The state provides limited support for older persons through the health and social protection systems, so families and women are left to organise care for them. The work of caring for older persons taking place in families is not recognised, valued or assisting gender and racial equality. In a rapidly ageing context, it is unsustainable and raises many questions about how the economy, social protection system and health system will cope in the coming years when the number of older persons living with multiple chronic conditions increases. 

South Africa has approximately 5.59 million people over the age of 60, about 9% of the population. It is estimated that this will grow to 17.5% by 2050 due to decreasing fertility rates and increasing longevity. Over the last decade, health researchers have been raising concerns about the increase in non-communicable diseases and the implications this has for the health system. We know that just under half of people over 60 have high blood pressure, 16% have diabetes and 14% have arthritis. 

Increases in non-communicable diseases increase the physical care needs required to undertake everyday activities such as walking, eating, washing and going to the toilet. Increasing longevity, coupled with an increase in non-communicable diseases, such as strokes, cancer, hypertension diabetes, increases the care needs of older persons, so how will society manage this care? 

The increasing number of older persons living with non-communicable diseases and chronic conditions will affect the demands placed on the healthcare system. State and private care services are patchy, often limited to urban areas and are often inaccessible for many due to poverty.

Currently, only 22% of older people in South Africa have medical insurance, varying from 6% of black South Africans to 74% of white people. The population of older persons on ARVs is also ageing, and managing HIV and the side effects of ARVs on top of multiple health conditions is challenging. The research points to how older persons in low-income households score poorly on quality-of-life measures and have less access to supportive services.  

Moreover, there is extremely limited state provision of elderly care, with approximately 417 residential facilities registered with the Department of Social Development (and many unregistered private facilities), nine of which are managed by the government, and 1,713 registered community-based care and support services for older people. 

As many will tell you, services can be inadequate and non-governmental organisations are often poorly funded. Subsidies paid by the Department of Social Development for frail, low-income older persons who need care in homes are woefully inadequate to support the care needs and leave many organisations with the work of sourcing additional funding to meet the gap, specifically in frail care, assisted living and social services through wellness centres. 

For people who can afford it, paid caregivers in the home (as paid care workers in the home or domestic workers) can provide support, but paying for care is unaffordable for most.  

Social grants

To date, state support for older persons has focused on social grants, which are the main source of income for most older persons, especially older persons living in rural areas and living in women-headed/female-dominated households. In the recent Budget, it was announced that the Older Person’s Grant (OPG) would be raised to R2,085. Approximately 3.84 million people in South Africa over the age of 60 receive the grant, and approximately two in three OPGs are paid to women. 

The OPG has assisted in many ways, especially in improving the dignity of older persons. Unfortunately, the grant is not enough as it is used to support households and so despite the presence of the OPG, approximately three-quarters of older persons live below the lower-bound poverty line. This has gendered consequences for women caregivers and receivers, especially women living in women-headed households.  

The vast majority of care for older persons in South Africa happens within families. We know that almost two-thirds of black and coloured older persons live in multigenerational households, but we know very little about how this care is experienced and what it entails. 

We know that women spend more time on care activities and there are expectations on women to be caregivers in families, but we don’t know how this shapes their lives, their employment opportunities, their financial, physical and psychological wellbeing and we don’t know whether the care provided meets the care needs of older persons. These are some of the questions we are addressing in our new research programme on Family Caregiving of Older Persons in Southern Africa. 

The majority of older persons are women

What we do know is that the majority of older persons are women and female predominance tends to increase with age. In 2020, before the Covid-19 pandemic, the life expectancy for women was 67.96 years and for men, it was 62.18 years. In South Africa, there are approximately three times more widows than widowers. The reasons are multiple, but men are more likely to die before women because there are higher levels of male mortality. These figures tell us about the gendered aspects of a rising population with poor health and care infrastructure. 

Data on healthy life expectancy show us that women not only live longer, but they live longer in poor health. Women are not only going to require care for longer, but the additional gender dimension is that it will be women who overwhelmingly provide the care. Another important feature of understanding the gendered dimensions of family care is to look at the living arrangements of older persons.  

Older persons who have fewer resources are also more likely to reside in multigenerational households and are more likely to be dependent on family care. But households have become more gendered and findings show us that almost half of all households had resident adults of only one gender. What were often termed women-headed households, now more accurately classified as female-dominated households, are more exposed to the risks and challenges of an ageing population. That is to say that the increasing care needs of the older person population will be felt most in women’s roles and responsibilities, especially in female-dominated households as such households are far larger, and they are much more likely to include children (under 18 years) and adults of pensionable age (over 59 years).

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While the older person may be a care provider, if they require care themselves, care responsibilities in the household can become extensive. As older persons in low-income households have the greatest ill health, their families are under the most pressure to provide care, yet have fewer financial resources to support that care. 

At the centre of thinking about family care for older persons lies very important gendered issues relating to where the care is required and located, who is doing the care work and how is it valued. There are no clear strategies on how the Department of Health or Social Development will meet the health and care needs of an ageing population. 

The Older Persons Act of 2006 was enacted after South Africa adopted the Madrid International Plan of Action on Ageing in 2002; however, there is limited policy development to address the increasing gaps in state services and no regard for how the state will support family care with an ageing population. (A recent policy brief published by the DSD based on an evaluation of implementation acknowledges that the act has been poorly implemented.) 

Given the particular gendered consequences of care provision and receipt in the coming years, the lack of policy action in this area is a failure of the state’s own commitments to fight for gender equality as agreed in The Beijing Declaration and Platform for Action. Any programmes or policy developments aimed at supporting family care of older persons need to take into account the increased workload that household members, most often women, will carry when caring for an older family member. DM/MC  

In this three-part series recognising and celebrating Women’s Day the authors focus on care and the ways in which women’s unpaid care work remains concealed and exploited. In focusing on long-term care for older persons, we consider where elderly care is located, who is doing care work and how it is valued. 

The second article in this series unpacks how family caregiving for older persons is experienced by women and demonstrates how caring for older persons reveals women’s insecurity and entrenches racial and gendered inequalities.