, Mediterranean countries are especially characterized by lower levels of formal care, which is explained by the large amount of informal care which is mostly privately paid. In these countries, the source of welfare is traditionally the family, which provides the bulk of LTC, due to the way individuals perceive their responsibilities and the lack of other care options. In Greece, for example, relatives feel a duty to care which is reinforced by legal duty, social attitudes and lack of alternative care [24, 25].
Other factors, such as the proportion of elderly people living alone, influence the availability of family care and the willingness of family members to provide it . In terms of living arrangements, the proportion of old people living alone varies across Europe, with the lowest number still seen in some Southern European countries (19%) compared with 34%, 32% and 24% in the Nordic countries, Western and Eastern European nations respectively .
In Spain LTC was not defined as a specific service within health and social policy until recently . Although several regions have begun specific programmes of building or subsidizing new facilities, there is a shortage of institutional care in many areas, and the majority of elderly people who receive care at home pay for private home help or rely on informal care . The indistinct pattern of Italy and its irregular dynamic reflect the high variability and fragmented policy within the LTC system. This is due to two factors: the growing responsibility of regional governments in health care organization and funding, and demographic and cultural reasons. The supply of beds in LTC institutions as well as the employment of cash for care programmes, for example, differs substantially across Italian regions [23, 28, 29].
The linear dynamic of the Czech Republic is to a certain extent explained by a recent reform that laid new foundations for the provision and funding of social services and emphasized cash allowances paid to those in need of care. This marked a major turning point in the Czech LTC system, even though it remains to be seen what further developments the implementation of the new system will produce . Central and South Eastern countries, despite the predominant role of informal care, show a level in the provision of formal care which is slightly above the average European level. Although the existing LTC infrastructure is very limited and poor, there is a lack of investment in new projects, and talks about privatization have not been supported by an adequate regulatory framework and financial support, these countries are service-oriented in the sense that residential care is the only alternative to informal arrangements and family networks . In Hungary, social services for the elderly and the disabled do have a relatively well developed institutional network, however, they do not meet growing needs either in terms of number of places or quality of the services . The unclear or irregular dynamics of these countries might be explained by the major transformations of their welfare systems in the past two decades, the majority oriented toward social insurance schemes. In Slovenia, for example, intensive debate resulted in a proposal for a LTC insurance scheme, but this scheme has yet to be implemented .
The scenario which arises from our analysis confirms the distinction between "weak family"/"individual" and "strong family" countries, which opposes the Northern and Western countries to Mediterranean and Southern ones. The latter ones are, in fact, characterized by traditional family structures, lower divorce rate, very late and increasing ages of leaving the parental home, most frequency of contact between parents and children .
These differences might result from religion traditions and cultural values, reflecting the European Protestant-Catholic dichotomy (Protestant emphasis on individualism versus Catholic family values) and the different social role attributed to men and women (high Femininity index in Nordic countries versus predominant Masculinity dimension of Latin ones) .
Our analysis has some limitations. First of all, the quality of the analysis is only as good as the quality and comparability of the international data allowed. For instance, data deriving from OECD are collected from national sources which vary from one country to another, so that variables such as Beds in institutions or Recipients in institutions may include different type of nursing homes or facilities. Also the variables expressing self-perceived health are influenced by subjectivity and international cultural differences, that could be the same that influence the self-reported level of "happiness", which is demonstrated to be higher in Nordic countries rather than in Southern ones .
Another limitation of the study is that some variables (i.e. the two related with the self- perceived health status and self-perceived activities limitation) were available only from 2004 onwards.
A relevant shortcoming of the MFA is that it fails to process missing elements, so that some relevant variables were excluded from the analysis . In fact, international sources do not report systematic or complete data regarding, inter alia, the formal and informal workforce employed in the LTC sector and the share of elderly people living alone.
Still regarding the statistical method, different rules exist to retain factors that can lead to different results. However the explained variance criteria with a cut-off point of 60% was chosen in order to explain enough variance with as few meaningful factors as possible [34, 35].
In addition, the interpretation of the factors generated in the MFA was "heuristic", meaning it was plausible and convenient even if not the only one possible; more than one interpretation can be made of the same data factored in the same way. Finally, the MFA does not identify causality.
The strengths of the study are many, however. It was an exploratory and dynamic analysis, that allowed us to take into consideration and to combine several important variables related to the LTC, thus having a global and integrated picture of them, allowing the confrontation of whole information, which is more rich than an examination parameter by parameter . In addition, MFA has very good visualization properties, which makes it a suitable technique for data exploration .
Finally it was possible to perform the analysis despite the lack of two variables for the first year .
This study may represent a useful contribution to the resources for decision makers when dealing with the future common challenges that, apart from specific contexts and issues, all EU countries have to face. Building adequate systems of LTC is one of the most important challenges, which involves the integration and coordination of care between different service providers and between health and social care. The main critical issues are the organization of the LTC system and the balance between formal and informal care, residential care, home care and cash allowance programmes, and provision by the public and private sectors . In the future, the availability of informal carers and their willingness to provide care will diminish, due to changes in family structure, growing participation of women in the labour market, and ageing of the partners and children who would otherwise supply informal care .
Given the general preference of elderly people to remain in their home for as long as possible with assistance, especially from their family, such informal care should be adequately supported by information, training, counseling, financial aid, employment leave and formalization of the role within the social security system .
Another relevant challenge will be the shortage of workers in this labour-intensive sector which requires adequate and well trained staff. Thus, policies aimed to improve the recruitment and the retention of qualified LTC staff and their working and contractual conditions will be needed . Other critical points will be access to care and its quality, along with the fiscal sustainability, in terms of resources and expenditures allocated to the LTC sector and to the social protection systems . It is recommended that countries should give priority to single entry point processes to manage LTC, in order to guarantee integrated and continuous care .
Finally, lack of international standard definitions, such as for disability and LTC expenditure, the use of different methodologies to gather data on the prevalence of old age disability and to measure the incidence of chronic conditions, some unclear demarcations (such as between the health care and social services sector, and between acute care and rehabilitation), and blurred boundaries between public and private sector provision, lead to the need for a more comparable, complete and up to date international database [7, 30].