Many of us will make choices about what care we can give to an older person and we will think about how we can arrange that care. These choices are heavily influenced by material, social, cultural and relational dynamics, but they are also governed by the availability of good quality, affordable institutional care. 

Read Part One in Daily Maverick Caring for the elderly — an age-old burden that rests heavily on the shoulders of women

Read Part Two in Daily Maverick Women pay a high and often invisible price for having to care for the elderly

Will I be able to access respite care if I take on the care of an older person? Will I be able to afford a carer to help me when I am at work? How much will it cost and how much care support will I require? Who else can help, and what choices do I really have? 

Imagine the following scenario: you and your partner are living in a house in a lower-middle class area. Your partner’s mother, 75, is diagnosed with a chronic condition and requires care. Your partner wants the older person to move into your house, but you think you are too busy to cope, so what would you do? What do we think about this scenario and what options do we consider when making a choice? 

Our study

In considering options, most participants in our study prioritised employment. Does the couple have the capacity to look after an older person if they are employed, as one person stated: “Who is going to look after the granny? What do they do? I wouldn’t expect them to quit their jobs to look after her. I would ask another family member at home whether they could do it.”

Some participants prioritised relational concerns, specifically how caring for an older person would impact on the marriage and family dynamics, as one person argued: “If there isn’t agreement between the partners and she is not volunteering, then it is going to cause huge marriage instability. My personal belief is that when you marry, your first obligation is to your family, and then to caring for your parents.”

Many participants considered an old age home as a reasonable option, something they would advise the characters to pursue. These ideas were primarily focussed on the quality of care that older persons might receive at an old age home. As one participant stated: “I think their mom is 75 years and they should place her in a home. Because there’s everything and they will look after her, they will feed her, bath and do everything.” But it was also based on the need for an older person to be socially included, which to some participants it was “better to put her in old aged home and sometimes people sometimes feel so down so maybe if she’s with other people they could help you and make you feel better and they could do things together like activities.”

The findings support existing research, which indicates a variation in support for institutional eldercare. 

During apartheid, the state provided subsidised residential care facilities for white older people, but this system could not feasibly be extended to the entire population from a financial perspective, nor was it desirable in terms of cultural values or global trends in elder care, which emphasise “ageing-in-place”. Both locally and internationally, there has been a drive to reduce admissions of older persons to assisted living facilities by promoting community-based care models that promote healthy ageing and support the quality of life and ongoing participation of older people in society. 

The Older Persons Act (2006) emphasises family- and community-based care, and the government has progressively de-funded facilities in favour of an ageing in place model. However, the lack of concomitant investment in community- and home-based care structures has left the country with a hollowed-out long-term care system, where there is insufficient funding to adequately support low-income persons in need of frail care in residential facilities, and very little support for care at community and familial level. 

High costs of private elder care

But given the high costs of private institutional elder care in South Africa, and the limited subsidies available for frail older persons who meet the stringent physical, cognitive and income criteria for subsidisation, most older people, regardless of what might be desired, will remain in family and community settings for as long as possible. 

Service centres for older persons and community-based care services are provided largely by NGOs with inadequate funding, and services are unevenly distributed across the country. Service centres are focused on active older adults through meal provision and opportunities for socialisation, income-generation projects, and access to social and sometimes primary healthcare services through older persons “clubs,” rather than addressing care needs. Community-based carer workers have high caseloads and are not able to provide substantive support. 

The question then becomes, how do we (and the state) better support community-based and family-based care in the context of population ageing?

Extending access to the Grant-in-Aid

To cater to older persons with care needs, the government offers the Grant-in-Aid (GIA), an additional grant of R505 paid to beneficiaries of the Older Persons Grant, War Veterans Grant and Disability Grant who are certified by a medical professional as in need of “regular attendance by another person” to subsidise care needs for those who are not in residential care facilities. The most recent statistics show that only around 6.5% of Old Age Grant beneficiaries are also receiving the GIA (34% of whom also receive grants for children, including child support grants, foster grants and care dependency grants), indicating that just less than 6.5% of older people in communities receive a GIA, many who are also primary or financial caregivers for children. 

While estimates and definitions for care needs vary, if it were to be based on the number of people living outside of residential care facilities who need assistance with basic activities of daily living (eg washing, walking, eating etc), we can see that the GIA coverage of persons with care needs is very low. Estimates on the number of older persons living in community settings in South Africa who need assistance with at least one Basic Activity of Daily Living (BADL) vary from 17% in people aged 60 and older in one rural area to between 38% and 49% of those aged 65-74 and 75+ respectively. One study estimated around 88% of people aged 50+ had BADL difficulties, when criteria such as catching public transport, concentrating and remembering things, or learning a new task, were included. Impairment in activities of daily living is strongly related both to age and socio-economic status, with poorer, older persons experiencing greater degrees of disability. 

Further study is needed on the reasons for low uptake of this grant, but other studies on Disability Grants and Care Dependency Grants indicate that poor awareness of the GIA, poor assessment tools and practices, as well as the complexities of applying for grants where medical assessment is required may act as significant barriers. 

Given the gaps in, high costs of and undesirability of residential care, increasing the value of and access to the GIA would go a long way in supporting the care needs of older persons and compensating family or other informal caregivers for care provided. 

Other options

Other important solutions are providing more funding for community-based care workers and NGOs that can offer more caregiver support, care equipment and consumables, education/training, respite care, home-based care support, as well as more specialised services such as support for dementia care. Increasing the quality and accessibility of integrated Primary Healthcare Services to older persons through training of health workers and improvements in transportation services (in urban and rural areas) to older persons to ensure that older people receive responsive care would assist them to remain healthy and active for as long as possible. 

The Revised White Paper on Families in South Africa (2021) acknowledges the role of the state in assisting families to balance care of older persons with care responsibilities for other kin and economic participation and some potentially valuable policy and programmatic interventions, These include: “personal income tax relief, care subsidies, and affordable and accessible child, community care and afterschool school care services, as well as psychological support to mitigate families’ burdens of caring for their children, older persons, and people with disabilities”. The White Paper also highlights the critical need to change perceptions of gender roles within family care, ensuring that all family members play appropriate roles and that policies are in place, such as extended paternity leave, to ensure that women’s share of caregiving responsibilities in the family are reduced, and men’s important roles recognised. Policies and programmes to support family care now need to be operationalised, implemented, and monitored. DM/MC

Prof Elena Moore is in the Department of Sociology at UCT, and was recently awarded a Wellcome Trust Career Award to develop a new research programme on Family Caregiving of Older Persons in South Africa. Dr Gabby Kelly is Deputy Director at the Samson Institute for Ageing. Her work focuses on the health, wellbeing and long-term care of older persons, as well as health and social policy for older persons and persons with disabilities.