Comprehensive Eldercare: Responsibility, Generosity and Equality

domestic workers
Foto: Carlos Lowry, CC BY-NC 2.0

Since the 1990s in a wide range of western countries new long-term care policies were introduced to publicly support care for the elderly. Demographic changes, increasing labour market participation of women, urbanization and/or financing constraints in prevalent social policy schemes resulted in a gap between increasing care needs, declining family respectively female care provision, and available public funding. Characteristic for the new social policies is their universal orientation, however, mainly on a medium or basic level of public support. The latter means that only a part of the required care provision is publicly covered, while still a wide range of care activities are defined as a part of family – or private responsibility either as providers or at least as financiers.

With this orientation the new policies differ significantly from the generous universal eldercare policies, which were established before the 1990s in the Nordic countries or in the Netherlands.

The development of universal long-term care policies on different levels of public support or generosity inspired scientific debates on the emergence of distinct forms of universalism in long-term care policies as part of a general welfare state debate. In this debate two basic forms of universalism can be distinguished – universalism as administrative or normative concept. While universalism as administrative concept only concerns the rationale behind the allocation of public resources, i.e. covering the whole population without means-testing, normative universalism emphasis on the outcomes of universal policies in particular socio-economic- gender or ethnic equality and social integration.

One central issue in international comparative research on welfare states is the impact of social policies on societal developments with the issue of equality in a prominent position. In the debate, generous social benefits proved to be one significant precondition to create equal outcomes among beneficiaries in a situation of social risk. Comparably, research on the effects of long-term care policies shows that the distinction between generous respectively basic or medium level of public support is highly relevant for outcomes related to equality. In the debate the intersection of different types of inequalities – gender, socio-economic class and migration status – gained relevance. In the following, the interrelationship between the generosity of long-term care policies and the development of patterns of national and transnational (in)equality will be shown with the examples of the situation of informal, family carers and the emergence of migrant care workers within private households.

Characteristic for western countries is the contribution of family members, friends or neighbours to care provision for frail elderly people. Country differences concern the extent and type of informal support, which proved to be interrelated to the level of generosity but also the family- respectively service-orientation of long-term care policies. The availability of professional services trigger a division of care activities between the family and professional services, where the professional carers take over the more time-consuming activities such as e.g. daily bodily care and the family less time-consuming support such as e.g. assistance with some household-related activities or social activities. It is not informal care as such but the time-intensity of informal support, which causes negative effects on informal carers.

Only comprehensive, time-consuming informal care shows a negative impact on the income situation of the individual or household, labour market participation, and patterns of social integration. It is above all women on lower educational training levels, who take over these comprehensive, time-intensive care activities. In contrast, generous universal public support and an orientation towards publicly financed services relieve care burdens for informal carers and thus reduces socio-economic- and gender inequality.

Since the end of the 1990s also in European countries a new type of comprehensive care arrangement gradually emerged in private households: The often irregular employment of care workers from foreign countries – mainly Eastern European countries or from the Global South. In a situation of demographic and societal change, migrant carers as live-in in private households providing comprehensive “24-hours care” are seen as a solution to the care gap. This new type of care arrangement is developing in countries with family-oriented long-term care policies characterized by an orientation towards cash payments and public support on a basic or medium level of generosity.

Efforts to regulate this care arrangement could in some countries change the irregularity of employment conditions, but not the precarious character of the work with employment- and working conditions below the national standards. In contrast, in countries with more generous, service-oriented public care provision and efforts to professionalize care provision this type of care arrangement does not emerge in a large scale. In these countries migrant care workers are recruited for professional care work in the formal care infrastructure.

International comparative research shows that the definition of private-public responsibilities in long-term care policies based on the level of generosity of public support and an orientation towards care within the family framework versus professional care services is decisive for the effects of care work on informal care workers or on the situation of paid respectively professional care work. High levels of private responsibility strengthen considerably gender- and socio-economic inequality in informal care provision and trigger the emergence of precarious live-in care arrangements for migrant care workers within private households. The contribution of international comparative research on long-term care policies to the ISA discussion on “global sociology and the futures we want” could be to show that there are possibilities to reduce inequalities in care provision even in a transnational perspective and define the necessary policy changes, opportunities and obstacles on the way there.


Hildegard Theobald is a professor of Organizational Gerontology and speaker of Gerontology, Department I, University of Vechta, Germany


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