Barbara Da Roit

Similar and Yet So Different: Cash‐for‐Care in Six European Countries’ Long‐Term Care Policies

CONTEXT In response to increasing care needs, the reform or development of long-term care (LTC) systems has become a prominent policy issue in all European countries. Cash-for-care schemes-allowances instead of services provided to dependents-represent a key policy aimed at ensuring choice, fostering family care, developing care markets, and containing costs. METHODS A detailed analysis of policy documents and regulations, together with a systematic review of existing studies, was used to investigate the differences among six European countries (Austria, France, Germany, Italy, the Netherlands, and Sweden). The rationale and evolution of their various cash-for-care schemes within the framework of their LTC systems also were explored. FINDINGS While most of the literature present cash-for-care schemes as a common trend in the reforms that began in the 1990s and often treat them separately from the overarching LTC policies, this article argues that the policy context, timing, and specific regulation of the new schemes have created different visions of care and care work that in turn have given rise to distinct LTC configurations. CONCLUSIONS A new typology of long-term care configurations is proposed based on the inclusiveness of the system, the role of cash-for-care schemes and their specific regulations, as well as the views of informal care and the care work that they require.Since the 1990s, cash-for-care schemes have been a common trend in social policies, particularly in the field of long-term care (LTC). Instead of services, these schemes give people monetary benefits, which they can use to purchase care services. Most of the literature on this topic concerns the common objectives and possible implications of cash-for-care schemes. One of the main ideas behind cash-for-care is “free choice”; that is, disabled (older) people and/or their families may choose among different kinds of care and care providers, thereby giving them both autonomy and control, which disabled peoples organizations have sought since the 1970s (Glendinning 2008). The resulting competition among care providers also has enhanced the quality and efficiency of care (Kremer 2006) in accordance with a “new public management” perspective (Ferlie, Lynn, and Pollitt 2007). Another objective is the recognition of (formerly unpaid) informal care, since many cash-for-care schemes allow beneficiaries to compensate or employ their relatives (Ungerson 1997). Finally, cash-for-care schemes can be seen as opportunities to offer LTC policies that are less expensive than traditional services. A closer inspection of cash-for-care schemes in various European countries also reveals some striking differences among them. First, the strict regulation of cash-for-care schemes has strongly influenced the “commodification of care” (Ungerson and Yeandle 2007), as well as the development of specific forms of care work and informal care (Da Roit, Le Bihan, and Osterle 2008). Moreover, besides some exceptions (Lundsgaard 2005), researchers have tended to focus on cash-for-care schemes as specific policy instruments separate from more general LTC policies. The aim of this article is, on the one hand, to extend the discussion about the diversification of cash-for-care schemes and, on the other, to place them in broader institutional frameworks, namely, as part of general LTC policies. We claim that only when looking at the diverse institutional contexts in which these new schemes developed and the specific regulations that they entail can we understand them. We first consider the policy and institutional context in which cash-for-care schemes have been introduced in Sweden, the Netherlands, Austria, Germany, France, and Italy, particularly the degree and forms of development of previous LTC policies and the specific policy debates concerning each. We then address the specific regulations of the schemes and their different visions of informal care and care work. Finally, we discuss three LTC patterns that emerged from our analysis.

Changing Intergenerational Solidarities within Families in a Mediterranean Welfare State Elderly Care in Italy

Intergenerational solidarity within families is the traditional source of support for dependent elderly people in southern European countries, where care needs have been mainly fulfilled by the unp...Intergenerational solidarity within families is the traditional source of support for dependent elderly people in southern European countries, where care needs have been mainly fulfilled by the unpaid work of women. Recently, the decline of informal care and the persistent lack of supply of formal services have been accompanied by the growth of commercial services mostly provided by migrant women hired by families in the grey market. The article is based on a qualitative study and explores the social processes underlying these changes. It suggests that although intergenerational solidarity is still crucial, it is expressed less through the direct provision of care and more through the supervision of paid services. This shift, which results mainly from a strategy adopted by middle-class women, challenges traditional gender relations and divisions of work. Moreover, it produces employment relations characterized by low pay and underprotection and reflecting conflicts over time and space typically present in informal care relations.

Migrant care work and care, migration and employment regimes: A fuzzy-set analysis

Migrant care work has emerged as an increasingly important solution to the challenges of growing eldercare needs in both the private and the public sphere. Migrant workers are employed in domestic services in Southern European and in some continental European countries, and they are a significant part of the work force in the formal care sector in many national contexts. The article provides an exploratory cross-country analysis of the phenomenon. After assessing the extent of migrant care work based on individually contracted workers in the domestic sector vs. organization-based care workers in nine European welfare states, it investigates which conditions sustain specific national patterns. Using fuzzy-set analysis the article demonstrates how the intersection of care, migration and employment regimes shapes different patterns of migrant care work.

The Netherlands: the struggle between universalism and cost containment

The Dutch home-care system is embedded in a universalistic and comparatively generous long-term care (LTC) scheme that was introduced in the late 1960s. The tension between guaranteeing access to good-quality care and controlling costs has been a key issue since the inception of the LTC scheme. The article addresses the question of how these two distinct objectives have been dealt with in the political debate and by policy-making in the past 20 years. It does so by looking at existing studies, official statistics and policy documents. First, the analysis shows that home care - the development of which results from the de-institutionalisation policies pursued since the 1980s - has shifted from being considered a cost-containment measure to representing a battlefield on cost containment. Second, the article argues that the issue of cost containment is a leitmotif in the development of home care that has been accompanied and legitimised over time by distinct normative views. On the one hand, traditional forms of cost containment - namely direct budgetary controls - have been predicated on the need to ensure the financial sustainability of the system and its universalistic features. On the other hand, the discourse and practice of cost containment has, since the early 1990s, also been accompanied by normative views that structurally challenge universalism through the introduction of new ideas about the responsibility for LTC risks, resource allocation and regulation of the system.

Strategies of Care : Changing Elderly Care in Italy and the Netherlands

Strategies of Care analyseert de veranderingen in de ouderenzorg vanaf het begin van de jaren negentig van de vorige eeuw. Auteur Barbara Da Roit doet dit aan de hand van een vergelijking tussen Italie - een land met een traditioneel, weinig veranderlijk en familievriendelijk model - en Nederland, dat een formeel zorgmodel heeft dat grondig wordt herzien. Het onderzoek bespreekt de trends in de zorgbehoeften van ouderen tegen het licht van de veranderingen in de zorgpakketten. Aan de hand van een analyse op basis van gesprekken met familieleden, professionele zorgverleners en sleutelfiguren in de ouderenzorg geeft dit boek inzicht in de manier waarop zorgpakketten worden geconstrueerd en de logica die daarachter schuilgaat.

The Southern European migrant-based care model: long-term care and employment trajectories in Italy and Spain

ABSTRACT The development of personal social services and female employment is intertwined, not only in the domain of childcare. With the ageing of the population, the changing forms of care and the developments in the eldercare labour market become crucial issues. The new risk of dependency represents a challenge, but also an opportunity. This paper provides an overview of the relationship between the development of long-term care policies and services in distinct European countries and female employment in the care sector. Whereas Northern European countries have developed policies in the field at an earlier stage and continental countries intervened with new policies in the last 10–15 years, in Southern Europe policies remain weak and fragmented. The paper concentrates on the case of Southern European countries, where the weakness of social policies and low development of services did not prevent the rise of a new care labour market. Next to still low employment rates among women, long-term care tends to be provided mainly by migrant care workers often in the underground economy regardless of their legal status. The last development is a key issue for Southern European countries, as discussed in the paper, not only for the current consequences on migrant workers, older people and their families, but also because it is likely to structure any possible future development in long-term care policies.

Cash for Care Schemes and the Changing Role of Elderly People's Informal Caregivers in France and Italy

In response to the ageing of the population and increasing care needs, long-term care has become a key policy issue in all European countries. The introduction of cash-for-care schemes — allowances provided to elderly dependent people and their families which they can either pass on to informal caregivers or use to employ a paid caregiver — has represented a key instrument and a common trend in European countries since the 1990s (Ungerson, 2005a, b; Ungerson and Yeandle, 2007). Various factors have been identified in the literature to explain this common evolution, such as the incapacity of the traditional welfare state to meet individuals’ needs, the trend towards marketization or the recognition of (formerly unpaid or cheaper) informal care (Ungerson, 1997, 2005).

Long-Term Care Reforms in the Netherlands

The foundation of the current Dutch long-term care system dates back to the end of the 1960s, when a compulsory social insurance to cover the costs of “exceptional medical expenses” (AWBZ) was introduced. Since then, the system has undergone a continuous process of reform. This chapter first reconstructs the original logic of the system through a historical and institutional analysis. The trends toward reform are then considered, looking at how the problem of change has been constructed and at the actors playing a relevant role in this process. Over the last decades, different logics have been adopted in the innovation of the system, ranging from the redefinition of eligibility criteria and resource allocation (deinstitutionalization of the service provision system and restrictions in access) to changes introduced in the governance of long-term care (users’ empowerment), to the redefinition of the boundaries of the system as such (the separation of care from household assistance and the shift of psychiatric cases to the healthcare system). All these aspects are described and critically reviewed in order to understand the directions and impacts of institutional change.

Children First? Changing Attitudes Toward the Primacy of Children in Five European Countries:

Parenting support is a new policy field, directed toward teaching parents how to assume their role. Its foundations are embedded in a child-centered social investment approach, which is becoming dominant in Western European welfare states. This article aims at exploring the extent to which ideas underlying these policies are coherent with individual attitudes toward children, parents, their relationship and their change over time. We analyze how these attitudes changed in five selected countries (France, Germany, the Netherlands, the United Kingdom, and Sweden), using data from all four waves of the European Values Study (1981, 1990, 1999, 2008). We also test what kind of values are behind these attitudes, employing logistic regression as method. Our main finding is that there has been a value shift in public sentiments regarding the primacy of children, which is no longer to be viewed as a traditional type of attitude.

The Gender Informal Care Gap: A fuzzy-set analysis of cross-country variations

ABSTRACT This article investigates the relationship between the ‘gender informal care gap’ – the relative contributions of women to informal care for non-co-resident relatives and other members of social networks, compared to men – and public care policies, level of care needs, labour market position and gendered care attitudes. Since the literature suggests that none of these factors alone can explain the gender informal care gap, we develop a model based on fuzzy-set/qualitative comparative analysis in order to identify patterns in the relationship between the factors. The analysis conducted at the macro-national level in 13 European countries, suggests that at the macro-level, the availability of public care services is crucial to understanding the gender informal care gap, while womens labour market position, the presence or absence of gendered care attitudes and the level of care needs play no or a relatively minor role.