In many countries over the past decade, there has been a shift in the setting of care from the hospital to the home. In Canada, public expenditures on home care have increased at an average annual compound rate of 17.4% from $62 million in 1975 to $2096 million in 1997, while total public health spending has only increased at a rate of 8.3%. Increased public spending on home care leads to an increase in publicly funded home care service use. This study suggests that household members may decrease their unpaid care contributions when public services increase; however, the results are not based on individual level data. Further research is needed because some studies have suggested that when the amount of public services provided increases, the amount of unpaid care is often not affected, thereby resulting in an increase in the total amount of care provided.

Background: In many countries over the past decade there has been a shift in the setting of care from the hospital to the home. In Canada, public expenditures on home care have increased at an average annual compound rate of 17.4% from $62 million in 1975 to $2096 million in 1997, while total publicly-funded health spending has only increased by 8.3%. This study examines the impact that this funding increase has had on household decision-making regarding the amount of publicly-funded home care service use versus unpaid caregiving.

Methods: The authors conducted analyses of data from multiple years of two national surveys for this research project. Data from the 1994/95, 1996/97, and 1998/99 National Population Health Survey (NPHS) were used to determine the care needs of respondents and the amount of publicly-funded home care received over a 12-month period. The analysis first determined the self-perceived need for home care services among individuals aged 55 years and over across all provinces between 1994 and 1998. The authors then examined whether individuals with self-perceived need for home care actually received any publicly-funded services. Data from the 1992, 1994, and 1996 General Social Survey (GSS) were used to determine the amount of unpaid care provided to respondents from family members and friends. The authors used this information to determine the extent to which increases in public funding influenced the amount of unpaid care provided.

Findings: Analysis of the NPHS demonstrated that need for care always exceeded the amount of publiclyfunded care provided, with some variation amongst provinces. Overall, 20% of respondents aged 55+ perceived a need for home care while 6% reported receiving publicly-funded services. The probability of receiving services was higher for women than men, older compared to younger individuals, and those with lower health status. Those with higher incomes were less likely to use publicly-funded care and this may be due to the income cut-offs in many of the provinces. Those with more education were more likely to access publicly-funded care, which might reflect a greater awareness of services. Individuals were more likely to receive services when public spending on these services increased. Perceived need for home care was not affected by the level of public spending on home care. A second set of analyses were conducted with the subset of individuals who self-reported a need for care. Amongst those reporting a perceived need for home care, men and those with lower incomes were more likely to receive publicly-funded care. Again, increased public spending resulted in an increase in home care service use among those with self-perceived need.

The analysis of the GSS demonstrated large differences in unpaid care provision amongst provinces. In 1992, 7.9% of Quebecers, 13.3% of Ontarians and 22.4% of Newfoundlanders reported providing unpaid care. Women, individuals with more than a high school education, and those with fewer labour market hours were more likely to provide care. As public spending on home care increased, unpaid caregiving decreased modestly, suggesting that individuals may substitute unpaid caregiving for publicly funded services.

Conclusions: Increased public spending on home care leads to an increase in publicly-funded home care use. Further research is needed to determine the impact of increased spending on the overall amount of care provided to individuals. This study suggests that household members may decrease their unpaid care contributions when public services increase. Further research is needed because some studies have suggested that when the amount of public services provided increases, the amount of unpaid care is often not affected, thereby resulting in an increase in the total amount of care provided.

Reference: Stabile M, Laporte A, Coyte PC. Household responses to public home care programs. Journal of Health Economics. 2006; 25: 674 - 701.

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