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The economics of caregiving

Increase in population life expectancy and new family arrangements produce higher demand for caregivers and complicate government decision-making

Linoca Souza

The number of people who need caregiving services is growing worldwide. According to the latest report by the International Labour Organization (ILO), the number will reach 2.3 billion people by 2030––five years ago, there were 2.1 billion. The aging population and new family configurations, with women working more and less available to take care of dependents, have led countries to rethink their systems for caring for vulnerable populations. With this view in mind, a comparative study by sociologists Nadya Araujo Guimarães, of the University of São Paulo (USP), and Helena Hirata, of the Centre for Sociological and Political Research in Paris, France, identified that, over the last 20 years, there has been an increase in arrangements that seek to take care of individuals who are deemed dependent, such as children, seniors, and people with disabilities. While in some nations the role of the State is predominant, in others, private institutions take a leadership position. In Latin America, the leadership role of families is significant. The recently published results of the study have emerged at a time when the issue of caregiving is gaining relevance in different fields of study.

According to a definition by the ILO, the work of caregiving, which may or may not be remunerated, involves two types of activities: direct, such as feeding a baby or caring for someone who is ill, or indirect, such as cooking or cleaning. “It is work that has a strong emotional element, where intimacy can grow, and which frequently involves touching the body of another,” says Guimarães. She shares that the concept of caregiving arose as a key category of the social sciences 30 years ago and that, since that time, it has become increasingly studied in fields such as economics, anthropology, psychology, and political philosophy. “As such, this has been a growing topic of discussion. Early studies about caregiving focused solely on the fact that it was a necessity in situations of dependence, but that view has been dropped. Today, it is seen as work that is essential to ensure the well-being of others, as anyone can fall ill and become dependent at any moment in their lives,” the sociologist explains. Advances in research have observed that the act of caregiving is distributed unequally in society, with women carrying the greater load. Data from an ILO report on the topic, published in 2019, show that, in the 64 countries studied, women dedicate on average 3.2 times more time than men doing non-remunerated caregiving work. This represents 4 hours and 25 minutes per day, in comparison with 1 hour and 23 minutes spent daily by men (see graph).

Reflecting on this imbalance, sociologist Heidi Gottfried, of Wayne State University in Detroit, Michigan, USA, explains that there is an ingrained notion among societies that caregiving is the result of love and, for this reason, should be provided at no cost. According to Gottfried, this idea, among others, comes from a cultural construct related to motherhood and that caregiving is a female ability. On the other hand, Guimarães recalls that women have increased their presence in the workplace since 1970. In five decades, the presence of women has risen from 18% to 50% according to data from the Brazilian Institute of Geography and Statistics (IBGE). “Considered natural caregivers, women began to work more outside the home. Combining this with an aging population, this has contributed to a kind of caregiving crisis in countries of the northern hemisphere and which has been resolved by commercializing these services, as well as increasing government involvement by creating public institutions focused on caregiving, expanding financial policies, and training and regulating the work of caregivers,” says the sociologist.

In Latin America, however, caregivers traditionally come from within families, with women being the primary unpaid caregiver for children, senior parents, and individuals with disabilities. With the few that can pay for such care, businesses offer caregiving services to make up the shortfall created by the State. “Scientific literature has emphasized the familial nature of this caregiving regime. It is characteristic of countries such as Brazil, Argentina, Chile, and Colombia, which are being studied by a Latin American network of researchers,” points out Guimarães. In her opinion, the importance of families in Brazil is identified in the results of the last edition of the Study of Family Budgets (POF) 2017–18, by IBGE. The study showed that, out of 57.2 million Brazilian households, 17.6% have spent some money on domestic services and caregiving services. “This means that 82.4% of homes meet their own needs for caregiving without turning to the market, and doing without domestic helpers and caregivers,” she points out.

Linoca SouzaA study led by Guimarães and Hirata also identified that the State is a collaborator in the process of organizing care. Pioneering initiatives began to evolve in the 1990s, with the most notable normative advances expressed in the Charter of the Rights of Children and Adolescents (ECA), which came into effect in 1990 (see Pesquisa FAPESP issue no. 296) in the National Seniors Policy of 1994, and in the Charter for the Elderly of 2003. Anthropologist Guita Grin Debert, of the University of Campinas (UNICAMP), recalls that the adoption of the National Seniors Policy and the Charter for the Elderly represented legislative progress. “The problem is that not everything that was planned for in these initiatives was effectively implemented,” she assesses. According to Guimarães, of USP, long term care facilities for people over 60 are still scarce and serve less than 1% of the population in this age category. “As such, caregiving for seniors is carried out by family members, or by contracting with caregivers and private companies, which are inaccessible for lower income households,” observes Guimarães. With more than 28 million people over 60 years of age in Brazil, 13% of the population is considered elderly, and this percentage will likely double in the coming decades, according to IBGE forecasts. It is estimated that one quarter of society will be in this age bracket by 2043.

Debert, of UNICAMP, also calls attention to the fact that the charter requires that each health clinic include a geriatrician––an impossible objective to reach in practice because there are not enough professionals with this specialization in Brazil. Furthermore, current public policy for this sector of the population tends to be localized. This is the case, for example, with the Monitoring Program for Seniors (PAI), created in 2012 by the municipality of Sao Paulo with the objective of promoting integrated care for people over 60 years of age who are physically weak, vulnerable, or socially excluded. “There are also university programs devoted to the elderly––their participation in sports, and cohabitating groups––but the majority focus on people who can travel independently,” notes the anthropologist.

Time spent by women providing nonremunerated caregiving services is three times greater than that of men

Comparative studies of the caregiving framework of countries that present distinctive realities allow for greater understanding of Brazilian characteristics. Hirata, who coauthors the studies with Guimarães and has integrated the National Center for Scientific Research (CRESPPA-GTM/CNRS) with the International Multidisciplinary Research Network “Labor and Gender Marketplace” (MAGE) in France, investigated the Brazilian, Japanese, and French systems. Her research states that, among the three countries, women are central in providing care. In Brazil, men occupy 4% of paid positions in the long-term senior care facilities studied, while in France they represent 10% and, in Japan, 40%.

According to Hirata, the Japanese statistic reflects public policy established in 2008 to bring an end to high unemployment rates caused by the economic crisis. Through this initiative, those without work could participate in a training program to work as caregivers, with a guarantee of employment at the end of the program. “Japanese workers would not have taken the initiative to seek work in this field, which has a strong female presence. But they preferred to make the move to avoid unemployment,” confirms Hirata. The involvement of the Japanese government in the caregiving system includes the collection of a tax equal to about R$250.00, which is withheld from the pay cheques of all individuals over 40 years of age.

This tax covers the cost of caring for seniors. Through this system, the government funds 90% of the costs of care for people over 65 years of age, whether they are living in institutions or under the responsibility of home-based caregivers. Studies referenced by Hirata indicate that 30% of seniors in Japan lived with their children in 2016. In the 1960s, this figure was 90%. “As such, the demand for caregivers or institutions has grown significantly,” notes Hirata, who estimates that 14% of Japanese seniors live in institutions, while the estimate in Brazil is 1%. “Today the key challenge in Japan involves children. The country essentially has no public daycares, partly due to a social convention that assumes they should be raised by mothers themselves.”

In France, the government finances a portion of caregiving services provided to people over 65, with support varying with the senior’s retirement income and level of dependence. Known as “allocation personnalisée d’autonomie,” the funding can be directed either to cover the expenses of long-term care facilities or to pay caregivers. “With the exception of couples, the support can also be used to remunerate a family member of the senior person. Contrary to the situation in Brazil, in France, family members are not considered to be the primary caregivers for the elderly,” explains Hirata. According to Hirata, the European country, where half of long-term senior care facilities are public, is fighting to create a fifth branch of Social Welfare, to fund the care of seniors and people with disabilities.

In the United States, the situation is considerably different. According to Gottfried, the most significant mark of the current system in the US is its level of commercialization. The US government subsidizes agencies and private for-profit organizations that offer caregiving services to seniors, including rehabilitation centers and in-home medical support. “This structure is based on the market and transfers risk and responsibility to families who carry the burden of finding and contracting care services,” states the sociologist in an interview given via email to Pesquisa FAPESP.

By 2030, 200 million more seniors will need caregiving services

While justifying the importance of developing comparative studies about the caregiving sector, Gottfried cites the fact that transnational immigrants comprise a growing percentage of the workforce. In 2019, migrant domestic workers worldwide totaled 11.5 million, with 8.5 million being women, she indicates, remembering that the caregiving sector moves a large volume of resources on a transnational basis. “A mother who leaves her children in their country of origin, under the responsibility of others, to work with unrelated families is part of a global network that has caregiving as its product. Money transfers sent to family members facilitate the purchase of consumer products, funding school for children, and even backing small businesses,” she notes. According to Hirata, in 2018, these transfers moved close to US$700 billion globally.

Having spent close to four decades developing comparative studies on work and employment, Hirata notes that official statistics available in each country as one of the key methodological challenges. In research conducted with Guimarães, where they compared work activities of caregivers in Brazil, France, and Japan, Hirata stated that some aspects of the caregiving industry could only be analyzed through qualitative studies. As such, they interviewed 300 caregivers. “The decision to take this methodological approach revealed that, among remote Brazilian populations, community life and support from neighbors and family members form a central pillar in the caregiving framework,” says Hirata. “As this does not appear in official statistics, this reality would not have been captured if we had limited ourselves to quantitative analyses.”

Latin American landscape

Linoca SouzaThe caregiving framework in Argentina and Chile shares similar characteristics to that of Brazil. Argentinian sociologist Natacha Borgeaud-Garciandía, researcher with Argentina’s National Council for Scientific and Technical Investigations (CONICET), and the Latin American Faculty of Social Sciences (FLACSO), notes that, in her country, the primary responsibility falls to the families, and within families, to the women. “This means that it’s impossible to assess the Argentinian system without considering the impact of non-remunerated familial labor and of the gender inequality inherent in this work,” says Borgeaud-Garciandía, also a publisher of a series of books called Horizontes de Cuidado (Care Perspectives). She explains that, in Argentina, there is no national policy on caregiving. “The State only gets involved to offer services for dependent seniors, in situations where they don’t have support from family or the market,” she explains. The country had 5.7 million seniors in 2018 and will likely reach 13 million in 2050.

In Chile, according to Chilean sociologist Sr. Arriagada Acuña, researcher with the Center for Women’s Studies (CEM) in Santiago, and a member of the Latin American network for caregiving research, the first laws directed toward the care of pregnant women and children were developed in the 19th century, followed by initiatives for seniors and people with disabilities. In her opinion, as in Brazil, today caregiving services for children are more structured in comparison with the national system for seniors. In 2013, Chilean public institutions represented 2.6% of all long-term care facilities for this age group of the population. “Furthermore, Chile has a lack of specialists in senior care, including geriatric physicians and nurses,” says Acuña.

The National Integrated System of Care, created by Uruguay in 2015, is considered a turning point in the history of caregiving policies in Latin America. According to sociologist Karina Batthyány, from the University of the Republic, in Montevideo, which is also a member of the Latin American network, scientific research on time spent by family members with distinct care activities serves as a starting point for developing public policy. The first actions taken were focused on children under 3 years of age, dependent seniors, people with disabilities, and caregivers. Examples of these caregiving policies include remote support services for seniors––to help them with daily tasks, establishing residence centers with day services, free training courses for caregivers, and lengthening paternity leave. “The system began prioritizing the most critical and vulnerable sectors. One of the challenges we face today is the need for the system to integrate caregiving policies for the entire population––to become more universal,” confirms Batthyány.

1. Challenges of aging: Public policies, gender, and generational relationships (no. 19/09742-6); Grant Mechanism Regular Research Grant; Principal Investigator Guita Grin Debert (UNICAMP); Investment R$91,767.57.
2. Work, caregiving, and public policies: Training, brokering, and access to work (no. 15/08047-1); Grant Mechanism Regular Research Grant – Visiting Researcher from Abroad; Principal Investigator Nadya Araujo Guimarães (USP); Visiting Researcher Helena Sumiko Hirata; Investment R$67,030.60.
3. Caregiving as a job: a concept of labour law based on gender (No. 16/18865-6); Grant Mechanism Doctoral (PhD) Fellowship; Supervisor Homero Batista Mateus da Silva (USP); Beneficiary Regina Stela Corrêa Vieira; Investment R$107,595.42.

GUIMARÃES, N. A. and HIRATA, H. (editors). Care and care workers – A Latin American perspective. Serie Latin American Societies – Current Challenges in Social Sciences. Springer, 2020.
DEBERT, G. G. and PULHEZ, M. M. (Eds.) Challenges of caregiving: Gender, Old Age, and Disability. Campinas: UNICAMP, Ifch, 2019.
GUIMARÃES, N. A. and HIRATA, H. (Eds.). Care in Latin America. Looking at the cases of Argentina, Brazil, Chile, Colombia, and Uruguay. “Horizons of Care” Collection. Buenos Aires: Fundación Medifé Edita, 2020.
GUIMARÃES, N. A. and HIRATA, H. The Gender of Care. Inequalities, Meanings, and Identities. São Paulo: Ateliê Editorial, 2020

Care work and care jobs for the future of decent work. International Labour Organization (ILO), 2018.