This special issue brings the family care of older people in Southern Africa into focus. The authors are part of the Care of Older Persons in Southern Africa Network (COPSAN),1 developed as part of a Global Challenges Research Fund award from the Academy of Medical Sciences during 2020–22. We have confirmed through this network that gerontological scholars are spread thinly across Southern Africa, often isolated within their university departments or in the gerontological aspects of their work. The COPSAN network of researchers, government officials and policymakers sought to build links and collaborations with colleagues across countries, both within the region – including Botswana, Lesotho, Malawi, Namibia, South Africa, Zambia and Zimbabwe – and across the UK and Canada, based on our shared interests in the issues of care, families and older persons in Southern Africa. These articles are a product of lively and engaging discussions, workshops and presentations that foreground the importance of theorising family care and supporting family care practices, while considering the role of the ‘local’ and ‘global’ discourses of care in which they are located.
In using the term ‘Southern Africa’, we draw on the African Union’s definition of Southern Africa (derived from the Southern Africa Development Community),2 which makes reference to a strong sociocultural perspective, as well as to the diverse yet connected Anglo-colonial histories across the region. This is a region where family care is the dominant, and usually only, means of support. We demonstrate that, so far, very little is known about the care of older people across Southern Africa (Kelly and Sebego, 2023), leaving vital empirical and theoretical gaps that the articles in this special issue begin to address. Throughout the special issue, we situate local conceptualisations of care against dominant care discourses to highlight the divide between global academic and policy hegemony, and the contrasting, context-sensitive analysis of the care practices of older persons. Global models of elderly care that derive from Anglo- and Euro-centric hegemonies of age, biology, frailty, independent living, transition and need must be carefully assessed in relation to the local to ensure that care is appropriate and sustainable. Specifically, we locate contemporary care practices in their colonial histories, migration flows, social protection systems and changing economies as we bring to the centre the ways in which people understand care and caring in the specific contexts they endure. Care cannot be understood without consideration of the social processes that have determined the conditions for caring.
We present analysis across countries and provide embedded and richly grounded accounts from within Lesotho, Malawi, Namibia, South Africa, Zambia and Zimbabwe, displaying the local emic terms for ‘care’ and the diverse care contexts in the region. As we uncover the political and gendered economies and cultures of the family care of older people, we show that experiences within, and the options open to, each country differ widely. In so doing, we challenge the persistent and pernicious homogenisation of Africa, and of Southern Africa in particular, demonstrating the diverse histories, institutions, economies, demographies, geographies, cultures and social and economic circumstances that structure contemporary family care.
We argue that while these countries face broadly comparable demographic challenges and experience some cultural commonalities, these must be theoretically and critically embedded in localised understandings and perspectives. As discussed later in this editorial, we posit that local understandings of ‘care’ may allow us to conceptualise care in more meaningful ways that are necessary to understand the complexity of care and care relations, and to direct policy prescriptions and resources appropriately. Our understandings of the care of older people must come from the region and must be nuanced and contextualised, politicised, classed, racialised and gendered.
Demographic context
Africa remains the youngest continent, and within Africa, sub-Saharan Africa is the youngest region, with persisting high fertility and high mortality. However, the share of the population over age 60 is expected to increase from about 5 per cent now to about 8 per cent by 2050 (Aboderin, 2019; He et al, 2020; UNDESA-PD, 2022). While this remains a far smaller proportion of aged persons than in high-income countries, both now and then, the anticipated increases in absolute numbers are substantial and growing fast. Without wishing to fall into Vera-Sanso’s (2022) trap of seeing demography as destiny (a discourse generally deployed to further neocolonial and neoliberalising political-economic agendas), the ageing of the African population is bringing to the fore the need for countries to be cognisant of profound changes in the age structures of their populations. The United Nations estimates that the population aged 60 years or older in sub-Saharan Africa will more than triple from 64 million in 2015 to 220 million in 2050, a more rapid rate of increase than is expected in any other region of the world. To put this in perspective, this is approximately twice as many older people in 2050 as there will be in Northern and Western Europe (105 million) or in North America (120 million) (UNDESA-PD, 2022).
Global policy instruments recognising this have proliferated, including the United Nations Sustainable Development Goals (SDGs), the 2003 African Union Policy Framework and Plan of Action on Ageing, the 2022 Revised African Union Policy Framework and Plan of Action on Ageing, the African Union Agenda 2063, and the 2016 African Union Protocol on the Rights of Older Persons in Africa. The health, relationship and livelihood situations of older people in Southern Africa present key challenges that all actors must now address. This is complicated. The context for ageing well across these countries includes many challenges, including conditions of poverty and a lack of state welfare infrastructure, HIV-AIDs (and now COVID-19), high morbidity and all-cause mortality for adults at younger ages, out-migration of younger adults, urbanisation, and living in conditions of informality. Aboderin (2019) notes that empirical evidence reveals high rates of disability and chronic illness among older people across the region, considerable unmet care needs in the aged population, wide deficits in the availability and quality of family care, costs in terms of money and health for both those cared for and carers, and widespread inequalities in access to charitable or paid care support. Further, ageing populations must compete with climate change and climate disasters, crises for youth, and wider economic challenges in securing policy attention (Aboderin, 2022).
However, as Vera-Sanso (2022) has long argued, we should not characterise older people only by their functional limitations; rather, as illustrated in the articles in this special issue, we need to simultaneously understand the substantial contributions to labour and care economies that older people in constrained circumstances make, often forced through circumstance. Common notions of old-age dependency in high-income countries are revealed as constructs that do not reflect the realities of care in countries where life courses are far from linear or homogeneous, mortality is high at all ages, labour is exploited, housing is insecure, resources are scarce, and there is little by way of welfare state services or supports. As the articles in this special issue show, in complex networks of care, social and economic contributions in various forms by older people may continue long after their own ‘unmet’ functional needs are ‘objectively’ defined. Understanding national, institutional and cultural histories as determining factors in conditions of ageing may lead us to ask not so much, ‘How do we care for our old?’, but, rather, ‘What conditions of post-colonialism, continued labour exploitation and poor social, community and economic infrastructures lead to poor conditions for people ageing?’, which, in turn, lead to people ageing poorly. This might remind us that even in the context of an ageing population, as Vera-Sanso and Hlabana (2023) argue, much of the work on later-life care is flawed, as it is subject to survivor bias: ‘it investigates the lives of the people who survived to age 60 or 65. In contexts where a large proportion of the population depend on family care yet family networks are devastated by morbidity and excess mortality, policies on later-life care, well-being and social equity cannot separate care needs from cutting early mortality.’ In this sense, we must heed Vera-Sanso’s (2022: 576) call for a ‘critical, decolonial sociology of ageing, in order to understand how ageing is differently produced’.
The six countries discussed in this special issue have different colonial, economic and political histories that set up different life courses for people and that shape where they are now and the resources they have access to. As Tables 1 and 2 indicate, these countries – South Africa, Zimbabwe, Namibia, Lesotho, Zambia and Malawi – vary in many economic dimensions and in the particulars of policies regarding older persons. The region includes countries with small and large populations, from relatively high to very low gross domestic product (GDP) per capita, in receipt of very little to more substantial official development assistance (ODA), with large to smaller rural populations (and agricultural employment), and with high and lower absolute poverty.
Overview of country indicators (2020)
Population (millions) | Poverty rate (%) | Unemployment rate (%) | Living in rural area (%) | GDP per capita (US$)a | Net ODA as % of government expenditure | |
---|---|---|---|---|---|---|
South Africa | 55 | 19 | 29 | 33 | 309.1 | 0.7 |
Namibia | 5 | 17 | 12 | 48 | 10.7 | 4.8 |
Zimbabwe | 15 | 38 | n.d. | 68 | 16.77 | 22.1 |
Lesotho | 2 | 50 | 24 | 71 | 1.84 | 15.6 |
Malawi | 18 | 52 | 6 | 83 | 11.96 | 74 |
Zambia | 17 | 54 | 7 | 55 | 19.2 | 19.1 |
Note: a Data available from: https://data.worldbank.org/indicator/DT.ODA.ODAT.XP.ZS
Socio-economic context for older persons (2020)
Population > 60 years | Over 60: % of population 2020 | Over 60: % of population 2050 | Poverty rate of older persons | Labour force participation rate | % living in rural area | Living arrangement: % multigenerational/skip generation | State pension coverage | |
---|---|---|---|---|---|---|---|---|
South Africa | 5.2 million | 10 | 18 | 19 | Male 11
Female 4 |
41 | 54/16 | 3.7 million |
Namibia | 154,000 | 7 | 12 | 17 | Male 34
Female 21 |
74 | 58/22 | 152,000 |
Zimbabwe | 950,000 | 7 | 9 | 38 | – | 81 | 45/29 | NA |
Lesotho | 156,000 | 8 | 14 | 50 | – | 43/29 | 83,000 | |
Malawi | 847,000 | 4 | 6 | 52 | Male 32
Female 15 |
93 | 39/34 | NA |
Zambia | 623,000 | 3.6 | 5.1 | 54 | Male 25
Female 12.1 |
– | 45/26 | NA |
Table 2 shows that while some countries have relatively small older populations, within 25 years, the proportion of people over 60 will double in almost all these countries. In some countries, such as South Africa, older persons will represent almost 20 per cent of the population by 2050. Planning social infrastructure that will cater for growing populations of older persons is critical for all countries, but the social make-up of the growing population differs radically. For example, many low-income countries have much larger rural populations. Family care in such circumstances, as we see in the articles on Lesotho and Malawi, encounters different challenges. The countries also vary in the extent of social protection, with South Africa and Namibia more generous and with more extensive coverage, providing social pensions and means-tested benefits to children and people living with disabilities, while Lesotho has low-value social pensions and cash transfers, Malawi and Zambia have slowly expanding programmes, and Zimbabwe has no social security at all. The contributions in this special issue, while recognising the benefit of state pensions, also note the limitations of cash transfers, which are heavily redistributed in households and often insufficient to meet the needs of older persons.
The make-up of households across the region also impacts the shape of family care for older persons. While Table 2 shows that many households in Southern Africa are multigenerational, the region includes countries with a high percentage of ‘skip-generation’ households (Zimbabwe, Lesotho and Malawi) and others with a much smaller percentage of such households (South Africa). While family members take on care responsibilities, much more evidence is required about who in the family is providing practical and emotional care to whom, how these kin networks operate over time, and who is financing care as we investigate the extent to which care practices are classed and gendered. Findings from South Africa, Namibia, Lesotho and Malawi highlight how such responsibilities and activities create considerable anxiety, stress and often isolation for the family members involved. We argue that it is a lack of investment in material, social and economic infrastructures to support multigenerational and reciprocal relations of care that undermines the ability of families and communities to care. Any inadequacies that family carers experience in the context of household complexity and poverty may result in neglecting older family members and further entrenching inequalities.
Conceptualising care in the Southern African context
Thinking about care includes a range of perspectives, including: care as an action and practice (Tronto, 1993); care as ‘a labour, attitude and a virtue’ (Kittay, 2002: 259–60); and care as shaped by social and economic conditions and structures. Conradi’s (2020: 23) review of care scholarship describes two strands: an ‘ethico-political’ strand and a ‘welfare-resourcing’ strand. For many scholars, including Tronto (1993), the divisions between these strands are less stark, as socio-economic conditions and ideologies often shape the ethics of care and are used to explain its absence. For countries in the Global South, thinking about care in relation to values, ideals, practices and especially materiality is critical to understanding care. In post-colonial contexts, an approach that foregrounds power relations and investigates the social distribution of care along the lines of class, race and gender is essential.
Scholars in the Global South have called for taking space and place seriously when theorising and understanding concepts of care (Raghuram, 2012; Reddy et al, 2014). Robinson (2020: 21) explains that care ethics is a relational approach to morality centred on relationality, context and experience, which should be understood as ‘a critical political theory that provides an alternative starting point for considering hierarchies of knowledge and power in the contemporary world’. Contrary to arguments made by Raghuram (2012), Robinson (2020: 22) states: ‘the ethics of care resists charges of being Western-centric or insufficiently intersectional when viewed as a relational ethic that resists the binary epistemological frameworks and ontologies that are the hallmark of modernity’. In this special issue, we draw on this mix of meanings of care, while privileging local understandings of care, as explained and experienced by people experiencing care, or its absence, in this context. We highlight how local meanings of care illuminate the links between care as a relational practice and the sources of social division and distribution that sustain it.
In doing so, we foreground Ubuntu as a key social value and norm shaping thinking, behaviour and customary laws about care and social life in Southern African societies. Ubuntu is given utmost importance in policy and legal texts, and is a key principle governing society. With the emphasis on interdependency, relationality and solidarity, scholars have noted the links between Ubuntu and an ethics of care (Gouws and van Zyl, 2015). For example, in South Africa (a legal-pluralist state), responsibilities to family members, including a duty to support, are part of customary law as well as of common and statutory law. As Moore (2019: 591) states: ‘customary law is based on family norms which involve these same individuals in networks of kin (and, less often, community) with norms of interdependence and mutual responsibility, and the subordination of individual interests to collective ones’. Sagner and Mtati (1999: 400) described kinship in Africa as a moral order, based on ideas of generalised reciprocity, which includes mutual obligations of support between kin. This moral order makes it extremely difficult, if not contrary to customary law, to escape or ignore family care duties to older persons, even at the expense of one’s own well-being – as is evident in the articles in this special issue. This moral order is also revealed as a moral framework of necessity, however. This is shown in Freeman’s (2023) discussion of the potential acceptability of hypothetical, government-provided, intimate bodily care to the participants in Malawi in her study, as well as in the inherent explicit and implicit tensions revealed across the articles in this special issue (especially those from Lesotho, Namibia and South Africa) regarding who in a family takes on which elements of care and for whom. The opportunities forgone by those who undertake prolonged and unsupported care work are an important driver of ongoing racialised, gendered and classed inequalities. Gouws and Van Zyl (2015: 173), while recognising the importance of Ubuntu and drawing a distinction between Ubuntu-talk and Ubuntu-do, argue for a critical perspective of care that examines inequalities in care and the relations of power that shape such care practices.
Attention to family care has intensified in the context of a ‘care crisis’, in which populations are ageing and welfare state support is retracting (Fast et al, 2021). In Southern Africa, such calls fall in a context of ever-increasing care responsibilities due to high levels of unemployment, poverty and the ongoing consequences of the HIV/AIDS and COVID-19 pandemics. While the literature on care crises in the Global North focuses on understanding family care in relation to formal/institutional care and life-course approaches (Moen and DePasquale, 2017), in the Global South, family care is known not as ‘informal care’ but as the dominant form of care in countries with no, or limited, long-term care services. The distinction between formal and informal care makes no sense where no formal care exists. In such settings, reliance on family care and the relevance of family care for filling large holes in social protection, health and care are critical.
Articles in this special issue
This special issue comprises seven original articles, two ‘Debates and issues’ articles and three book reviews. The first article, by Kelly and Sebego (2023), demonstrates how research on long-term care in Southern Africa lacks a clear and well-funded research agenda. They caution that a lack of adequate empirical evidence stymies progress in policy development. In the second article, Ncube, Gutsa and Price (2023) explore what care and caring mean for older people ageing far from their place of origin in conditions of informality in Zimbabwe. The authors argue that the notion of housing and home as care is central to understanding care in context and to the notion of a successful life. The following article, by Vera-Sanso and Hlabana (2023), focuses on men and their roles in, and experience of, care and caring, and discusses how these have shifted over their lives. Drawing on interviews with former miners living in Lesotho to challenge views of hegemonic masculinity in care studies, the authors conceptualise care/caring as involving three ‘active’ dimensions. In the fourth article, Moore (2023) examines the position of female co-residential employed caregivers in South Africa. Her article reveals how family care of older persons is located in multiple care contexts and shows how in taking responsibility for caring for an older person, a family member may also have to take responsibility for other relatives the older person can no longer support, increasing inequalities for caregivers along racial, class and gender lines. The fifth article, by Freeman (2023), looks at equitable, sustainable and acceptable long-term care in Malawi. Freeman draws on qualitative data from men and women needing and providing care in rural southern Malawi to challenge the implied universalism of some of the key terms of reference in the (glocalised) African long-term care discourse. The sixth article, by Ananias and Keating (2023), aims to enhance understanding of experiences of family care, its contexts and its consequences among carers in marginalised communities in Namibia. The article reveals that care is not always shared within families and can have dire consequences for carers and their families, foreshadowing the generational replication of carer exclusion. The seventh article, by Kabelenga (2023), draws on focus groups with community leaders in rural and urban Zambia to understand the formation and perpetuation of powerful norms of family care in later life. The articles close with Curreri, McCabe, Robertson, Aboderin, Pot and Keating (2023), who show that care is believed to be best provided within the family home, both through a sense that this is the right place to care and due to a lack of acceptable alternatives in these regions.
There are two ‘Debates and issues’ articles in this special issue. Kelly and Black outline the potential of geographical information systems (GIS) in public service planning for older people in the African continent, while Gie and Hoffman present a case for developing a long-term care economy based on a pilot programme run with local government. This special issue also includes reviews of three recently published books on ageing, care and filial piety in the Global South context.
Together, the articles in this special issue reveal some of the variation in thinking about care in the Southern African context. For example, conceptualisations of care for older persons that focus on ‘intrinsic capacity for independence’ seem misplaced in settings characterised by interdependence. We consider what constitutes care when necessities, such as food, housing and land, are critical to human functioning. In attempting to uncover the meaning of care and its multiple dimensions, the articles shed light on the ways in which drawing on Southern Africa’s vernacular languages and understandings opens up possibilities and multidimensional meanings of ‘care’ in these contexts.
In the Lesotho context, Vera-Sanso and Hlabana (2023), in framing discussions around the Sesotho word ‘thlokomelo’ (meaning ‘care’ and ‘being aware’, that is, attentive and empathetic), primed their interviewees to reflect on and use such concepts, and argue for a three-dimensional concept of care that includes: (1) anchoring care by providing the resources needed for care to happen; (2) direct care work; and (3) receiving care. Each is essential for understanding Basotho men’s involvement in, and receipt of, care from a life-course perspective. Their article emphasises how former mine workers’ identities are grounded in care relationships that upend outdated perspectives on African men and care as violent, uncaring or absent. Freeman, in the article from Malawi, presents care in dual terms, referring, on the one hand, to body maintenance (bathing, ablutions and feeding) and, on the other, to support, including assistance with crop work or material assistance, such as providing food or cash transfers. The parsing of ‘care’ into chithandizo understood as ‘help’ (in the form of financial or material assistance), and chisamaliro, understood as care (in the form of assistance with household activities, daily living activities and supervision when someone is ill), highlights differences between them. This differentiation of care is particularly significant in this context, where people engage in productive work until they can no longer do so. This situation, combined with seasonal periods of insufficiency, drought and hunger, radically shapes expectations and possibilities for the elderly, and with them, the forms that care must take. In their study of older Zimbabweans living in conditions of informality, Ncube, Gutsa and Price (2023) show how people conceptualise the provision of housing and space as a central way of providing care, even as their own physical disabilities and health challenges severely limit their daily lives.
Drawing on these insights from the region, based on how things play out in reality, such concepts as ‘living independently’ become absurd. Although the concept of independence underpins many policy discourses about care, it derives from a model of personhood and autonomy that is not only ‘foreign’ in Southern Africa but also unrealistic in most other parts of the world. The African context shows the importance of conceptualising care relationally and illuminates how very ‘odd’ Western concepts of the person and of relationships are in other global contexts. Freeman, in her article, outlines their absurdity in the Malawian case; parallels can also be drawn elsewhere, based on findings in each of the articles and indeed in other parts of the world.
Sitting alongside ‘ways of seeing’ care is ‘taking account of the context’ in which care takes place. The region has experienced many crises, including poverty, landlessness, unemployment, HIV-AIDS and COVID-19. In the absence of systems of support, what do people do? Moore, in her article, contributes new insights into the complexities of kin networks of care across time, highlighting the care responsibilities older relatives have often had for grandchildren and other extended family members, especially in contexts of HIV/AIDS. In taking responsibility for caring for an older person, a family member may also be taking responsibility for relatives the older person can no longer support. The cumulative impact of HIV/AIDS, tuberculosis (TB), malaria, increasing non-communicable diseases, drought and poverty is revealed when an older woman becomes ill. The physical care required in households increases extensively when she not only requires care herself but also can no longer provide care for others.
Care work is happening alongside women’s increased entry into the labour force, which reduces the time available for the provision of unpaid care. Care work thus impacts on other forms of work, including subsistence work. In the case of South Africa, Moore (2023) highlights how employed co-residential caregivers manage this responsibility, while Freeman (2023), in the context of Malawi, outlines how having to attend to ‘care work’, as it is often understood, takes people away from the subsistence work that is also essential for caring. In Namibia, Ananias and Keating (2023) describe the constrained circumstances for those who care for older people that set up a tricky bind between navigating multiple forms of work and responsibility, all of which are essential to sustaining livelihoods.
Through all the articles runs a seam of understanding about the complexities of colonial, institutional, migration and economic histories across time. These have shaped the contemporary conditions and structural inequalities within which people care, challenging essentialist and biological notions of care, and revealing their social and political construction. Ncube et al (2023) demonstrate how older immigrants in Zimbabwe have been driven to age in places of informality and hardship, without land rights or economic support to fall back on, and with limited kin networks. Their case study shows that infrastructural interventions aimed at improving living conditions by changing the conditions in which people age have the potential to support family and community care.
Political and policy construction of family care
A major contribution of this special issue lies in the attention it draws to the divide between the significance of family care to older persons and the scant attention (and funding) it receives in local policy and research agendas. Six of the contributions point to ways in which long-term care for older people in policy texts is grounded in familialist assumptions derived from colonial and apartheid-era constructions of ‘African families’. Neocolonial expectations and understandings of the family surface when familial care of older persons is assumed. The articles show how this often results in care being unrecognised and in care needs being unmet. Unmet care needs are blamed on ‘broken’ and fragmented families, where family care is characterised by a ‘care deficit’. In this special issue, we hope to show, in contrast, that any ‘care deficit’ in fact emanates from an unsupported care infrastructure in which ‘care’ draws people towards paid work activities and subsistence work. Among other evidence in this special issue, the contributions of Curreri et al (2023) and Kabelenga (2023) reveal powerful normative obligations on families to provide family care for older persons that are deeply held. A policy discourse on ‘fragmented families’ and ‘care deficits’ shifts attention from building stronger care infrastructure that could change the social conditions of ageing for older people and their families.
This special issue reflects on the production and experience of care for older persons in Southern Africa, providing much-needed evidence on vital issues. It highlights the pressing need for better understanding of family care of older persons and contributes important new findings that we hope will pave the way for future research-based articles on care in the Global South, both in this journal and elsewhere. More evidence about the realities of care in these contexts is needed for family practices to be better understood so that families can be supported to provide care in ways adapted to demographic changes and gender and racial transformations, and that contribute to reducing poverty and increasing opportunity.
Conflict of interest
The authors declare that there is no conflict of interest.
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