As elsewhere, the absolute number of older persons in South Africa (SA) is expected to rise, from 4.8 million older persons (age 60 and above) recorded in 2017 to approximately 11.6 million by 2050 (UNDESA, 2017). The demographic transition overlaps with an epidemiological transition, with an increase in non-infectious disease, chronic disease and disability, especially among older people. However, there is a dearth of formal long-term care (LTC) services in sub-Saharan Africa (SSA), and those that exist are almost exclusively in the private sector and unaffordable for most older persons. Family care is the mainstay of LTC, where cultural norms of family solidarity and obligation are strong (Aboderin and Epping-Jordan, 2017) and recognised as an African value in pan-African policies. The majority of LTC is provided by women, which places a disproportionate burden on them and makes it more challenging to further their education and/or participation in economic activities. There is growing consensus that families alone cannot provide sufficient, adequate and sustainable LTC. It is thus imperative that African countries develop LTC systems to support older persons and their families.
The 2017 African Union (AU) Common African Position on LTC Systems for Africa and, in response to the United Nations Decade for Healthy Ageing, the 2022 AU Policy Framework and Plan of Action on Ageing emphasise the need to develop equitable and sustainable LTC systems. To this end, it is important to note that LTC systems do not equate only to institutionalisation. The global and continental policy architecture, rather, advocates for LTC services to be provided to most older persons within the community, complemented by residential care. However, unlike welfare states in the Global North, with well-established formal care systems, questions arise as to whether African countries have the resources and political will to provide formal LTC services to most older persons. Moreover, despite African governments’ commitments, little, if any, consideration has been given to the possible role of an LTC economy in SSA, with a large focus placed on enhancing education, skills, decent work and business opportunities for young people in other domains.
Drawing on a pragmatic contextual and policy analysis, and recognising pan-African, national and local policy architecture, this commentary aims to explore the development of an LTC economy in Gauteng Province, South Africa. We problematise decent work at the LTC nexus with employment opportunities, and discuss recent policy developments that have successfully built a case for developing Gauteng’s LTC economy.
Trend 1: Population ageing and development of LTC
It is estimated that 27 per cent (about 16 million) of SA’s total population (61 million) lived in Gauteng in 2022 (Stats SA, 2022a: vii). De Kadt et al (2021: 30) found that 36 per cent of 13,616 study participants in Gauteng lived below the poverty line of USD80.31 per capita per month. Although mostly a youthful population, the largest number of older persons (age 60 and above) reside in Gauteng, comprising just less than 25 per cent (1.4 million) of SA’s total number of older persons in 2022 (Stats SA, 2022a: 31).
LTC for older people in Gauteng is currently provided by the family, communities, non-profit organisations, the state and the market (Makiwane et al, 2022). SA’s Older Persons Act 13 of 2006 and Gauteng Older Persons’ Rights Strategy (2020–25) focus on providing community-based and home-based care to enable older persons to reside in their homes and communities for as long as possible. However, the Gauteng Department of Social Development (GDSD, 2021: 96) reported that in 2020, only 20,168 older persons in Gauteng received any such care. As in the rest of SSA, most older persons are unable to afford private LTC services and the burden of care falls on (female) family caregivers.
Trend 2: Youth unemployment
Despite the trend of population ageing, SSA has the youngest population in the eight Sustainable Development Goal regions. Compared with the wider region, southern African countries have declining fertility rates, slower population growth, an increasingly older population and a higher ratio of working-age people to the non-working age population (Schwidrowski and Branz, 2021). These trends may present an opportunity for a demographic dividend, which, as outlined in AU policies, is economic growth driven by an increase in the skilled workforce, coupled with transformative government policies.
However, since the economic crisis of 2008/09, SA has seemingly missed the opportunities presented by these favourable demographics. Unemployment, especially youth unemployment, is one of the country’s most pressing development challenges. Statistics South Africa (Stats SA, 2022b: 28) estimate that 45.8 per cent of those aged 15 to 34 years in Gauteng were unemployed in 2020. Additionally, more female youth in SA than male youth (50 per cent versus 43 per cent in the third quarter of 2021) are unemployed or not in education or training (Stats SA, 2021: 14).
Generally, few sectors have opportunities for growth in decent work, especially for youth and women. However, the World Health Organisation (WHO, 2016: 12) estimates that there will be a global needs-based shortage of over 18 million health workers by 2030, especially in low-resource settings. Therefore, investing in the health and social care workforce through training and decent employment opportunities might be an important means for both providing welfare for the population and addressing youth unemployment (Horton et al, 2016). Such investments are, however, complex because they depend on country/regional priorities and policies, related agendas, diverse stakeholders, and current and future trends.
Policy developments: towards developing the LTC economy in Gauteng
The two trends are normally addressed separately. However, recent policy developments have illustrated how these might be addressed concurrently to develop Gauteng’s LTC economy. An LTC economy can be defined as the spectrum of LTC work, which supports the sustenance and basic daily needs of older persons (UN Women, 2018). Relatedly, the major approach adopted by feminist economists to understand and theorise the care economy is one centred on the process of social reproduction, which enables individuals, families and societies to continue. Folbre (2014: i135) expands on this by defining care work as being located in different areas of the economy (that is, family and formal care) and being performed for different care recipients, including older persons.
Gauteng, as SA’s economic powerhouse, is ideally positioned to lead developments in this domain. As a first step, two important policy instruments have been executed: in 2020, the Growing Gauteng Together 2030 Action Plan was launched, which aims to, among others, ensure an inclusive, growing economy and the development of the potential of women and youth, including promoting labour-absorbing industries, developing the township economy and ensuring everyone receives a decent living wage. Second, with relevant stakeholders, the Gauteng Older Persons’ Rights Strategy (2020–25), launched in 2022, aims to (albeit rather rhetorically) change the lives of older people by facilitating the provision of affordable, accessible, non-discriminatory, quality services to all older people. Although this strategy highlights the need for trained caregivers, caregiver training and many other factors related to caregivers are not addressed.
Building on these policy documents, the Gauteng Department of Economic Development (GDED) pioneered the co-creation of the Gauteng Care Economy Strategy (hereafter, the Strategy) in 2021/22. After internal consultations at the end of 2022, it is anticipated that the Strategy, as a first attempt to operationalise LTC, will be presented to the Executive Council for consideration in the first quarter of 2023.
The Strategy explicitly aims to create sustainable decent employment and entrepreneurial opportunities for unemployed youth (especially females) in the Gauteng LTC sector, while improving and strengthening existing care infrastructure and policies to ensure the delivery of affordable, accessible, culturally appropriate, equitable and quality LTC to older persons. The strategy will evolve over a five-year implementation period.
The development of the Strategy comprised four distinct approaches:
Co-creation and political will: Led by the GDED, policymakers from different departments and researchers from different disciplines co-created the Strategy; facilitating inter-sectoral buy-in and collaboration.
Pragmatic approach: Pragmatism was generally utilised as an approach to policymaking (Horton et al, 2016; Greenhalgh and Engebretsen, 2022). It combined multiple scientific methods with science-informed narratives from practice and linked these together with real-world action.
Generational approach: Strategic investments across the life course and the generations potentially enhance well-being and capacities in older age to benefit both older and younger people today and in the future. The expansion of formal LTC services could both contribute towards meeting the growing LTC demands of older persons and supporting family caregivers, and simultaneously increase decent employment opportunities for the unemployed, especially unemployed youth. The low pay, poor social status and gendered framing often associated with the care workforce may prove a challenge in attracting unemployed youth, especially men, and it will be important for caregiving jobs created to be attractive. The Strategy accordingly seeks to develop care career trajectories, focusing on developing youth’s skills through comprehensive accredited training programmes and developing decent employment and enterprise-creation opportunities.
Gender equality approach: This approach is underpinned by the 5R Framework for Decent Care Work1 (a gender-responsive and human rights-based approach to public policy) (Elson, 2017; Addati et al, 2018). Apart from creating decent employment opportunities, especially for youth and women, investments in the health and social care sector could improve the support provided to female family caregivers and enable them to (re-)enter the labour market or informal economy. Significant macroeconomic gains can be earned when female youth and women are given the opportunity to realise their full potential in the labour market, as well as improving overall well-being for themselves, their families and their communities.
Challenges and caveats
Employed paid caregivers throughout SA currently face several challenges, including precarious working conditions, poor wages, limited/little training and support and the lack of career-advancement opportunities. Therefore, the status quo in Gauteng’s LTC economy needs to be (re)considered and addressed. The Strategy incorporates the principle of decent work, which provides: opportunities for productive work; a fair income; security and protection against vulnerabilities in the workplace; social protection; freedom to organise and participate in decision-making processes; and gender equality (ILO, 1999). In practical terms, in the Strategy, this includes registering caregivers, setting out labour standards for caregivers and developing decent employment and enterprise-creation opportunities.
Gender inequality is widespread throughout the health and social care workforce, and many paid caregivers in SA are women who often work in precarious conditions. Women’s rights should be recognised, prioritised and realised when developing the LTC economy. The Strategy thus aims to develop a robust, resilient, gender-responsive LTC economy. In line with the 5R Framework, the creation of paid caregiving jobs in the LTC sector assists in recognising, reducing and redistributing unpaid care, and LTC work needs to be rewarded accordingly. While the Strategy prioritises employment opportunities for female youth, it also aims, on the basis of gender redistribution, to create new opportunities for much-needed male youth caregivers.
Three caveats also need to be discussed. First, the realpolitik of developing decent employment opportunities for women and female youth in, and attracting males to, the LTC sector is complex. As such, it may be argued that the Strategy re-genders LTC by focusing on creating employment in a sector in which women are often overburdened and marginalised. Beyond the idea of decent work and the 5R Framework, hierarchies, vulnerabilities, gender stereotypes and political representation need to be challenged and addressed, with a focus on growing women’s leadership within the sector. Furthermore, in order to fully guarantee caregivers’ representation, a statutory body representing caregivers should be formed nationally.
Second, funding the implementation of the Strategy is still a challenge to be considered in more detail. The Strategy utilises a combination of financing mechanisms, including well-managed public–private partnerships. An investment case for Gauteng’s LTC economy will need to be developed for a clear action plan on how to secure and sustain funding.
Third, there are many research and data gaps that will need to be addressed for effective implementation, including documenting the extent of unmet needs and understanding the social care workforce, the potential for market making and norms and attitudes regarding training and undertaking care work, especially among unemployed youth. The Strategy also recommends a well-managed, inter-sectoral, digital data repository for the sector.
In this commentary, we have discussed a rationale for developing Gauteng’s LTC economy, as well as recent policy developments related to this. There are several reasons to be optimistic about the Strategy, such as the pioneering work conducted on decent work, intersectorality and an inclusive economy. We have also highlighted complexities that are intended to stimulate further intersectoral debate. Our central argument is that LTC should be seen as an investment, rather than an economic burden, which could lead to a substantial increase in employment opportunities and, in turn, contribute to healthy ageing.
The authors would like to acknowledge the government officials from the Gauteng Provincial Government who co-created the Strategy.
Conflict of interest
The authors declare that there is no conflict of interest.
Aboderin, I. and Epping-Jordan, J. (2017) Towards Long-Term Care Systems in Sub-Saharan Africa: WHO Series on Long-Term Care, Geneva: World Health Organisation.
Addati, L., Cattaneo, U., Esquivel, V. and Valarino, I. (2018) Care Work and Care Jobs for the Future of Decent Work, Geneva: International Labour Organisation.
De Kadt, J., Hamann, C., Mkhize, S.P. and Parker, A. (2021) Quality of Life Survey 6 (2020/21): Overview Report, Johannesburg: Gauteng City-Region Observatory.
Elson, D. (2017) Recognize, reduce, and redistribute unpaid care work: how to close the gender gap, New Labor Forum, 26(2): 52–61. doi: 10.1177/1095796017700135
Folbre, N. (2014) The care economy in Africa: subsistence production and unpaid care, Journal of African Economies, 23(1 SUPPL1): i128–56. doi: 10.1093/jae/ejt026
Greenhalgh, T. and Engebretsen, E. (2022) The science–policy relationship in times of crisis: an urgent call for a pragmatist turn, Social Science & Medicine, 306: 115140.
Makiwane, M., Alubafi, M.F. and Gumede, N.A. (2022) Understanding and evaluating older persons services: the case of the Gauteng Province, South Africa, Journal of Population Ageing, 15(4): 999. doi: 10.1007/s12062-020-09288-1
Schwidrowski, Z. and Branz, G. (2021) Southern Africa’s Credit Outlook: Will the Demographic Dynamics Become a Growth Dividend or Social and Fiscal Burden?, Berlin: Scope Ratings.