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The migrant-in-thefamily-model. Should we look for alternatives?

Francesca Bettio Universit di Siena- Italy (bettio@unisi.it)

Background papers:
Bettio, F. and Veraschagina, A. (2012), Long-Term Care for the elderly. Provisions and providers in 33 European countries , Luxembourg: Publications Office of the European Union Bettio and Mazzotta (2011) The future of care in Europe. Exploring the trade-offs that are driving change. Kurswechsel 4 / 2011 : 36 48

My broad brushes talk

Change in care regimes: elderly care Drivers of change: affordability and public finance sustainability Comparing country answers to these conflicting goals Perhaps the most important new answer: the migrantin-the-family model Family managed employment versus formal employment Which alternatives?

Care regimes are changing: re-clustering of countries changing: rein eldercare





Component 2 0









0 Component 1

Change in care regimes: technicalities and bottom line regimes:

4 indicators Coverage rates of home care and of institutional care ; share of recipients relying exclusively on family and friends when care is provided intensively (daily or almost daily); share of recipients relying on paid and professional care givers when the recipient is severely disabled. Principal Component Analysis was used to identify the countries scores for the X and Y components; these were used as entries in the clustering exersise (multidimensional scaling). At least five clusters can be identified .With the exception of the first cluster none assembles countries with a distinctive but common architecture, financial, institutional or cultural. Countries are moving away from traditional typologies of care or welfare systems. Clear examples: Austria, France, Spain.

Clustering of countries: Intermediate results of PCA

Component 1 can be interpreted as strength of outsourcing towards home care provided by paid/professional carers:
It correlates positively with CR_home, and with the share of families relying on paid care and professionals at severe stages of disability; negatively with the share of families relying on friends and family members when care is provided intensively.

Component 2 can be interpreted as strength of outsourcing towards residential care or paid/professional services at home:
It correlates positively with CR_residential and with the share of families relying on paid care and professionals at severe stages of disability, and negatively with the share of families relying on friends and family members when care is provided intensively.

Drivers of ongoing change: change: affordability and financial sustainability

One key driver of change is the search for answers to the often conflicting goals of ensuring affordability (to the user) and sustainability of public finances. Withing Europe at least four typical answers to the problem of affordability of home care underpin the reclustering under way:
Universal services but rationalized face time: the Nordic countries Outsourcing to migrant workers or the migrant-in-the-family model and its variants: Mediterranean countries (including Cyprus and Turkey!) and Austria The service voucher option: France and Belgium Minimal outsourcing: Poland and other Eastern European countries

Success of the migrant-in-the-family model migrant-in-the Italy: latest estimates about 90% of home care workers are migrant (NNA 2010) Spain: Despite the text of the Ley de Dependencia the rationing of services and the level of fees encourage families to opt in favour of cash transfers and buy services from family hired care workers (Leon, 2010 among others). Greece: A significant proportion of the existing home care demand is met by hiring migrant care workers, mostly from the Balkans and Eastern Europe (Lyberaki 2008) Cyprus: Home care is largely provided by family carers or live-in female migrant workers mostly from Asian countries Standard contracts set by the government contribute to keeping the wages of these workers very low (Ellina 2010). Turkey: Turkish-speaking female elderlcare workers migrating from countries such as Bulgaria, Moldova, Romania and Ukraine are often employed by well-to-do families (Ozar 2010) Austria: estimated 40,000 illegal care workers in around the mid-2000s (Rudda and Marschitz 2006) before important social security rebates were offered in case of regular employment. Hungary: no quantitative estimate available, but Romanians from nearby Transylvania hired to provide live-in care have recently attracted research attention (Frey 2010)

Reasons for success

- Scarce pre-existing elderly care infrastructures - Increased female mobility from within and outside Europe - long hours of care against selective affordability. - A more palatable brand of commoditization of care work (continuity with unpaid family care)?

Comparing the migrant-in-the-family and the Nordic models: migrant-in-theHours of care

The Nordic Model* In the Netherlands a person in need of guidance , receiving nursing care, home help, personal care and day care was given about 17 hours plus about 2 hours of informal care p.w. (Plantenga and Remery 2010) In Iceland elderly in need of nursing care received 3.9 hours p.d. on average* in addition to home help (2.3 hours p.w., overall average: xxxx). In Sweden, the average number of hours was 2.9 per week (Nyberg, p. 16). In Denmark, average referral hours per week ranged between 4 to 6 p.w. (Sjrup 2010, p. 5).

The migrant-in-the-family model Even outside the 24 hours arrangement hours tend to be long, although statistics are not easily available.

*(Figures are not strictly comparable because of differences in disability profiles of users across countries)

Comparing the migrant-in-the-family and the Nordic models: migrant-in-theAffordability

Nordic model Netherlands. the maximum user s contribution for home care was equivalent to 15% of the median net income for a 65+ living alone (reference income) in 2005. Iceland. the average user fee is 3 /hour. Denmark. On a monthly basis an elderly receiving care plus meals on wheels would pay 14% of the reference income for older people

Migrant-in-the-family-model (24 hours) Italy: 110% of reference income if regular; up to 40% discount in black market Spain: about the equivalent of the reference income (700 euros p.m. aroound 2008) Greece: Between 0.72 and 1.44 of the reference income Turkey: 500-2000 euros per month, depending on qualifications, irregular. Austria: regular nursing home care on a full 24-hour basis between 2.5 and 3.3 of the reference income; most were hired irregularly before granting of social security rebates in 2007

Key implications of the migrant-in-the-family model

Selective rather than universal affordability . The migrant-in-the-family (12 or 24hrs option) becomes affordable to a large minority of potential users if: -subsidized (cash for care schemes) -hiring is at least partly irregular or regularisation is subsidized. -Has expanded a problematic area of employment that of family managed employment.

What is distinctive of family managed care ?

Quality of employment: - Families, like firms are interested in maximizing the hours of work if the hiring and the salary are per period, or minimizing hourly costs if hiring on a per hour basis - But families may be less concerned about workers skilling or career, and more able to hire on the irregular market - They are also less able to exploit economies of scale and economics of scope than larger organizations are Quality of care: -Because investment in technology (e.g. assistive technology) may be far too expensive for the single family, quality of care may suffer. - However, family employers are averse to cutting face care time, and monitor much better the human and emotional component that contributes to the quality of care . Do we know enough? Perhaps the biggest drawback is that we simply know little about family managed care employment

Family managed employment and the knowledge gap: start with the statistics gap
Eurostat has decided to exclude family managed employment from the count of formal childcare workers on the ground that the quality of care is not certified by an accountable structure . However, statistics are separately collected for family managed childcare employees such as babysitters In contrast the issue is ignored for eldercare. Indirect confirmatiion of how important they may be is provided by the SHARE survey , as shown in the figure

Which alternatives to family managed employment of migrant workers?

- Formal employment as in the Nordic model may prove financial unsustainable if universal services are granted and extended hours of care are strongly entrenched in the local culture Compromise solutions such as given in the French system are worth experimenting. Here personalized and monitored care budgets are combined with cheques services from credited providers