The Future of Long-Term Care in Portugal: A Strategy for an Older, Longer-Living Society

Portugal’s future long-term-care challenge can be seen in an ordinary household long before it appears in a national budget. A couple in their seventies may live independently today, require occasional help in ten years and later need a combination of healthcare, home support, rehabilitation, technology and family assistance. Whether they can continue living where they choose will depend on decisions Portugal takes years before either person becomes dependent.

This long-term horizon brings together the themes developed across the Portugal Ageing, Long-Term Care & Community Support Knowledge Hub. The country has already built important foundations: the Serviço Nacional de Saúde (SNS), the Rede Nacional de Cuidados Continuados Integrados (RNCCI), extensive social responses delivered through the social and solidarity sector, municipal initiatives, growing recognition of informal carers and substantial recent investment in continuing-care infrastructure.

The strategic question is no longer whether Portugal needs more long-term care. It is what kind of long-term-care system an older, longer-living society should build.

By 2050, around one third of Portugal’s population is expected to be aged 65 or over. Life expectancy at 65 is also projected to continue rising. At the same time, the ratio between older people and the working-age population will become markedly more demanding. These trends do not make dependency inevitable, but they increase the number of people likely to live for longer with frailty, dementia, multimorbidity or functional limitations.

The future therefore requires a strategy extending beyond beds and services. Portugal needs to shape the trajectories that produce demand, build a larger and more sustainable workforce, support families without depending on them indefinitely, finance care more transparently and connect health, social support, housing, technology and communities around the person.

Demography will change the scale of the system

Portugal’s demographic transformation is structural rather than temporary.

In 2024, approximately 24% of the population was aged 65 or over, one of the highest proportions in the European Union. By 2050, that share is expected to be around 34%.

The old-age dependency ratio is also projected to rise sharply. Current projections indicate that the number of older people relative to those aged 20 to 64 could move from around 43 per 100 in 2025 to approximately 66 by 2045.

This matters because formal care does not exist independently from the wider labour market.

The same demographic change increasing demand for care also constrains the pool of workers available to provide it, finance it through taxation and support relatives informally.

Portugal will therefore face several linked pressures:

• more people living into advanced old age;
• greater prevalence of complex and multiple health conditions;
• increased demand for both health and long-term support;
• fewer working-age people relative to the older population;
• greater pressure on family carers; and
• growing competition for workers across health, care and other sectors.

The correct response is not to frame longevity as a problem. Longer life is a social achievement.

The policy task is to ensure that longer life is accompanied, as far as possible, by longer periods of health, independence and participation.

Portugal’s future strategy must begin before dependency

The strongest long-term-care systems of the future will not begin when someone becomes eligible for intensive support.

They will intervene earlier.

Portugal’s Plano de Ação do Envelhecimento Ativo e Saudável 2023–2026 already points in this direction. Its six pillars span health and wellbeing, autonomy and independent living, lifelong development, healthy working lives, income and the economy of ageing, and participation in society. The plan contains dozens of measures intended to strengthen prevention and improve quality of life over the longer term.

The strategic principle should survive beyond the current plan period.

Falls prevention, physical activity, nutrition, vaccination, management of chronic disease, social connection, accessible housing and early rehabilitation all influence future dependency.

This is where prevention and early intervention need to become core long-term-care policy rather than an adjacent public-health agenda.

Prevention should not be used to imply that individuals are responsible for avoiding dependency. Many conditions cannot be prevented, and people must remain entitled to dignified support when dependency develops.

The strategic value lies in changing population trajectories where possible.

If even a proportion of older people maintain mobility, nutrition, social connection and confidence for longer, the effect accumulates across millions of future care decisions.

Healthy ageing needs to become measurable

Policy aspirations are insufficient without evidence.

Portugal should increasingly measure whether prevention is delaying functional decline, rather than relying primarily on programme participation.

For example, a municipal physical-activity programme may report hundreds of attendees. That demonstrates activity. A stronger evaluation examines whether participants maintain mobility, confidence, social connection or independence.

The same principle applies nationally.

Life expectancy alone does not reveal whether additional years are lived in good health. Portugal already faces an important gap between longevity and healthy life expectancy for many older people.

This means future planning needs to monitor:

• functional ability at older ages;
• multimorbidity and frailty;
• healthy life expectancy;
• falls and avoidable deterioration;
• social participation and isolation;
• carer burden; and
• regional differences in these outcomes.

The objective is not to turn ageing into a collection of performance scores. It is to identify where prevention is genuinely changing the future pattern of dependency.

Home should become the default strategic starting point, not the only acceptable outcome

Most older people prefer to remain in familiar homes and communities for as long as possible.

Portugal’s future long-term-care strategy should therefore continue strengthening support at home.

But “ageing at home” needs careful interpretation.

It should not mean leaving someone in an unsuitable house with minimal formal support because residential care is expensive. Nor should it mean expecting relatives to compensate automatically for gaps in public provision.

A sustainable home model combines several elements:

• accessible housing;
• flexible Serviço de Apoio Domiciliário;
• primary healthcare and home-based clinical support;
• rehabilitation and ECCI where appropriate;
• transport and community infrastructure;
• assistive technology where useful;
• respite and support for families; and
• a realistic route to more intensive care if circumstances change.

The emphasis should be on choice and sustainability.

Residential care will remain necessary and appropriate for some people. A future strategy should not treat admission to an ERPI as policy failure where it reflects informed choice or a level of dependency that cannot safely or reasonably be supported at home.

The stronger aim is avoiding premature institutionalisation caused primarily by the absence of alternatives.

A home-care scenario shows what the future system needs to do differently

Consider a 79-year-old woman living alone in Aveiro in the early 2030s. She has diabetes, arthritis and mild frailty but remains active in her neighbourhood. Her daughter lives 40 minutes away and works full time.

Under a reactive model, little formal support may be offered until a fall or hospital admission significantly changes the situation.

A stronger future model would recognise earlier signals.

Her primary healthcare team identifies increasing falls risk. A home assessment finds a difficult bathroom and poor lighting. Minor adaptations are arranged. A community exercise programme helps maintain strength. When she later needs support with personal care, SAD is introduced without requiring the family to create an emergency before assistance becomes available.

Several years later, increasing frailty results in a hospital admission. Rehabilitation and, where appropriate, home-based continuing care are mobilised around discharge. Her daughter remains involved but is not treated as the default provider of every unmet need.

The important shift is temporal.

Support is not waiting for dependency to become severe enough to trigger a crisis.

This is the practical value of independence and community inclusion as long-term outcomes rather than simply service principles.

RNCCI will remain central, but its balance may need to keep shifting towards the community

The RNCCI is one of Portugal’s most important strategic assets.

It creates a recognised space between acute healthcare, rehabilitation, continuing dependency and social support. Recent investment has expanded and modernised significant inpatient capacity, while home-based ECCI provision has also been developing.

The 2026 ECCI expansion is especially important for the future.

An initial pilot involving five ULS organisations supported around 550 people per day. The model was then opened to additional ULS organisations choosing to participate, with potential to extend daily home-based continuing care to substantially more people.

The Government explicitly described this expansion as part of developing a stronger home-care model before wider adoption decisions.

The strategic opportunity is significant.

Over the next decade, Portugal could increasingly use RNCCI as a flexible continuum rather than primarily as a network associated with facilities.

That would mean strengthening rehabilitation, home-based continuing care, palliative support, transitional pathways and links with SAD and primary healthcare.

The future should not be “beds versus home”.

It should be a network able to move intensity up and down as needs change.

Hospital capacity and long-term-care capacity will become increasingly interdependent

Population ageing means hospitals will continue treating more older people with complex needs.

Hospital efficiency will therefore depend increasingly on what exists beyond hospital walls.

A person cannot be discharged safely if rehabilitation, home support, residential care or family arrangements are unavailable.

Conversely, weak community support can contribute to avoidable hospital use.

This makes hospital and home-care interfaces a strategic rather than operational issue.

Portugal should increasingly plan hospital, RNCCI and community capacity together.

The Digital Twin Scenario Modeller can help organisations explore the relationships between demand, workforce, capacity and service stability. It is not a Portuguese national forecasting instrument, but scenario modelling illustrates the discipline future planning requires: assumptions about hospital flow should be tested against the actual capacity of receiving services.

The workforce will determine how much of Portugal’s ambition can actually be delivered

Long-term-care strategy is often discussed through policy, funding and infrastructure. In practice, workforce will determine the ceiling of what Portugal can implement.

Portugal currently has a relatively small formal long-term-care workforce in relation to its older population compared with many OECD countries.

Demographic ageing will increase the challenge.

The future workforce cannot be built through recruitment campaigns alone. Portugal needs a clearer proposition for long-term-care employment.

That includes:

• pay and employment conditions capable of competing for labour;
• training linked to increasing complexity;
• structured supervision;
• career progression and professional development;
• better use of multidisciplinary skill mix;
• retention of experienced workers;
• fair integration of migrant workers; and
• different workforce models for rural and home-based care.

Long-term care also needs stronger status.

Work with frail older people, dementia, complex medication, rehabilitation and end-of-life needs requires judgement, relational skill and practical competence. A future system cannot rely indefinitely on treating direct care as low-skilled labour.

This is why workforce competence in ageing services needs to develop alongside capacity expansion.

Migration will remain important, but it is not a standalone workforce strategy

Portugal has become increasingly reliant on international migration across parts of its economy, including care.

Migrant workers can make an important contribution to the future long-term-care workforce.

But migration should not be treated as a mechanism for avoiding structural workforce reform.

Workers recruited internationally still need adequate pay, housing, employment security, language support, training, supervision and realistic opportunities to remain in the sector.

Ethical recruitment also matters because many countries supplying migrant care workers face their own ageing populations and workforce shortages.

The more sustainable objective is a mixed workforce strategy: improve domestic retention and participation, make care a more attractive career, support migrant workers fairly and use technology to reduce avoidable administrative burden rather than substituting indiscriminately for human labour.

The Predictive Workforce Risk Module can help organisations examine how turnover, vacancies and continuity interact with service risk. For future strategy, this type of analysis becomes important because workforce fragility can undermine expansion long before formal capacity targets appear to be missed.

Family care must become visible in national capacity planning

Portugal cannot plan its future long-term-care system accurately while treating unpaid family care as an unlimited external resource.

Families currently provide enormous amounts of support.

This is likely to continue, but the conditions around family care are changing.

Smaller families, geographic mobility, women’s labour-market participation, longer working lives and ageing spouses all reduce the assumption that one relative will always be available to provide intensive care.

Portugal’s Estatuto do Cuidador Informal represents an important recognition of carers as people with their own needs and rights.

The next strategic step is to incorporate carer sustainability into planning.

If policy assumes that a person living at home has “family support”, decision-makers need to understand what that phrase actually means.

Does a daughter visit once a week? Is an 82-year-old husband providing lifting and night-time supervision? Has the principal carer already reduced employment? Is the arrangement likely to remain sustainable if dependency increases?

These questions influence real service capacity.

This makes carer support and family partnership central to future long-term-care strategy.

The future care settlement needs a clearer financial logic

Portugal’s public spending on long-term care is expected to increase over coming decades.

Current projections suggest public long-term-care expenditure could rise from around 0.5% of GDP in 2025 to approximately 0.9% by the middle of the century.

This increase occurs alongside wider ageing-related spending pressure.

Total ageing-related public expenditure is projected to rise substantially through the 2030s and 2040s, with pensions and healthcare accounting for much of the increase.

The fiscal challenge is therefore real.

But the policy response cannot be reduced to expenditure restraint.

Underfunded long-term care does not eliminate cost. It redistributes it.

Families may reduce employment. Households may purchase private support. Hospitals may retain people who no longer need acute treatment. Preventable deterioration may increase future dependency.

A future funding strategy should therefore examine the whole economic effect of care.

This requires greater transparency about:

• what the state finances;
• what households contribute;
• what families provide unpaid;
• how provider payments relate to actual delivery costs;
• where health and social funding interact; and
• which preventive investments create value elsewhere in the system.

Portugal may not need one single long-term-care financing mechanism, but it does need a clearer settlement about how responsibility is distributed.

A family funding scenario shows why affordability will become strategic

Consider a middle-income couple living in the Porto metropolitan area in the mid-2030s. One partner develops advanced dependency after neurological illness. The other can provide companionship and some supervision but cannot safely manage all personal care.

Several sources of support may exist: healthcare through the SNS, RNCCI where eligibility applies, social responses through supported or privately purchased provision, and family assistance.

The household’s experience of the system will depend not only on nominal entitlement but on practical availability and personal contributions.

If formal home support is limited, the family may purchase additional hours privately. If that becomes unaffordable, the caring spouse may absorb the work until the arrangement becomes unsafe.

A sustainable future system should be able to identify this affordability pressure before crisis.

The policy question is not necessarily whether every element should be free.

It is whether contribution rules, public support and service availability combine to create reasonable access according to need.

This is where future financing will intersect with equity.

People with similar dependency should not face radically different outcomes simply because one family can purchase additional capacity and another cannot.

Residential care must evolve around higher complexity and quality of life

Even with stronger home-based services, Portugal will continue to need substantial residential provision.

The future ERPI population is likely to include more people with advanced frailty, dementia, multimorbidity and complex health needs.

This changes what residential care needs to become.

Traditional models based mainly on accommodation and routine personal support will face growing pressure to integrate stronger clinical coordination, rehabilitation, palliative capability, dementia competence and technology.

The workforce will also need to reflect increasing acuity.

But higher complexity should not transform residential settings into hospitals.

People still live there.

Quality therefore needs to combine clinical safety with autonomy, relationships, meaningful activity, privacy and ordinary life.

This is one reason quality and governance in ageing services will become increasingly important as dependency rises.

The strategic measure should not simply be whether Portugal has enough beds. It should be whether residential settings can safely and humanely support the population that will increasingly need them.

Housing policy will become long-term-care policy

Many future care decisions will be determined by buildings.

Portugal has large numbers of older homes that were not designed for limited mobility. Stairs, inaccessible bathrooms, poor thermal performance and difficult entrances can turn manageable frailty into dependency.

Housing adaptation should therefore become a larger part of long-term-care prevention.

Portugal already has programmes and investments addressing accessibility, but future demand will require a more systematic connection between housing and ageing policy.

Potential priorities include:

• earlier adaptation before crisis;
• accessible new housing design;
• age-friendly neighbourhoods;
• thermal resilience;
• housing options between independent living and traditional residential care; and
• better coordination between housing, municipal and care services.

The future is unlikely to be served well by a binary choice between an inaccessible private home and an ERPI.

Portugal could benefit from a wider range of intermediate housing-with-support models adapted to its legal, cultural and provider context.

Climate resilience will become part of ageing and care planning

Portugal’s ageing population is also increasingly exposed to climate-related risks.

Heat can worsen cardiovascular, respiratory and renal conditions and can be particularly dangerous for frail older people living alone. Wildfire, flooding and extreme weather can disrupt transport, electricity and community access.

Long-term-care strategy therefore needs a stronger climate-resilience dimension.

Residential providers need emergency preparedness appropriate to heat and infrastructure failure. Home-support organisations need mechanisms for identifying people at greatest risk during extreme weather. Municipalities need local vulnerability data. Telecare and digital systems require contingency planning for power and telecommunications disruption.

This connects future ageing policy with emergency preparedness.

The objective is not to create a separate climate-care system.

It is to recognise that future service continuity depends increasingly on environmental conditions.

Technology should reduce fragmentation rather than create another layer of it

Digital transformation will play a larger role in Portuguese long-term care over the next decade.

Portugal already has substantial SNS digital infrastructure, telemedicine capability, emerging telemonitoring, expanding home-based care and developing applications of artificial intelligence.

Future technology could support:

• shared care information;
• remote monitoring;
• telerehabilitation;
• digital care planning;
• workforce scheduling;
• risk identification;
• demand forecasting; and
• administrative automation.

But the strategic objective should remain service improvement.

Technology that creates additional systems which cannot communicate will worsen fragmentation. Remote monitoring without response capacity generates alerts rather than care. AI without transparent governance can introduce new forms of risk.

Portugal should therefore prioritise interoperability and system integration over technology accumulation.

The Digital Transformation Readiness Assessment can help organisations test whether strategy, infrastructure, cyber resilience, information governance and workforce capability are developing together. The broader lesson is that digital maturity is organisational, not merely technical.

Artificial intelligence may help, but accountable human judgement should remain central

Artificial intelligence will almost certainly become more visible in health and long-term care through the 2030s.

Potential applications include forecasting demand, detecting deterioration patterns, supporting rehabilitation, summarising documentation and helping teams prioritise workload.

Portugal should explore these opportunities without assuming experimental capabilities are established care.

Several principles should remain clear.

AI should support rather than obscure professional responsibility. Outputs should be understandable enough to challenge. Data quality and bias require oversight. People should retain meaningful rights where automated systems influence consequential decisions.

Technology may improve productivity, but it should not become a justification for removing human contact from services where relationships are part of the intervention.

The future workforce is more likely to work with AI than be replaced by it.

Regional inequality could become more pronounced without deliberate intervention

Portugal’s demographic ageing is geographically uneven.

Interior territories often combine older populations with depopulation, fewer workers, longer travel distances and smaller provider markets.

Metropolitan areas face different pressures, including housing cost, concentrated demand and workforce competition.

A future national strategy therefore cannot rely solely on uniform service ratios.

Territorial planning needs to understand:

• age structure;
• dependency and health status;
• existing provider capacity;
• workforce availability;
• family proximity;
• transport;
• housing;
• digital connectivity; and
• distance from health and long-term-care infrastructure.

The strongest national strategy would define common expectations while allowing different local delivery models.

A rural municipality may need greater use of mobile teams, shared workforce, transport support and telehealth. An urban area may need more intensive home-care capacity and housing solutions.

Equity means achieving reasonable access despite different geographies, not making every service configuration identical.

Municipalities and the social and solidarity sector will become more strategically important

The future of Portuguese long-term care will not be determined only by national ministries and the SNS.

Municipalities increasingly influence the conditions that make independent ageing possible: housing, transport, public space, community activity, local social responses and territorial coordination.

IPSS organisations, Misericórdias and other social and solidarity-sector bodies remain major providers of SAD, residential care, day services and community support.

These organisations possess local knowledge that national systems cannot easily reproduce.

The future opportunity lies in turning local knowledge into strategic intelligence.

If providers repeatedly observe increasing loneliness, carer breakdown, inaccessible housing or unmet home-support demand, those patterns should influence municipal and national planning.

The relationship should therefore move beyond purchasing service volume towards shared understanding of population need.

Portugal will need a stronger national long-term-care evidence architecture

A future system cannot be governed effectively through fragmented activity data alone.

Portugal already collects extensive information about RNCCI activity, social responses, healthcare, capacity and demographic trends.

The next step is connecting these data around outcomes.

National and territorial leaders increasingly need to understand:

• how long people wait for different forms of care;
• whether rehabilitation improves function;
• whether people remain independent for longer;
• how continuity varies between services and regions;
• whether carers remain able to sustain their roles;
• what drives hospital readmission and delayed transitions;
• how quality of life differs between service models; and
• whether expansion is reducing or reproducing inequality.

This is where quality data and performance metrics become essential to policy rather than merely provider reporting.

The Quality Dashboard Builder can help organisations structure balanced views of capacity, workforce, quality, risk and outcomes. The principle for national strategy is similar: Portugal needs enough shared measures to see how the system performs across boundaries without reducing care quality to one number.

A future strategy should create a clearer long-term-care compact

Over the next decade, Portugal may need a more explicit social settlement around long-term care.

Citizens need greater clarity about what they can reasonably expect from the state, what may require personal contribution, what responsibilities services hold and how informal family support is recognised.

Providers need sustainable funding expectations and a credible workforce strategy.

Families need support before care arrangements collapse.

Health and social systems need incentives to invest where benefits cross institutional boundaries.

A future national long-term-care compact could therefore be built around several principles:

• prevention and healthy ageing as the first layer of care policy;
• home and community support as the preferred starting point where appropriate;
• residential care available when needs or preferences require it;
• RNCCI as a flexible bridge across rehabilitation, continuing care and home support;
• family care recognised but never treated as limitless;
• a professionalised and sustainable workforce;
• greater transparency of public and household financing;
• territorial equity rather than nominal uniformity;
• technology used to connect rather than depersonalise care; and
• outcomes and quality of life as measures of success.

This would not require Portugal to replace its current institutions.

It would give those institutions a clearer shared direction.

Governance needs to become more anticipatory

Most care governance responds to current performance.

Future demographic pressures require governance to become more forward-looking.

National and territorial leaders should increasingly ask not only whether services are coping today, but what current trends imply five or ten years ahead.

Workforce turnover, waiting lists, declining family availability, regional migration and increasing complexity can all act as early-warning indicators.

The Governance Maturity Assessment can help organisations structure questions about evidence, accountability and escalation. At system level, the same principle applies: information should not merely describe pressure after it becomes severe. It should trigger earlier decisions about capacity, funding and service design.

What Portugal’s future direction can contribute internationally

Portugal’s long-term-care future will be shaped by institutions unique to the country: the SNS, Social Security, RNCCI, IPSS organisations, Misericórdias, municipalities and a strong tradition of family care.

Other countries cannot simply reproduce this structure.

Yet Portugal’s strategic challenge reflects wider questions confronting ageing societies.

How much care should happen at home? How should families be supported? What happens when the labour force grows more slowly than the care population? How should prevention be funded when benefits emerge years later? How can health and social support share responsibility without becoming one organisation? How should technology be governed when it enters private homes?

The transferable lesson is not a particular Portuguese programme.

It is the need to treat long-term care as infrastructure.

Like transport, housing or healthcare, long-term care shapes whether citizens can participate in society and whether other public systems function effectively.

Countries that plan it only as a residual safety net will increasingly experience pressure elsewhere.

Conclusion

Portugal is approaching a decisive period in the development of long-term care. By the middle of this century, around one third of the population is expected to be aged 65 or over, life after 65 will continue to lengthen and the relationship between older and working-age populations will become significantly more demanding. The country will need more formal care, but scale alone will not determine success.

The stronger strategy is to shape the whole trajectory of ageing. Prevention should preserve function before dependency develops. Home support, housing and community infrastructure should make independence more sustainable. RNCCI should continue evolving as a flexible bridge between hospital, rehabilitation, continuing care and the home. Residential provision should become more capable of supporting higher complexity without losing its focus on ordinary life and dignity.

Above all, Portugal will need people, funding and governance capable of sustaining these ambitions. Families cannot remain an invisible reserve of unlimited capacity. Technology cannot substitute for absent workers. New infrastructure must be accompanied by recurrent finance, and national policy must respond to profound territorial differences.

Portugal already possesses many of the institutions required for this transition. The next phase is one of alignment: connecting prevention, care, housing, workforce, technology, finance and evidence around a clearer long-term national settlement. If that alignment is achieved, longer lives need not translate automatically into longer periods of dependence. They can instead become the foundation for a care system designed around independence, resilience and dignity across a much older Portuguese society.