Measuring and valuing unpaid care work : assessing the gendered implications of South Africa's home-based care policy.
The objective of this research is to reveal the implications of the choice of home- and community-based care as opposed to other policy choices and, using a gendered lens, to find a plausible way of assessing the social and economic effects of this care policy for households, families, and centrally for women. Women’s paid and unpaid work, the continuum of paid and unpaid health/care work, care work, the care economy and community care are reviewed, as well as household structure, unemployment and the provision of health and welfare services in South Africa. The costs of unpaid care provision, methods for and issues to do with measuring time-use, and approaches to valuing unpaid care work are also considered. Time-use and financial cost information obtained as part of the 2004 KwaZulu-Natal Income Dynamics Study qualitative study from 19 family caregivers of 17 terminally ill people in 16 households, is the central source of data. The qualitative study employed a modified extended case study method. The psychological, emotional, social and physical costs of unpaid care work are not counted. Instead, caregivers’ labour time spent in unpaid care work is counted and valued using four methods (average earnings, opportunity cost, generalist, specialist), and financial costs to households of unpaid care provision are also counted. In this way unpaid care work is assigned various costs, a necessary step if this work is to be included in policy making processes. The findings are not representative but make possible some speculation about home-based care in KwaZulu-Natal. Findings on financial costs suggest that the welfare grant to the poorest elderly is subsidising the health services. On average 10 hours are spent by household caregivers in unpaid care work per ill person per day, and women are accounting for the bulk of this time. Moreover, in terms of valuing, most appropriate to the poor in KwaZulu-Natal is the generalist method using the proportionate approach and median earnings rates. If family caregivers were paid for the time spent in unpaid care work and households were reimbursed for their financial costs, for 2004/5 using the low estimate it would cost approximately R585 per month per ill person for unpaid care provision that takes place seven days a week and 10 hours per day (R7,619 per month using the high estimate). When multiplied by the number of AIDS-sick people in KwaZulu-Natal, this spending on costed unpaid care provision exceeds the monthly health and welfare spending on home-based care in KwaZulu-Natal for 2004/5 of approximately R2 million by R104,025,512 million if the low estimate is used. These costs are compared to the costs of a selection of similar public and private interventions in South Africa. Without fail the costs of unpaid care provision do not exceed 26 percent of the costs of alternatives. The findings show that the home- and community-based care guidelines have inequality-creating effects: wealthier families may be able to buy in care if necessary, while poorer families have to provide this care themselves. Moreover, government is saving substantially on the health budget by limiting the provision of public inpatient care. Because of the high costs of operation of both high- and low-cost inpatient centres, as well as home-based care as delivered by NGOs/FBOs/CBOs, the potential for these interventions to deliver to all of those in need of such care, when compared with unpaid care provision, is not great from the perspective of a government seeking to cut costs. The findings show that home-based care is cost-effective for government but not for family caregivers who carry the bulk of care costs. Policy options such as payment for caregiving, the basic income grant and expansion of the expanded public works programme are presented. Since family caregivers are meeting a minimum standard of productive participation, it is argued that a citizen based model of social protection be adopted. Finally, what worked and did not work with regard to the study is used to inform recommendations for improved future research on unpaid care work in South Africa.