XXXIV Simposio Análisis Económico A double sample selection model for unmet needs, formal care and informal caregiving hours of dependent people in Spain

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


Motivation

Factors affecting the supply of informal caregiversAverage household size:

1998 3.23 people2007 2.74 people(Continuous Household Budget Survey, INE)

Number of children per woman1975 2.803 children2008 1.458 children(Basic Demographic Indicators, INE)

Divorce rate (per 100 mariages)1980 4.7%2007 63.92%(Social Indicators, INE)

Female labor participation1987 31.83%2008 60.13%(Active Population Survey, INE)


Motivación

Factors affecting the demand of careNumber 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


Motivation

Preferences of elder people and informal caregiversOpinion about the participation of Public Sector in long-term care

Preference for the place for receiving care in case of need


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 disabilitiesDownfalls 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


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


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?


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)


Descriptive statistics

Classification in three dependency degrees:Moderate: needs help for DLA one a daySevere: needs help two or three times per dayGreat: needs help for DLA several times per day

Two levels of supervision inside each degree:Level 1: can perform the activity by himselfLevel 2: requires some degree of support

Compare the survey questionnaire with the official one47 tasks grouped in 10 activities (+ an additional activity for mentally ill/cognitive disabled)

25-49: Moderate; 50-74: Severe; 75-100: Great



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)


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 CareDay Centre



Relation betwen FC and UN according to dependency degreeComparison 1994/2004

Decrease in 2004Higher for great dep.

Slight increase in 2004


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


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


Explanatory variables

Carerecipient’s characteristicsGender, sex, marital status, level of education, dwelling arrangements, degree of dependency, pathologies, type of benefit received, monthly household income

Caregiver’s characteristicsGender, 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 carePrivate formal careSocial services: Home Care (coverage index, time devoted to personal care, hours/week, cost/hour, copayment), Day Centre (coverage index, % psycogeriatric places, copayment)

Identification of equationsNot included in FC equationNot included in UN equationUnderlined not included in Hours equation

Size of muncipality


Bivariate probit model: Results

Correlation coefficient NegativeDependent people who receive FC are less prone to suffer UNBigger effect in 2004

Marginal effects for binary variables using the sample mean and the sample median

Pathologies

Almost constant for dementia osteoarticular problems



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 GDDifferences 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



Higher coverage index of Home Care/Day Centre FC=0&UN=1 & FC=1&UN=1In 2004, the negative effect over: FC=0&UN=1 is higher for Day Centre

FC=1&UN=1 is higher for Home Care



Home Care includes personal care and houseworkingMore 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



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


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=0UN=0

FC=0UN=1

< FC=1UN=1

< > FC=1UN=0


Informal Caregiving Hours: Results

Higher coefficients for FC=1&UN=1 as compared to FC=0&UN=1 .



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. .



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.



Difference between with/without UNFC=0&UN=0 vs. FC=0&UN=1

1994 1.09 more hour/week2004 1.68 more hour/week

FC=1&UN=1 vs. FC=1&UN=01994 1.70 more hour/week2004 2.01 more hour/week


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


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


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?


THANKS FOR YOUR ATTENTION

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XXXIV Simposio Análisis Económico A double sample selection model for unmet needs, formal care and informal caregiving hours of dependent people in Spain