Who cares? Evidence on informal and formal home care use in Estonia

Mozhaeva, Irina Article Who cares? Evidence on informal and formal home care use in Estonia Baltic Journal of Economics Provided in Cooperation with: Baltic International Centre for Economic Policy Studies (BICEPS), Riga Suggested Citation: Mozhaeva, Irina (2019) : Who cares? Evidence on informal and formal home care use in Estonia, Baltic Journal of Economics, ISSN 2334-4385, Taylor & Francis, London, Vol. 19, Iss. 1, pp. 136-154, https://doi.org/10.1080/1406099X.2019.1578478 This Version is available at: https://hdl.handle.net/10419/267566 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=rbec20 Baltic Journal of Economics ISSN: 1406-099X (Print) 2334-4385 (Online) Journal homepage: https://www.tandfonline.com/loi/rbec20 Who cares? Evidence on informal and formal home care use in Estonia Irina Mozhaeva To cite this article: Irina Mozhaeva (2019) Who cares? Evidence on informal and formal home care use in Estonia, Baltic Journal of Economics, 19:1, 136-154, DOI: 10.1080/1406099X.2019.1578478 To link to this article: https://doi.org/10.1080/1406099X.2019.1578478 © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 22 Feb 2019. Submit your article to this journal Article views: 1507 View related articles View Crossmark data Citing articles: 5 View citing articles Who cares? Evidence on informal and formal home care use in Estonia Irina Mozhaeva Faculty of Business, Management and Economics, University of Latvia, Riga, Latvia ABSTRACT Despite increasing attention to long-term care (LTC) and related challenges in the Estonian social policy agenda, the distributional fairness of LTC services in the country has received very limited attention. Using SHARE data, we address informal and formal home care services and identify the socio-economic factors that drive or hinder their use among the Estonian elderly. The relationship between informal and formal home care utilization is estimated applying the new approach to instrumental variable method proposed by Lewbel [2012. Using heteroscedasticity to identify and estimate mismeasured and endogenous regressor models. Journal of Business and Economic Statistics,30(1), 67–80]. We find that it is important to distinguish among informal care provided by household members, other relatives and non-relatives because the same socio-economic factors might differentially affect the propensity to use these kinds of care. The estimation results indicate that informal care provided by non-relatives complements formal home care. LTC policy in Estonia ensures the absence of tangible financial, ethnic and urban/rural barriers to the use of formal home care. ARTICLE HISTORY Received 25 April 2018 Accepted 31 January 2019 KEYWORDS Estonia; formal home care; informal care; long-term care; SHARE JEL CLASSIFICATION I11; I12; I18; J14; C25; C26 1. Introduction Rapid population ageing is expected to pose various challenges for long-term care (LTC) systems all over Europe in the near future. The social and economic consequences will vary across countries depending on a number of factors, starting with old-age and care-dependency ratios and ending with the priorities defined by policy makers and the ability of responsible authorities to create sustainable LTC systems. Countries with generous LTC policies, such as Denmark, Netherlands and Norway, are predicted to experience substantial increases in public expenditures (EC, 2018), withholding the pressure on informal carers, while systems with high reliance on familial care, e.g. Estonia, Latvia, and Bulgaria, are expected to rein in public expenditure growth by paying the price of greater withdrawal of working-age informal carers from their labour markets, which will have non-negligible negative effects on these economies, especially in the face of diminishing numbers of younger entrants into labour markets and shrinking working-age populations. © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. CONTACT Irina Mozhaeva [email protected] Faculty of Business, Management and Economics, University of Latvia, Aspazijas Boulv. 5, Riga LV-1050, Latvia BALTIC JOURNAL OF ECONOMICS 2019, VOL. 19, NO. 1, 136–154 https://doi.org/10.1080/1406099X.2019.1578478 Forecasts for Estonian demographics show that in the year 2030, the share of the population aged 65 and over will increase from the current value of 19% to a quarter of the population, implying a tangible increase in care-dependency ratios in the near future. These demographic trends in line with gradually growing disability rates already pose increasing burden on both informal and formal LTC in Estonia. Public (and private) expenditures on inpatient care have expanded significantly in recent years (World Bank, 2017), highlighting the need for more efficient integration of the health and social LTC sectors and increasing the role of less expensive home-based services that are found to reduce the utilization of institutional care (Kehusmaa, Autti-Rämö, Helenius, & Rissanen, 2013; Van Houtven & Norton, 2008). While the LTC system in Estonia is characterized by an unusually strong family responsibility, and familial care is expected to remain the backbone of the LTC system, the anticipated demographic changes will put enormous pressure on informal carers, implying substantial negative economic and social consequences if no political action is taken. Although LTC and related challenges are high on the political agenda in Estonia, insufficient political and scientific attention is being paid to a related and important social issue – ensuring adequate, equitable access to LTC for all individuals based on their needs and independent of their socio-economic status. Examining the inequality aspect in Estonia is extremely important given very low public spending on LTC and one of the lowest coverage indicators in the EU, which is estimated at approximately only 1/3 of the care-dependent population (EC, 2015). In this paper, based on the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 6 data, we examine the association between socio-economic and need factors and utilization of informal and formal home care among the Estonian elderly aged 60 and over. We conduct our analysis in two stages. First, we examine the socio-economic and physical and mental health factors that drive or hinder the use of various kinds of informal care. Second, we analyse inequities in access to formal home care controlling for the use of informal care. There is no united approach to analysing the causal relationship between formal and informal care. Many past studies were concerned with the effect of publicly provided LTC on informal care (e.g. Arnault & Goltz, 2013; Christianson, 1988; Langa, Chernew, Kabeto, & Katz, 2001; Motel-Klingebiel, Tesch-Roemer, & Kondratowitz, 2005; Stabile, Laporte, & Coyte, 2006; Viitanen, 2007). Another angle, i.e. the effect of informal care on the utilization of formal LTC services, was considered by Bolin, Lindgren, and Lundborg (2008), Bonsang (2009), Lo Sasso and Johnson (2002), Pezzin, Kemper, and Reschovsky (1996), and Van Houtven and Norton (2004), among others. Other authors have aimed at generalizing two-way substitution between informal and formal LTC (e.g. Chen, Yamada, Nakashima, & Chiu, 2017). Holly, Lufkin, Norton, and Van Houtven (2010) argue that differences in institutional settings across countries must be taken into account when defining the direction of causality in an analysis of informal care provision and formal home care. Given the legislative framework of the LTC system in Estonia described further in this paper, we analyse the effect of informal care on the utilization of formal home care services, not the reverse. We follow previous research that has highlighted the importance of taking into account the endogeneity inherent to formal and informal care: while the decision to provide/seek informal care and the decision to use formal home care are simultaneously determined, failure to control for endogeneity may result in misleading BALTIC JOURNAL OF ECONOMICS 137 conclusions (Bolin et al., 2008; Van Houtven & Norton, 2004). In this research, exogeneity of the informal care variable was rejected (Rivers & Vuong, 1988); therefore, in our paper, the relationship between formal home care and informal care is estimated by applying an instrumental variable approach. Research on the distributional fairness of LTC provision in Estonia, especially of the social components, is scarce. We have identified only one study by Bremer et al. (2017) that examines the utilization of informal and formal home care and their determinants and includes Estonia as one of the eight countries analysed; however, this study focuses on a narrow target group of persons with dementia. At the same time, high variability in population and LTC system characteristics across the European landscape implies substantial differences in the effects of socio-economic determinants on the utilization of LTC (e.g. Ilinca, Rodrigues, & Schmidt, 2017; Marcinkowska & Sowa, 2011); therefore, countryspecific analysis is essential to disentangling the factors that hinder the use of LTC services and contribute to the existing inequalities within a country. This paper extends the literature in two main ways. First, it fills a gap in country-specific information on the socio-economic determinants of informal and formal home care utilization in Estonia. Second, we propose analysing informal care by splitting it into three kinds based on the nature of the relationship between the caregiver and the recipient –informal care provided by (1) household members, (2) relatives not living in the same household and (3) non-relatives. Most authors analyse informal care using a single variable (e.g. Bakx, 2010; Balia & Brau, 2014; Bolin et al., 2008; Bonsang, 2009; Holly et al., 2010; Van Houtven & Norton, 2004), mostly reflecting care provided by descendants only. Others, including Litwin and Attias-Donfut (2009) as well as Marcinkowska and Sowa (2011), distinguish between care received within and outside the household; however, the latter encompasses assistance provided by relatives and non-relatives and is therefore not homogeneous in the sense that the two components are obviously driven and hindered by different underlying factors. Distinguishing between care provided by relatives within and outside the household is also important given that the content and intensity of these kinds of care usually differs considerably. The approach adopted in this paper sheds light on some peculiarities of the determinants of informal LTC use, proposing that the same factors may affect the propensity to use various kinds of informal care in different directions. This approach also raises some important points on the association between informal and formal home care use in Estonia: our results suggest that informal care provided by non-relatives complements formal home care, while the effect of informal care provided by relatives, living either with the elderly person or separately, on the utilization of formal home care is not statistically significant. The obtained results suggest that despite low overall coverage, current social LTC policy in Estonia ensures equitable access to formal home care services among the elderly. The remainder of this paper is organized as follows: Section 2 provides insights into the peculiarities of the organization of LTC in Estonia and describes public support for informal caregivers. Sections 3 discusses the relationship between informal and formal home care and the endogeneity issue, and details the econometric methodology employed in this paper. Section 4 describes the data. The empirical results are presented and discussed in Section 5. Concluding remarks are provided in Section 6. The descriptive statistics are presented in the Appendix. 138 I. MOZHAEVA 2. Background: LTC system organization in Estonia The LTC system in Estonia is characterized by great reliance on informal care and an unusually strong family responsibility: the Constitution of the Republic of Estonia (Art. 27) stipulates that the family is responsible for taking care of its members in need of assistance. The family members who are required to provide such care include spouses and adult firstand second-degree ascendants and descendants (Family Law Act, 2009). If a person has no relatives or relatives cannot provide the assistance necessary for objective reasons, then state and local governments step in. There is no care insurance scheme in Estonia. Responsibility for formal LTC provision in the country is shared by the health care and social welfare systems. Health care services are organized at the state level by the Estonian Health Insurance Fund (EHIF), whereas social LTC services are split between the state and local governments. As in many other European countries, the separation of funding streams between state and local governments provides little incentive to coordinate care between the health and social systems. The social LTC system maintained by local governments offers general care home and day care centre services, home care, childcare, support person and personal assistance services, curatorship, transportation and housing services (Social Welfare Act, 2015). Municipalities can also ensure dwelling adaptation and provision of special equipment according to the needs of the disabled person. Local governments are free to define their own policy for social LTC provision. The supply of these services is defined primarily by the social budget of each local government; therefore, the provision of social LTC is highly unequal across municipalities (World Bank, 2017). Due to strong budget limitations, social services are usually not advertised, and hence, public awareness of such opportunities is limited. Depending on the policy of each municipality, eligibility requirements for some social LTC services, e.g. home care, do not necessarily include official disability status. This approach is based on the concept that the provision of LTC should not be strictly linked to the official disability group, thus the social LTC system in Estonia also covers persons with health deterioration, including frail elderly persons (World Bank, 2017). 2.1. Support for informal caregivers Informal care can be considered the backbone of the current social LTC system in Estonia and is supported by local governments in the form of caregiver allowances. Most municipalities provide this type of benefit regardless caregiver-recipient kinship; however, some pay allowances only to non-relatives who provide a disabled person with necessary care. For example, in the case of incapacitated elderly persons, 1 some municipalities, including Pärnu city, Rakvere city, Haapsalu city, Lihula parish, and Saue parish, provide caregiver allowances only to carers who do not have family ties with the disabled person, thus targeting the most vulnerable elderly –those who do not have close relatives. The size of the allowance depends on the municipality, the disabled person’s age and the severity of disability. In 2015, the monthly allowance for carers of retirement-age disabled persons ranged from 7 EUR to 200 EUR; allowances for carers of frail elderly persons without official disability status were available in approximately 1/10 of municipalities and BALTIC JOURNAL OF ECONOMICS 139 ranged from 15 to 70 EUR per month (World Bank, 2017). If a caregiver is registered with the Unemployment Insurance Fund as unemployed, the local government must pay a social tax for this person. 2.2. Formal home care Formal home care usually is provided to persons with serious health deteriorations who live alone. The smallest standard package of home care services includes purchasing food once or twice a week and providing help with paying bills. As a rule, the price of this package is very low (a few euros) and can be adjusted if the person has a very low income; such payments do not cover the actual costs of care and are meant to stimulate the person to remain active and try to execute everyday activities independently. Nevertheless, some municipalities (e.g. Pärnu city) provide completely free home care services to persons who do not have any relatives. If necessary, more intensive and diversified help is provided to the disabled person: a social worker can, for example, clean the house, cook food, help with bathing, take the person to a doctor; however, services directly related to the duties of medical workers are not included. 2 Local governments make a decision about the provision of home care services based on an assessment form (questionnaire) completed by a social worker or sometimes also by the person claiming for the service. In some municipalities, general physicians are involved in the assessment process; in others, such involvement is required only when a specific care plan is necessary. The service package and individual care plan is based on the results. Reassessment usually is carried out on an annual basis. The same assessment tool is, as a rule, used for the various social LTC services provided by a local government. Due to the strict budget limitations of local governments, the provision of formal home care in Estonia is being expanded too slowly to meet the growing need for home-based services among the elderly, increasing the burden on institutional care and implying higher private and public expenditures (World Bank, 2017). 3. Relationship between informal and formal home care and endogeneity 3.1. Theoretical framework Different LTC policies across countries result in not only varying coverage and distribution of services among socio-economic groups but also different associations between informal and formal home care. As Van Houtven and Norton (2004) note in their paper, whether formal and informal care are complements or substitutes is an empirical question. In the case of Estonia, this relationship is defined not only by the tightness of family and community ties, the level of altruism and the willingness to provide assistance to non-relatives but also by the adherence to principles and the strictness of local governments in deciding whether to provide social care services to elderly persons with families, for example, living in another municipality or region. Holly et al. (2010) state that various institutional settings and markets for formal home care imply different incentives for both informal caregivers and the disabled; therefore, the direction of causality between informal and formal home care use can vary. The theoretical 140 I. MOZHAEVA framework proposed by Van Houtven and Norton (2004) is based on the assumption that incapacitated parents optimize their consumption of formal services given the amount of informal care provided by children. Conceptually, this framework does not suit the Estonian case for two related reasons: first, an additional decision maker –the local government –has to be introduced; second, in Estonia, elderly persons with children living in the same municipality are not usually eligible for formal home care. Nevertheless, in this paper, we assume the direction of causality from informal to formal care as this complies with the overall legal framework of LTC in Estonia that stipulates that the family is primarily responsible for those in need of care and that, in the absence of family, state and local governments step in (see Section 2). As Bolin et al. (2008) highlighted, while the amount of informal care provided may be viewed as an outcome of a game between the elderly person and his or her relatives, one should take into account that the utilization of formal and informal care is endogenously decided. We tested the null hypothesis that informal care is exogenous in the formal home care equation (Rivers & Vuong, 1988); the hypothesis was rejected at the 7.6% level. Hence, the specification of our formal home care equation is formulated treating informal care as endogenously defined. 3.2. Econometric approach In this paper, we analyse the association between formal home care and informal care applying models with two different specifications: in the first, a single informal care variable representing any kind of informal care received by a person is included in the formal home care equation, whereas in the second, the informal care variable is split into three parts according to the nature of the relationship between the caregiver and the recipient –informal care provided by (1) household members, (2) relatives not living in the same household and (3) non-relatives. We did not manage to find good instruments that would simultaneously strongly correlate with the three informal care variables but not with the (estimated) error term of the formal home care equation. Therefore, we apply the approach proposed by Lewbel (2012) and employ the ivreg2h model implemented in Stata by Baum and Schaffer (2012) as an extension of Baum, Schaffer, and Stillman’s ivreg2 model (Stata J., 2003,2007,2010). Lewbel’s elaborated methodology serves to identify structural parameters in regression models with endogenous regressors in the absence of external instruments; this method exploits model heteroskedasticity and constructs instruments as simple functions of the available regressors. The Stata command ivreg2h written by Baum and Schaffer (2012) provides estimates for models using only external or generated instruments, as well as estimates using both the selected instrumental variables and generated instruments that supplement the external ones in order to increase the efficiency of the IV estimator. In this study, we rely on the ivreg2h option with the generated instruments. In his earlier paper, Lewbel (2012) proposed the new method providing an estimator for models containing a continuous endogenous regressor, and in a recent work (Lewbel, 2018), he has shown that the assumptions required for his estimator can be satisfied when an endogenous regressor is binary, as in our case. BALTIC JOURNAL OF ECONOMICS 141 4. Data This study uses micro data from the sixth wave (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE), a multi-disciplinary survey conducted biennially since 2004; it provides broad information on family networks, health, and economic and social conditions of the European population aged 50 and over. The survey design is harmonized with the US Health and Retirement Study and the English Longitudinal Study of Ageing, allowing for international comparison with Europe and the US. The sixth wave of the SHARE covered 17 European countries and Israel, providing data on more than 68 thousand respondents. In this paper, we concentrate on the case of Estonia. A detailed description of the data, the content of the questionnaire and the fieldwork methodology is provided by Börsch-Supan et al. (2013). 4.1. Sample and dependent variables The sample includes all individuals aged 60 or older surveyed in Estonia who personally completed the questionnaire or for whom the information was collected via a proxy interview, and whose LTC service utilization and socio-economic status (SES) could be identified in the database. Some values for SES and control variables have been imputed using the previous SHARE waves (wave 5 or otherwise wave 4) in order to maximize the sample size. The resulting sample consists of 4108 observations. The data set has a sufficient number of observations on users of formal care and informal home care services to ensure large enough cell sizes for the econometric analysis. Table A1 displays descriptive statistics for the variables used in the analysis. 4.1.1. Informal care In this study, we split the informal care variable according to the nature of caregiver-recipient relationship and analyse care provided by (1) household members, (2) relatives not living in the same household and (3) non-relatives. We create three binary variables and estimate the associations between various socio-economic factors and the probabilities of using each of these three kinds of informal care. Information on the amount of care received within the household is not collected by the SHARE given the complexity of such estimates for respondents and, therefore, the substantial anticipated bias. Hence, in this study, the regularity of care is analysed only for informal care provided by relatives living separately and non-relatives. For this purpose, we create two ordinal variables where each is a discrete realization of several underlying ordinal indicators and describes the frequency of informal care received within the last 12 months: 0 –never received such care, 1 –less than once a month, 2 – approximately 1–3timespermonth,3–approximately once a week, 4 –approximately 2–3 times per week, 5 –approximately daily or several times a day. 4.1.2. Formal home care The formal home care measure includes only the social component of home-based services, i.e. it does not cover home nursing services. The variable encompasses professional care services such as help with personal care and domestic tasks in person’s home, as well as other tasks such as help with drug dosages that an elderly cannot perform independently due to physical, mental, emotional or memory problems. The SHARE does not 142 I. MOZHAEVA We find that measures reflecting a person’s disability status, such as limitations in mobility and activities of daily living, are strongly positively associated with receiving formal home care, while the effect of a more subjective indicator –self-assessed poor health – is less robust. According to the obtained results, the effect of the memory variable is not statistically significant, suggesting that the system manages to cover persons with cognitive impairments, probably thanks to the proximity of social services to residents and cooperation with GPs, as well as the so-called ‘neighbour watch’when a disabled person’s neighbours alert social services about a need for assistance; this information channel was rather efficient in small municipalities (See endnote 2); however, its role is expected to diminish after the administrative reform. While cognitive scores among the elderly in Estonia are low compared to the average EU peer (World Bank, 2017), it is particularly important to maintain an LTC system that does not exclude persons with cognitive impairments. 6. Conclusions Given that the Estonian LTC system is centred on informal care and public spending on social LTC as well as the associated coverage indicators are low, analysing the distributional fairness of LTC services is particularly important in Estonia. Using wave 6 of the SHARE, this study examines the socio-economic determinants of the utilization of informal and formal home care services among the Estonian elderly aged 60 and over. We highlight the importance of analysing informal care by splitting it into different kinds based on the nature of the relationship between the carer and the recipient. In this paper, we distinguish among three kinds of informal care –care provided by (1) household members, (2) relatives not living with the elderly person and (3) non-relatives. This approach reveals that the same determinants affect the propensity to use various kinds of informal care in different directions. Such distinctions stem from a number of factors, starting with considerably different intensity and content of care that is usually provided to elderly persons within and outside the household and ending with varying incentives for care provision: while the legislative framework places the burden of care onto close family members, other relatives and non-relatives accept this burden voluntarily and are more often supported by local governments through caregiver allowances. 8 Disaggregation of informal care according to the carer-recipient relationship also allows more accurate conclusions about the association between informal and formal home care. When using a single informal care variable, we find that informal care complements formal home care, which contradicts the overall LTC policy in Estonia in which public home care provision is conditional on the absence of familial care. However, when three kinds of informal care are included in the formal home care equation, a strong positive effect is observed only for assistance provided by non-relatives, whereas the effects for the other two kinds of care (provided by relatives) are not statistically significant. The positive association between assistance received from non-relatives and the probability of formal home care use suggests that when the amount of the former is insufficient, a person seeks formal care. However, the legislative framework does not preclude the reverse consecution and, hence, causality between informal care provided by non-relatives and publicly provided home care could be reciprocal. Further research would be necessary to investigate the causal effects of these two sources of care. BALTIC JOURNAL OF ECONOMICS 149 The results of the developed formal home care models suggest that the currently defined social LTC policy in Estonia ensures equitable access to formal home care services: after adjusting for the need level, we find no tangible income-, ethnicityor educationrelated inequities in formal home care utilization. The absence of urban/rural disparities in access to formal home care indicates that the proximity of social services to clients in rural municipalities facilitated a more individual approach, which at least partly compensated for limited budget resources and a lack of specialized staffin small municipalities. The administrative reform implemented in 2017 is expected to allow more efficient planning and distribution of resources, and provision of more diversified social services in cases of need; however, it implies that local governments and social services are, on average, located farther away from the clients. Therefore, it is important to reassess the situation using data collected after the reform and related major reorganizations to determine whether the system managed to maintain equity in the provision of formal home care along the urban/rural dimension as well as along other dimensions. Notes 1. In these municipalities, the policy defined for families of disabled children is different: parents (and other relatives) of disabled children are eligible for caregiver allowances. 2. Insights from site visits and interviews with local government and social service representatives conducted as part of the World Bank ‘Estonia Long-Term Care RAS’project (January 2016). 3. These results are available upon request. 4. The analysis conducted with the full sample and subsample for all the three types of care indicates that the observed differentiated effects of some factors on various types of informal care do not stem from the different samples or from the selection bias discussed above. 5. If we exclude from the model the variable ‘at least one person’s child is employed’, which correlates with the number of children, all categories of the number of children variable become statistically significant. 6. As for a person’s equivalised household income variable, the proxy for children’s income (‘at least one person’s child is employed’) is not statistically significant in the formal home care model. To test the validity of the proxy variable, based on the SHARE data, we developed several models analysing the utilization of various social and health care services among the elderly. The proxy was proven to behave similarly to the person’s equivalised household income variable –it has a strong significant effect with the same sign in the models that include the person’s household income variable and it is not statistically significant in the models in which the person’s household income is not significant. 7. Although the effect of the rural area dummy is statistically significant in the formal care equation with a single informal care variable (Table 2), it is not robust and becomes non-significant if the correlated covariate –at least one person’s child is employed –is removed from the model. 8. In 2015, many municipalities in Estonia did not provide caregiver allowances to family members of disabled elderly persons and paid them to non-relatives only. Acknowledgements The author is especially grateful to Prof. Mihails Hazans for valuable comments and discussions. The author also expresses gratitude to the journal’s editor and anonymous referees for their valuable comments and helpful suggestions and to the SHARE team for providing the survey data. 150 I. MOZHAEVA Disclosure statement No potential conflict of interest was reported by the author. Funding This work was supported by the Latvian State Education Development Agency under research project Nr. 1.1.1.2/VIAA/1/16/069, measure ‘Postdoctoral research support’.; SEDA Notes on contributor Irina Mozhaeva is a researcher at the University of Latvia and an external consultant at OECD. She received her PhD in economics (subfield –econometrics) from the University of Latvia. Her research and publications focus on health economics, social policies, social inclusion, etc. She has participated in numerous World Bank and OECD projects in Latvia and Estonia, e.g. ‘Estonia: Long-Term Care’, ‘Active Ageing’,‘Developing a Health System Strategy for Priority Disease Areas in Latvia’,‘Connecting People with Jobs’,‘Investing in Youth: Latvia’,‘Latvia: Who is Unemployed, Inactive or Needy? An Assessment’,‘Latvia Public Expenditure Review 2010’, as well as in the other national research projects. References Arnault, L., & Goltz, A. (2013). How would informal caregivers react to an increase in formal homecare use by their elderly dependent relatives in France? In Economics Papers from University Paris Dauphine. Bakx, P. (2010). Determinants of long-term care use (Master’s thesis). Retrieved from https://www. netspar.nl/assets/uploads/MA_Pieter_Bakx_2010.pdf Balia, S., & Brau, R. (2014). A country for old men? Long-term home care utilization in Europe. Health Economics,23(10), 1185–212. Baum, C. F., & Schaffer, M. E. (2012). Ivreg2h: Stata module to perform instrumental variables estimation using heteroskedasticity-based instruments. Boston: Statistical Software Components S457555, Department of Economics, Boston College. Baum, C. F., Schaffer, M. E., & Stillman, S. (2003). Instrumental variables and GMM: Estimation and testing. The Stata Journal: Promoting Communications on Statistics and Stata,3(1), 1–31. Baum, C. F., Schaffer, M. E., & Stillman, S. (2007). Enhanced routines for instrumental variables/GMM estimation and testing. The Stata Journal: Promoting Communications on Statistics and Stata,7(4), 465–506. Baum, C. F., Schaffer, M. E., & Stillman, S. (2010). Ivreg2: Stata module for extended instrumental variables/2SLS, GMM and AC/HAC, LIML and k-class regression. Boston: Statistical Software Components S425401, Department of Economics, Boston College. Bolin, K., Lindgren, B., & Lundborg, P. (2008). Informal and formal care among single-living elderly in Europe. Health Economics,17(3), 393–409. Bonsang, E. (2009). Does informal care from children to their elderly parents substitute for formal care in Europe? Journal of Health Economics,28, 143–154. Börsch-Supan, A., Brandt, M., Hunkler, C., Kneip, T., Korbmacher, J., Malter, F., …Zuber, S. (2013). Data resource profile: The survey of health, ageing and retirement in Europe (SHARE). International Journal of Epidemiology,42(4), 992–1001. Bremer, P., Challis, D., Rahm Hallberg, I., Leino-Kilpi, H., Saks, K., Vellas, B., …Sauerland, D. (2017). Informal and formal care: Substitutes or complements in care for people with dementia? Empirical evidence for 8 European countries. Health Policy,121(6), 613–622. Chen, C. C., Yamada, T., Nakashima, T., & Chiu, I. M. (2017). Substitution of formal and informal home care service use and nursing home service use: Health outcomes, decision-making preferences, and implications for a public health policy. Frontiers in Public Health,5, 297. Retrieved from BALTIC JOURNAL OF ECONOMICS 151 https://www.researchgate.net/publication/321269155_Substitution_of_Formal_and_Informal_ Home_Care_Service_Use_and_Nursing_Home_Service_Use_Health_Outcomes_DecisionMaking_Preferences_and_Implications_for_a_Public_Health_Policy Christianson, J. B. (1988). The evaluation of the national long-term care demonstration: The effect of channelling on informal caregiving. Health Services Research,23(1), 99–117. European Commission, DG ECFIN. (2015). The 2015 ageing report: Economic and budgetary projections for the 28 EU Member States (2013–2060). European Economy, 3/2015. European Commission, DG ECFIN. (2018). The 2018 ageing report: Economic and budgetary projections for the EU Member States (2016–2070). Institutional Paper 079, Brussels. Family Law Act. (2009). Retrieved from https://www.riigiteataja.ee/en/eli/ 530102013016/consolide. Greene, V. L. (1983). Substitution between formally and informally provided care for the impaired elderly in the community. Medical Care,21(6), 609–619. Holly, A., Lufkin, T. M., Norton, E. C., & Van Houtven, C. H. (2010). Informal care and formal home care use in Europe and the United States (Working Paper). Lausanne: University of Lausanne. Ilinca, S., Rodrigues, R., & Schmidt, A. E. (2017). Fairness and eligibility to long-term care: An analysis of the factors driving inequality and inequity in the use of home care for older Europeans. International Journal of Environmental Research and Public Health,14(10), 1224. doi:10.3390/ ijerph141012243 Kehusmaa, S., Autti-Rämö, I., Helenius, H., & Rissanen, P. (2013). Does informal care reduce public care expenditure on elderly care? Estimates based on Finland’s age study. BMC Health Services Research, 13, 317. doi:10.1186/1472-6963-13-317 Langa, K. M., Chernew, M. E., Kabeto, M. U., & Katz, S. J. (2001). The explosion in paid home care in the 1990s: Who received the additional services? Medical Care,39(2), 147–157. Lewbel, A. (2012). Using heteroscedasticity to identify and estimate mismeasured and endogenous regressor models. Journal of Business and Economic Statistics,30(1), 67–80. Lewbel, A. (2018). Identification and estimation using heteroscedasticity without instruments: The binary endogenous regressor case. Economics Letters,165,10–12. Litwin, H., & Attias-Donfut, C. (2009). The inter-relationship between formal and informal care: A study in France and Israel. Ageing & Society,29(1), 71–91. Lo Sasso, A., & Johnson, R. (2002). Does informal care from adult children reduce nursing home admissions for the elderly? INQUIRY: The Journal of Health Care Organization, Provision, and Financing,39, 279–297. Marcinkowska, I., & Sowa, A. (2011). Determinants of the probability of obtaining formal and informal long-term care in European countries (ENEPRI Research Report No. 99, Contribution to WP3 of the ANCIEN project). Brussels: CEPS. Motel-Klingebiel, A., Tesch-Roemer, C., & Kondratowitz, H.-J. (2005). Welfare states do not crowd out the family: Evidence for mixed responsibility from comparative analyses. Ageing and Society,25,863–882. Pezzin, L. E., Kemper, P., & Reschovsky, J. (1996). Does publicly provided home care substitute for family care? Experimental evidence with endogenous living arrangements. The Journal of Human Resources,31(3), 650–676. Rivers, D., & Vuong, Q. H. (1988). Limited information estimators and exogeneity tests for simultaneous probit models. Journal of Econometrics,39, 347–366. Social Welfare Act. (2015). Retrieved from https://www.riigiteataja.ee/akt/130122015005. Stabile, M., Laporte, A., & Coyte, P. C. (2006). Household responses to public home care programs. Journal of Health Economics,25, 674–701. Van Houtven, C. H., & Norton, E. C. (2004). Informal care and health care use of older adults. Journal of Health Economics,23(6), 1159–1180. Van Houtven, C. H., & Norton, E. C. (2008). Informal care and medicare expenditures: Testing for heterogeneous treatment effects. Journal of Health Economics,27(1), 134–156. Viitanen, T. K. (2007). Informal and formal care in Europe (IZA Discussion Paper No. 2648). Institute for the Study of Labor. Wold Bank. (2017, June). Reducing the burden of care in Estonia (Interim Report). Washington, DC: Wold Bank Group. Retrieved from https://riigikantselei.ee/sites/default/files/content-editors/ Failid/hoolduskoormus/estonia_ltc_report_final.pdf. 152 I. MOZHAEVA Appendix Table A1. Descriptive statistics (part I). Weighted N Share, % Received informal care 1556.6 37.9 Received informal care from household member/s 284.4 6.9 Received informal care from relatives not living in the same household 1230.9 30.0 Received informal care from non-relatives 354.8 8.6 Frequency of informal care received from relatives living separately never 2877.1 70.0 less often than once a month 230.6 5.6 1–3 times per month 321.9 7.8 approximately once a week 309.2 7.5 approximately 2–3 times a week 101.2 2.5 approximately daily 268.1 6.5 Frequency of informal care received from nonrelatives never 3753.2 91.4 less often than once a month 120.2 2.9 1–3 times per month 84.5 2.1 approximately once a week 98.4 2.4 approximately 2–3 times a week 4.4 0.1 approximately daily 47.2 1.2 Received professional homecare 225.2 5.5 Age 60–69 1590.9 38.7 70–79 1529.2 37.2 80 and over 987.9 24.1 Gender male 1354.7 33.0 female 2753.3 67.0 Lives with a spouse / partner 1853.4 45.1 Number of children 0 454.3 11.1 1 1089.8 26.5 2 1676.0 40.8 3 586.3 14.3 4 or more 301.6 7.3 Number of siblings (alive) none or does not know 1606.0 39.1 1 1300.1 31.7 2 681.5 16.6 3 or more 520.4 12.7 Education (ISCED-97) ISCED 0–2 (pre-primary, primary or lower secondary) 1369.0 33.3 ISCED 3 (upper secondary) 1268.5 30.9 ISCED 4 (post-secondary non-tertiary) 614.8 15.0 ISCED 5–6 (tertiary) 855.7 20.8 BALTIC JOURNAL OF ECONOMICS 153 Table A2. Descriptive statistics (part II). Weighted N Share, % Rural 1220.8 29.7 Region (NUTS 3) Northern Estonia 1187.9 28.9 Western Estonia 589.5 14.4 Central Estonia 500.3 12.2 Northeast Estonia 550.9 13.4 Southern Estonia 930.2 22.6 NA 349.3 8.5 Household equivalised net income, EUR below 2000 257.5 6.3 2000–3999 989.7 24.1 4000–5999 1811.8 44.1 6000–7999 540.2 13.2 8000–9999 200.2 4.9 10,000 and above 308.6 7.5 Language of the interview Estonian 3215.7 78.3 Russian 892.3 21.7 Poor SAH 993.8 24.2 Number of limitations with ADLs and IADLs 0 2723.4 66.3 1–5 1017.2 24.8 6–10 243.7 5.9 11–15 123.7 3.0 Number of mobility limitations 0 1316.2 32.0 1–5 1992.4 48.5 6–10 799.4 19.5 Memory (scale 0 –extremely poor to 10 –extremely good) 0 822.5 20.0 1–3 1302.8 31.7 4–6 1645.5 40.1 7–10 337.3 8.2 At least one person’s child is employed 2564.6 61.8 154 I. MOZHAEVA