Dipartimento di Scienze Politiche
Corso di laurea magistrale in Sociologia e Management dei servizi sociali
Tesi di laurea
TOWARDS A NEW MODEL OF TECHNOLOGY-BASED
ELDERLY CARE? CHANGES, PERSPECTIVES,
AND CRITICAL ISSUES
IN A NORWEGIAN CASE-STUDY
Relatore
Prof. Matteo VILLA
Candidata
Gloria ZIGLIOLI
SUMMARY
Preface p.1
1 Welfare state: causes, meanings and types 5
1.1 Economic and political theories behind the welfare
state 5
1.2 Welfare State system as a complex institution: key
aspects and interacting actors 7
1.3 Categorisation of welfare state regimes 12
2 Long-term care policies. Recent evolution, critical aspects,
political and social outlooks in the European countries 17 2.1 Gender analysis and the recast of family policies' reward 18 2.2 New profiles of social risk link to the demographic
changes 24
2.3 Institutional development about long-term care (LTC)
policies in Europe 29
2.4 New resources renovating the welfare state: role, significance, application and concerns of ICTs in long- term care field
43
3 The interaction between technology and society. Rethinking the relationship in order to overcome the dilemma and make technology more socially and politically acceptable 51 3.1
Technological revolution and postmodern society. Beyond the complex equation between technical progress and social progress
53
3.2
Technology and social change dynamics in a sociological perspective: traditional W. F. Ogburn's studies and a recent space for STS approach
60
3.3 Synthesis of the major theories of technology: technological determinism, social constructivism, and action-network theory
65
4 New technologies and welfare state: general application
fields and experiences in Europe 77
4.1 Technological tools and robotics in surgery 78
4.2 Assistive technology 80
4.3 E-health debate. Evolution and implications 84 4.3.1 e-health and m-health: care-oriented information and communication technologies. Institutional and
academic definitions
84 4.3.2 Main European e-health political strategies,
documents and applications 87
4.3.3 New care technologies: a different way to think and
take care. Features, benefits and challenging issues 93
5 A specific case-study: Norway 101
5.1 Norwegian healthcare system at a glance. Balancing
tradition and course changes of recent reforms 102
5.2 LTC in the Norwegian in the healthcare services. Regulatory references, significant reforms and new practices
109
5.3 Research introduction: approach, main goals, and
methodological notes 115
5.4 Research report and data 118
5.4.1 User groups 118
5.4.2 Elderly health conditions in Norway and care services 120 5.4.3 Welfare Technology. Discussing the dynamics, the outcomes, and future perspectives in services
organization
122
a) Welfare technology: balancing opportunities and
users' need variation 123
b) Ambitious goals, small scale results 125
c) Distinguishing end-users groups 127
d) Hoping for a win-win solution 128
e) Which are the main technical and ethical issues, and
for whom? 129
Concluding remarks 135 Appendix 1 Welfare technology projects in Norway 138
Appendix 2 Frivolltun and Feviktun 140
It is not enough just to predict the problems.
It is also important to make predictions about the resources
and determine how the users' own resources can be utilised.
(Norwegian White Paper No. 29, 2012-2013)PREFACE
In the last few years, unprecedented challenges and new social risks are testing the capacity of welfare policies implemented by many European countries to provide responses to emerging needs.
In particular, the scientific and political debate gives great importance to the demographic phenomena: the consequences of aging of population and the decline in birth rates are critical, above all from a social point of view, and for welfare programs too.
The general economical and social crisis brings to the unyielding need for a recalibration mechanism between long-term care policies and public spending, as well as the recovery of different and new parameters of efficiency, sustainability and inclusion of interventions and welfare benefits. This is the framework of the wellbeing technology research path, having its theoretical references in a more elaborate welfare perspective, called welfare technology, that revolutionizes the entire public system. Generally speaking, the research originates from the following question: what makes a technology oriented towards the human well-being? That is to say, from which conditions and through which tools is it possible to create a complex system of technologies for the care of humans, that could improve their quality of life?
People often know the potential of some technologies, that end up becoming indispensable, but at the same time we have always been warned of a disrespectful use of some of them.
Thus, given the particular context in which they are used and the close connection between the person and the technology, it is important investigate how they can find contact points, ensuring user's safety and minimizing risks as much as possible. More specifically, it seems interesting to wonder how a technological welfare system can find new responses to the inadequacies of current public welfare systems.
The reflection should then also be extended to that multitude of context factors, such as political and professional culture, services' standardization, institutional rigidity, and other consolidated values and practices which can inhibit or encourage that change in programming LTC policies and in the system as well.
While generating other limits and other issues, perhaps the non-substitute but complementary use of technology to human action can provide grater flexibility and savings to the service, allowing a concrete analysis of practices to be avoided or to be modified in order to overcome the fragmentation of measures. As mentioned before, however, a more abstract reflection on the cultural, legal and ethical boundaries can not be avoided. The first to be discusses is the concept of responsibility: whom can be attributed the responsibility of robot's action? The machines need input to activate itself. Moreover, if a technological device suddenly ceases to work, then the responsibility for failing and the consequences that this implies, whom should be attributed?
Secondly, the sustainability concept is questioned, in terms of combine economic and social sustainability. On the one hand, investing in wellbeing technologies, even though initially expensive, in the long run can allow the social state to contain additional costs that make it now too much expensive.
In addition, investing in such technologies seems a functional way of prevention, which would limit the waste of resources and the delivery of overly expensive services. The issue of environmental sustainability could also arise, given the future widespread use of these technologies. From this point of view, considering the scarcity of material and economic resources that can be used, it is very important to get into the questions of the design and construction of technologies.
Closely related to sustainability, is the concept of accessibility. It is easy to imagine that the amount to be paid for having that kind of technology is particularly pricey. If people should buy it privately, important inequalities would arise according to the economic availability of each. Due of this, to avoid the coming up of further disparities, the public system should equip itself with some technological devices, making them available to those who do not have enough material resources. In fact, the ways to get hold of the technologies and the agreements that the public administration can discuss with the companies that develop them is different and more advantageous. Furthermore, investments by the public sector could be aimed at providing the care facilities of some specific technologies, in order to overcome the housing accessibility. In fact, only in large spaces and with a few obstacles,
it is possible to insert a robot and allow it to perform its functions of help and support for human life.
This last consideration, can not refer to other types of wellbeing technology, falling under the field of smart home, such as alarm devices, gas detectors, or small devices tracking the person's movements.
Finally, a wide reflection must be directed at some of the major fears and risks that the implementation of technology generates between potential users and their family, and among care professionals too.
First of all, the idea of a complete substitution of the human being and of its specific nature (for instance, empathy, interaction, creativity, emotionality, thoughtful...). Contrary to what this fear suggests, robotic technology should be considered not a substitute but complementary to human care. It has been discussed for a long time about the features that make up a good relationship of care, and there seem to be many needs and expectations. In fact, although a robot can be projected with many humanoid characteristics, it can not completely replace human's features; but it is also true that in some cases, the ongoing care or assistance relationship doesn't seem so empathetic and easy as it appears. The various complexities that embrace the bond between caregivers and people cared are changing, both in their quantitative and qualitative dimension.
For these reasons, and given the several condition of fragility, maybe an artificial aid can be used. In any case, it is important to consider and understand the implications of all possible alternatives, taking into account the differentiation of needs and the heterogeneity of situations.
Sometimes, some specific technological devices might be desired, if not even preferred, to take away all those feelings of inadequacy, embarrassment and anxiety, that often occur when a state of fragility raises, even if human ties could weaken.
In this scenario there is also the risk associated with loneliness. In fact, thinking of specific technological devices or artificial intelligence that can provide continuous help, dealing with several activities of human daily life, can lead to a situation of limited communicative, emotional and affective exchange, as well as almost the totality of the psycho-physical efforts are canceled. A situation that is already present due to improper TV or other technologies usage.
Although it is possible to create circumstances of solitude, it is good to consider that sometimes they may also be sought; and it is equally true that being a human caregiver is not a guarantee of relational effectiveness or contrast to solitude. Indeed, if the robot-person relationship is difficult due to structural features, in the case of human relationships the barriers assume different facets. In this latter case, subjects' language, culture, personality, expectations and needs play a crucial role, and they seem to be much more challenging to overcome.
Concluding, therefore, the node to be investigated is precisely the possibility of developing a technology that supports human activity and does not replace it. In particular, it would be a care-oriented technology, that does not replace the caregivers, but that helps them and reforms the way to take and give care, creating a complex of services that are more users-oriented and modern too.
The aim of the research is to investigate the field of the well-being technology, studying in particular the changes at institutional level, including services' organization through the experiences in the norwegian Agder region. However, in this thesis work, the evidences emerging from the qualitative research will only be presented at the last instance. At first, the characteristics of european long-term care policies will be debated, focusing on their different evolution and on the challenges that induce a need for transformation. Secondly, by an analytical path through the various theories that describe the relationship between social changes and technological innovations, will be presented the current social scenario, in which the implementation and development of well-being technologies could find its own important space. Thus, in the third chapter will show few consolidated experiences of well-being technology through Europe in the general area of medical treatment, getting into the specific e-health field. As mentioned before, the last section is about the special case of Norway: its welfare state, with the focus on aging population and long-term care policies, in which welfare technology experiences rise, changing the way to provide care services.
CHAPTER 1
Welfare state: causes, meaning and types
The chapter aims to present a general theoretical analysis focusing on the different welfare systems. It appears essential to establish an overall framework based on the social policies evolution timeline for a better comprehension of existing policies and transformations across Europe. This logical step from the general to the specific is motivated by the preliminary need to clarify the main distinctive features of each identified welfare system, as they are linked to the dominant cultural values, that consequently shape the strategies implemented by the government to deal with risks and individual needs. Indeed, in every country, distinctive system of welfare state emerged, in response to different economic, political, institutional and social changes which took place in the last centuries. During the recent years, particularly, the presence of new emerging social risks (among all the one of becoming reliant on care, tied to the increasing of ageing population) refers to the need to upgrade the existing structure of welfare policies. Thus, only after reviewing some fundamental concepts, the understanding of long-term care policies' development and transformation should appear clearer and more straightforward.
1.1 Economic and political theories behind the welfare state
The first step to be taken is to clarify what is meant by “welfare state”, and some of its explanatory factors.
In one of the most important reference works dealing with the analysis of the welfare state, Esping-Andersen (1990: 1-2) highlights that
The welfare state has been approached both narrowly and broadly. Those who take the narrower view see it in terms of the traditional terrain of social amelioration: income transfers and social services […]. The broader view often frames its questions in terms of political economy, its interests focused on the state's larger role in managing and organizing the economy. In the broader view, therefore, issues of employment, wages, and overall macro-economic steering are considered integral components in the welfare-state complex.
In this first chapter the welfare state will be discussed adopting the broader approach, because the attempt to explain it in its complexity and differentiation can not be addressed by considering only the size and the amount of social benefits that constitute it. Indeed, given the broader view mentioned above, the concept of “welfare capitalism” used by Esping-Andersen (ibid.) is preferred, due of the deeper implications of welfare on the capitalist economy (Ranci & Pavolini, 2015: 27). Following the interpretative theory discussed in the structuralist approach to welfare state, it seems that “its birth and expansion is grounded in the capitalist systems”1: the instability of the capitalist economy, requires significant state
intervention, through public expenditure to support citizens' income, to tackle unemployment and to redistribute income more equitably (ibid.).The requests for greater protection and safety emerging with the modernization process, had as main answer the practice of state intervention in economic matters for regulatory purposes, that Asa Briggs emphasizes to be “deliberately used […] in an effort to modify the play of market forces” (Briggs, 1961: 228). The role and the actions that the market in the capitalist economy intends to achieve for its protection, engender poverty, social risks, as well as inequalities. Thereby, Briggs (ibid.) continues, the welfare state functions
In at least three directions – first, by guaranteeing individuals and families a minimum income […]; second, by narrowing the extent of insecurity by enabling individuals and families to meet certain “social contingencies” (for example, sickness, old age and unemployment) […]; and third, by ensuring that all citizens […] are offered the best standards available in relation to a certain agreed range of social services.
The contradictions of modernization create the conditions for the welfare state's development, namely as Esping-Andersen (1990: 13) has argued “the industrialization makes social policy both necessary and possible […] as the modern industrial economy destroys traditional social institution”. Nevertheless, several scholars questioned this perspective, highlighting the importance of institutional dynamics (alongside the economic and political ones), foundational to the process of welfare state evolution (Ranci & 1 Translation by the author
Pavolini, 2015: 38) that consolidate over time a new idea of state and relationship with citizens, associated with new responsibilities and duties for both of them. Such change in pattern, establishes “specific social rights when pre-established events occurs, as well as contribution obligation” (Ferrera, 2012: 17)2. The institutional approach is the core of an important
study conducted by Flora and Heidenheimer (1981: 22-23) in which they contend that the modern welfare state was not only born from “the transformation of the absolutist state into mass democracy […]. With the structural transformation of the state, the basis of its legitimacy and its functions also change”. Among the main determinants promoting the development of welfare state, arises “the legal or de facto enactment of parliamentary responsibility” (ivi ). Indeed, the extension and redefinition of political and social citizenship, through the stages that Rokkan (i v i ) distinguishes as participation (to the construction of the state in a democratic form, granted to all population groups to be represented), and a s redistribution (of resources, goods and benefits for the equalization of economic conditions), are essential conditions for the establishment of welfare systems. Moreover, another important stage is the so identified as nation building : in fact, the welfare state is a political and administrative system, institutionalised in accordance with the establishment of national states (i v i ; Kazepov & Carbone, 2007). The words of Esping-Andersen (1990: 32) on that are relevant: “The historical forces are interactive. They involve, first, the pattern of working-class political formation and, second, political coalition-building in the transition from a rural economy to a middle-class society”. Finally, both contributions, at least briefly, help to understand part of the complexity in investigating social policy field. In conclusion, a multifactorial reading is necessary, aimed at considering the positive or negative interaction of the economic, political, institutional and social dimensions on the welfare state.
1.2 Welfare state system as a complex institution: key aspects and interacting actors
The “welfare state” is the set of public policies having as main purpose the wellbeing of citizens, pursued by implementing actions to protect against
the main social and economic risks, and by combating social and economic inequalities, promoting equal opportunities among citizens through coordinated services and benefits that promote better living conditions (Ranci & Pavolini, 2015: 20). The so labelled “new raison d'etre” of welfare state is “the provision of secure social services and transfer payments in a standard and routinized way that is not restricted to emergency assistance” (Flora & Heidenheimer, 1981: 23). Alber (1988: 451) claims that “a welfare state can be defined as a polity in which state responsibilities extend beyond the mere maintenance of internal order and external security to a public responsibility for the well-being of citizens”. The interventionist function in the market dynamics and distributive function “to provide a more equal distribution of material rewards and life chances” (ibid.) that the state should perform are the identifying features of a welfare state in the strict sense of the term. Thereby, Esping-Andersen (2002: 6) explains effectively:
The core welfare issue is not so much how many people at any given moment are low-paid or ill-housed, but how many are likely to remain persistently low-paid or ill-housed. Our society will probably not be able to avert that some people, for some period of their lives, will encounter social ills. […] The foremost challenge we face is to avert that social ills become permanent, that citizens become entrapped in exclusion or inferior opportunities in such way that their entire life chances are affected.
The definitions so far expressed, seem to represent a welfare system architecture based entirely on the government activities. Of course, the government's role in welfare production is primary, even if a broader and more rigorous definition must consider the whole of interventions related to the welfare state as the set of actions implemented by public, private actors, and no-profit organizations as well (Naldini, 2006: 21).
Every welfare model, in fact, has its particular working principles, which mainly follow “the division of responsibilities between markets, families and government” (Andersen 2002: 11), considered by the same Esping-Andersen (ivi ) as the “three welfare pillars”. The interdependence among them helps to make sure that “the family, just like government, may in theory absorb market failures; similarly, the market (or government) may
compensate for family failure” (ivi ). In the same way, Ferrera (2012: 14), in an attempt to represent the complexity of synergistic actions which contribute to shape a welfare system, graphically recurs to a quadrilateral called the “diamond of welfare”. As can be seen in the picture 1.1, in addition to the fundamental elements already identified by Esping-Andersen, a fourth producer of welfare emerges: associations.
Pic. 1.1 Diamond of welfare
Source: Ferrera, 2012
As will be seen later, the main distinctions among the various welfare state models consist essentially in assigning a greater or lesser weight, both in terms of responsibility, but also of resources, to the aforementioned elements. In particular, the different layouts generated by the reciprocal and interdependent relationship among those main agents represents the touchstone on which, according to Esping-Andersen (1990: 3) is possible to identify “three highly diverse regime-types, each organized around its own discrete logic of organization, stratification, and societal integration”. Basically, “what involves the system of formal and informal relations among
the four vertices, is labeled welfare's system” (Ferrera 2012: 14)3.
Although, the three pillars or the four spikes of welfare always contribute in different proportions and with different tools to the social protection system, the difference among the various welfare regimes is in the political choice to consider one of them as main or more adequate in contrast to the risks and needs that individuals face in their life. As pointed out by Esping-Andersen (2002: 13) :
Neo-liberals advocate the primacy of markets (and usually ignore the family), while conservatives favour more family and local community social responsibility. And social democracy's long-standing preference for collective solutions is anchored in its fear that both the family and the market alternative offer insufficient security while fostering inegalitarian results.
The types of schemes identified by the danish author, in addition to relying on the properties of the welfare state programs, refer to two important indexes: that of de-commodification, and de-stratification, to which he subsequently adds that of de-familization. In this respect, Esping-Andersen (1990: 2) asserts: “The existence of a social program and the amount of money spent on it may be less important than what it does. […] Issues of de-commodification, social stratification, and employment are keys to a welfare state's identity”. The former means the degree of individuals' dependence on the market, otherwise stated, using the words of Esping-Andersen (ivi ) “when a person can maintain a livelihood without reliance on the market”. Obviously this depends on the width of social benefits, that is to say the degree to which citizens of a specific welfare regime “can freely, and without potential loss of job, income, or general welfare, opt out of work when they themselves consider it necessary” (ivi ).
The term de-stratification is used to answer the question concerning the power of reverse to inequality, promoted by social policies. However, reading the words of Esping-Andersen (i v i ) “we can easily identify alternative systems of stratification embedded in welfare states”. Following his analysis, this means that the welfare state is a system of stratification as well. Certainly, in a different way and causing more or less significant 3 Translation by the author
disparities. In particular, the various forms of stratification reflect the enforceability's criterion of the social rights which lie behind the assistance, insurance or social security schemes at the base of public interventions. The assistance approach to public intervention is characterized by services destined to specific (target) categories of beneficiaries and subject to means-test. ”Social assistance policies are selective and residual” (Naldini 2006: 25)4.
These characteristics, associated with the discretionary choice that the public sector has in providing social benefits, “promotes social dualism, punishing and stigmatizing recipients” (Esping-Andersen 1990: 24).
The social insurance model, introduced for the first time in Germany, during Bismarck's conservative period, and pursued in Italy as well, is also labelled “employment”. This is because the main recipients are “male breadwinners” (Ferrera 2012: 42). People entitled to the benefits (e.g. insurance against sickness, accident, old age, and unemployment) must previously fulfill a contributory duty. According to Esping-Andersen (1990: 24), this model, in terms of stratification, consolidates “divisions among wage-earners by legislating distinct programs for different class and status groups”. And more, he notes (2002: 15) that “work-conditional benefits may produce unwanted externalities, such as downward pressures on wages. […] One result may be to relegate lower income households to the status of second-rate welfare citizens”.
The last way in which the welfare state takes shape is through social security scheme. Opposed to the German tradition mentioned above, it is also called the “via inglese” (Naldini 2006: 28) (english fashion5), given the
historic Beveridge Report. It wanted to achieve the idea and practice of considering all citizens as the recipients of the main social benefits (healthcare first). A social protection scheme was thereby implemented, based on the universalism, guaranteeing equal performance for everyone, irrespective of their status and contribution, while for direct monetary transfers it set “a national standard to lead a dignified life” (Ferrera, 2012: 21)6. However, although this system aims “to cultivate cross-class solidarity
[…] flat-rate universalism inadvertently promotes dualism […] similar to that 4 Translation by the author
of the social-assistance state: the poor rely on the state, and the remainder on the market” (Esping-Andersen 1990: 25).
This three-way split shows three ideal types, in the Weberian sense: there are not, except for very few cases, countries that present purely and integrally only one of the three cases for all public welfare policies. In every country, in fact, more social protection schemes coexist, even if it is possible to find a greater tendency of institutions to prefer one model rather than another. In this respect, the argument is not distinctly political or economic, but is also strengthened trough the traditions, values and the culture of each country.
Thus, once again, the complexity of the arrangements among economy, politics and welfare emerges, underlying the various welfare regimes. 1.3 Categorisation of welfare state regimes
Starting from the consideration of specific comparison stones, various classifications of welfare system have been produced. Highlighting certain welfare's aspects rather than others, however, very different national welfare systems emerge. Following the comparative analysis of Esping-Andersen, three welfare-state regimes are identified: which are, “three worlds of welfare capitalism” (Esping-Andersen, 1990).
In the first cluster, whose archetypal examples are US, UK, Ireland, Canada, the means-tested assistance scheme and social-insurance plans are predominant, with the exception of the national health system. However the benefits are modest, and often the recipients of the main public services are stigmatized. The de-commodification index is low, encouraging individuals to rely on market and private welfare provision. At the same time, the state has a marginal role, creating a dualism between beneficiaries relating to the state, and market-welfare recipients (Esping-Andersen 1990, 2002; Ferrera 2012).
The conservative regime-type, also considered “strongly corporatist” (Esping-Andersen 1990: 27) is widespread in continental European countries such as Germany, Austria, and France. It is the regime in which insurance schemes are dominant and there is a strong link between employment (belonging class) and rights. In particular, “employment-linked social insurance protects well those with stable, lifelong employment […] it
offers inadequate security for those with a tenuous connection to the labour market” (Esping-Andersen 2002: 16).
Basically it produces a dualism between “privileged insiders and precarious outsiders” (ivi ). At last, the state's role is defined according to the “principle of subsidiarity” (Esping-Andersen 1990: 27): its intervention is residual and determined by unsuitableness of other providers such as individuals themselves, family and associations in being able to cope with situations of risks, and necessity. Italy, which Esping-Andersen included in this regime-type, due to some of its specificities, was considered in a posthumous analysis conducted by Italians academics, as a typical country of the so labelled “quarta europa sociale” (Ferrera, 2012: 43) (fourth social Europe7),
together with other countries of southern Europe. Despite having some of the distinctive features of the countries related to the conservative model, such as the dominance of social insurance schemes, this pattern is characterized by a strong tradition of family solidarity, “(stateness)” (ivi ) and a deranged labor market, in which the presence of (black economy8) is
significant (i v i ). On one side, “welfare states have either relied on continued family support” (Esping-Andersen, 2002: 17), investing it with responsibilities and obligations that do not always find effective responses, which by the way “negatively affect women's search for economic independence” (ivi ). On the other side, the rigid structuring of the labor market combines “strong protection for the stably employed […], inadequate security for workers with irregular careers […] with huge barriers to labour market entry” (i v i ). It is in the scenario just described that Ferrera (2012: 48) offers the concept of functional bias9, by specifying the
attitude to disproportionate expenses, covering the age-related risk and underestimating the risks and needs expressed at other periods of life. Consequently, the family fulfills a function of safety valve10, partially
mitigating the level of de-commodification; while social policies provide “an ineffective response to social exclusion” (Esping-Andersen, 2002: 17). The different duties that the family exercises, according to the tradition of solidarity, or in response to the deficits of public intervention, establish its 7 Translation by the author
8 Translation by the author 9 Translation by the author
importance as a real welfare institution in the countries of southern Europe. A further aspect that distinguishes the countries of Mediterranean Europe is the introduction of a public healthcare system with universalistic scope and the experimentation of services in the form of fixed-sum monetary transfers in contrast to poverty (Ferrera, 2012: 44), so as to create a blended model of public intervention (Ranci & Pavolini, 2015: 71). Finally, the presence of the Catholic Church especially in Italy, is “strongly committed to the preservation of traditional family-hood” (Esping-Andersen 1990: 27).
The third regime-type is defined social democratic and it is the welfare model typical of the Scandinavian countries: most social protection schemes are founded on the principles of universalism, as “all strata are incorporated under one universal insurance system” (ivi ). It is “unique in its emphasis on the government pillar” (Esping-Andersen, 2002: 13), the reason why the de-commodification index is high. This kind of welfare state seeks both to minimize the dependence of individuals on their value and power in the market; and to maximize “citizen's employability and productivity” (ivi ). Likewise the index of de-stratification is high, since the nordic welfare state “would promote an equality of the highest standards” (Esping-Andersen, 1990: 27), “grants transfers directly ant takes direct responsibility of caring” (i v i ), guaranteeing the entitlement to the social benefits to all citizens, regardless of being in need or workers (Ranci & Pavolini, 2015: 70). In such a way, citizens living in these countries get economically generous benefits, as well as they can enjoy “highly developed services for children, the disabled, and for the frail elderly” (Esping-Andersen, 2002: 14). Indeed, compared to previous regimes, the Scandinavian model “via its de-familialization” (ibid.) enhances individual independence, especially by allowing women to combine work with home commitments, without necessarily having to make an exclusive choice between them, thus consolidating the so labelled “dual earner model” (Ferrera, 2012: 42). In this respect, the words of Esping-Andersen (1990: 28) are significant, as outline that “the social democratic regime's policy of emancipation addresses both the market and the traditional family”. Inevitably, a universalistic welfare system aimed at maximize inclusion has enormous costs of maintaining, but it just as “well positioned to face the exigencies of post-industrial change” (Esping-Andersen, 2002: 14).
The analysis should be brought to fruition by identifying the fifth social Europe11 (Ferrera, 2012: 45), or that cluster including the countries of
central-eastern Europe. Their particular historical events delayed their adhesion to the European Union, hardening the transition to democracy and the market economy (ibid.). The welfare state of these countries is an hybrid system, combining both the occupational and the liberal approaches within it, although the liberal component was mitigated by the acquis communautaire (ibid.).
The regimes' categorization of Esping-Andersen, to which are added two “social Europe” discussed by Ferrera, seem to provide a rather complete picture of the European welfare states (but not only, because the danish author extended his analysis to the OECD countries). In each cluster are mentioned several national cases that, as explained previously, do not appear identical but share some substantial characteristics for which it is possible to pick put them as liberal, conservative, social democratic or familistic. But is ought to recognize that no pure cases exist.
“The Scandinavian countries may be predominantly social democratic, but they are not free of crucial liberal elements. Neither are the liberal regimes pure types. […] And European conservative regimes have incorporated both liberal and social democratic impulses” (Esping-Andersen, 1990: 28).
This is especially evident during the moments (as it is happening in these years) when the welfare systems go into crisis showing their structural deficiencies (Ferrera, 2012: 53). These circumstances involve a greater fund of knowledge and recognition of new risks and needs, giving life to more and more mixed welfare state regimes. Moreover, in these phases of economic crisis, huge public budget deficits and continuous transformations, the welfare state's ability to resist and respond effectively to old and new risks, is compromised. The most widespread keyword in the recent years among political decision makers and some scholars, appears to be that of the “retrenchment” (Ranci & Pavolini, 2015: 85), which indicates the strategy undertaken by the governments of reduction and cuts in social spending. However, to this neoliberal approach that sees in a rigid policy of austerity the only and most efficient way currently practicable, there is now an opposed perspective, defined “social investment” (i v i ). “These ideas
developed partly as a critique of neoliberalism” (Morel et al., 2013: 6), conceiving a more positive theory of the State (Giddens, 1998; Morel et al., 2013). The reforms inspired by Social Investment are distant from those approaches to reforms focused on the deregulation of the labor market and on the reduction of social spending. The SI new orientation for social policies aimed to modernized the welfare state for better dealing with the new social risks and the transformations of modern societies, such as ageing population, more precarious forms of works, and still unsolved pressures for reconciling work and family life. In particular, this approach “is geared towards ensuring that the returns to social expenditures are maximised, in the form of active employment and social participation, social cohesion and stability” (Van Kersbergen & Hemerijck, 2012: 476). Furthermore, “the State is assigned a key role in fostering the development of human capital and in providing the necessary services and benefits to help make efficient use of human capital and to avoid human capital depletion” (Moreal et al., 2013: 7). In the reading of Esping-Andersen, one of the first to be interested in Social Investment (since the famous 2002 text “Why we need in new welfare state”): “it is basically assumed that social outlays are an unproductive, yieldless consumption of a surplus produced by others […] The need to rethink our social accounting practice is gaining urgency” (Esping-Andersen, 2002: 9-10). According to him, social policies should be seen as an essential productive factor for the economic development. Indeed, the main investment that welfare systems should take is in future human capital: “educational expenditures yield a dividend because they (may) make citizens more productive”, declares Esping-Andersen (ibid.). Reforming actions in the direction of a substantial strengthening of policies for education, as well as for the activation of workers and the promotion of childcare services are the most significant examples to which the system has to invest (Ranci & Pavolini, 2015: 89).
In such a way, “a new synergic link between welfare and economic development”12 (ibid.) is proposed. Although many efforts are still
necessary, the conviction that the SI strategy is one of the best possible pathway “for welfare state adjustment and the expectation that in the longer run this will pay off in terms of economic and social achievements, is 12 Translation by the author
still, by and large and in spite of the financial and economic crisis, intact” (Van Kersbergen & Hemerijck, 2012: 476).
CHAPTER 2
Long-term care policies. Recent evolution, critical aspects,
political and social outlooks in the European countries
In recent decades, the needs of the economic and social systems have changed, and the increasingly alarming and widespread presence of so-called “new social risks” requires welfare systems to provide different answers. The so-called new social risks are understood as “situation in which individuals experience welfare losses and which have arisen as a result of the socio-economic transformations […] generally subsumed under the heading of post-industrialisation” (Bonoli, 2007: 497). Long-term care for elderly people is one of them, but it can not be considered separate from other sectors of the welfare state, for example programs and interventions for the reconciliation of care and work. A brief presentation of the main changes occurred in this area will be functional to addressing the LTC policies discourse more comprehensively. Ranci and Pavolini's comparative study on the policies and the practices related to LTC among the different regime-types of welfare state will be presented here. Although it cannot be possible to cover all aspects of all countries, the aim of this chapter is to show the general background and the reforms that have taken place in LTC during the last decades, based on new social risks and pressures that the whole system is undergoing. Above all, the impact of the demographic crisis on the welfare system and the society organization as well is alarming. The welfare state caring regime is in a particularly critical position, entailing significant consequences both for formal and informal caregivers. Therefore, many discuss the possibility to employ certain technologies – which fall into the umbrella term of caring technology or welfare technology – to cope with that issue, increasing the elders' quality of life. Their potential, as well as the limitations and perplexities are numerous, and they do not only concern economic or political aspects, but also include cultural and ethical dimensions. The development and the implementation of technology isstrongly grounded in both historical and cultural fields. Indeed, may be important to consider the value system referring to the family and care, as well as few general situational variables, such as the conditions of the labor market and the participation of women.
2.1 Gender analysis and the recast of family policies' reward The analysis of the LTC policy field necessarily includes elements that are not purely related to “caring”, but also those that in some way influence or are influenced by it. Above all, it refers to gender issues, and to family policies, which consequently also affect the composition of the labor market. However, the institutional commitment and the different combination of policies in the above mentioned areas alone, are not sufficient to decline the whole sector of the LTC policy. Even more it is a duty to consider the role and the implicit action of values and traditions spearheading the individual and collective approach to matters of care. All of these factors are feeding back on themselves, generating a system that is not only and exclusively the result of purely political choices.
First, the gender perspective in welfare studies has shed light on the implications generated by the various care systems adopted by each country, both in fostering or discouraging women's access to the labor market, and in the concrete possibility of reconciling employment and family responsibilities (Naldini, 2006: 55). “The operation of LTC systems clearly has an impact on social inequality, particularly in terms of gender” (Pavolini & Ranci, 2013: 51). The existence and wide dissemination of the so called “women-friendly” policies are important as they would allow to undermine the traditionally diffused idea among most European countries (with very few exceptions) according to which “caring capabilities were “natural” or inherent in women” (Saraceno, 2008: 1). Indeed, as pointed out by Pavolini and Ranci (2013: 7) “caring […] was not only considered as a moral obligation to be shared by families and society, but it was also constructed as the responsibility of women rather than men”. Thus, the family, and especially the woman as a part of it, has traditionally absorbed the tasks and responsibilities about care. As care was, and in some contexts is still, considered as a “labor of love” (expression used by Finch and Groves in 1983, sounding like an oxymoron), this leads that often the intra-family
care work has not received the appropriate legal and economic appreciation, pushing women to second-class status. Indeed, the founding presupposition of all modern European welfare states, is the reference to a male breadwinner family model: an ideal type that clearly separates the roles and responsibilities between men and women; the first ones engaged in the labour market, while the latter manage the housework commitments. Such a model assumes different forms among the European countries, due of a greater or lesser force of it. Summarising the work of Lewis and Ostener, dating back to the end of the last century, it is possible to distinguish a first group (states such as Germany and UK) marked by a strong male breadwinner model, that is closer to the ideal type; another one defined moderate (including France) in which the position of women both as workers and as mothers is recognized; and the last cluster labelled weak male breadwinner (popular especially in the Scandinavian countries) that admits rights to women regardless of their being mothers or wives (Naldini, 2006: 49-50). Historical and social developments are showing a surpass in the assumption according to which the married women “would withdraw into housewifery”, also because “women themselves increasingly insist on greater economic autonomy and professional development” (Esping-Andersen, 2002: 20). As a result, even at the political level, since a few years the question of “women-friendly” policy is growing up, returning the gender equality issue at the centre of public debate, with the purpose “to create a new and more egalitarian equilibrium between men's and women's life” (ibid). Notwithstanding, the responses generated by the most European countries to this social challenge are not always suitable and adequate. Indeed, as Esping-Andersen (ivi ) noted: “It is clearly difficult to reverse centuries of acquired behaviour, and the search for an immediate patent solution would probably be futile”.
Secondly, family policies “are politically sensitive and were even more so in the turbulent 20th century of European history” (Sundstrom et al., 2008:
237), and they represent a notably relevant welfare's field also for caring. The female contribution in caring for both children and elderly members of the family, has always been decisive and often considered as an obligation, thus reducing their job opportunities. The issue of paid work and family care reconciliation was explored in numerous bibliographic and empirical studies,
and “it is commonly though that many women are “squeezed” in multiple roles: caring for frail parents, working and at the same time providing for family and small children” (ivi ). Particularly, it appears more difficult “for family members to reconcile their caring responsibilities with paid employment when their older relative has more extensive care needs” (Pavolini & Ranci, 2013: 51). Additionally, the ongoing challenge “to make parenthood compatible with a life dedicated to work and careers as well” (Esping-Andersen, 2002: 20) is one of the main to deal with.
Always the role of the State, expressed through laws, regulations, incentives and taxes, was also, in a sense, a way “to monitor and influence family life” (Sundstrom et al., 2008: 237). In recent years, welfare programs have given centrality to the care issue. Indeed, as already stated, in most countries the care needs of the elderly have been considered a family matter. However, the new social risk of long-term care as well as the social investment trajectory – see paragraph 1.3 – “have turned the private issue of care into a public concern” (Morel, 2006: 227), also trying to ensure new balances between motherhood, family responsibilities in general and employment, in order to promote full women's occupation, as well as supporting birth and fertility rates (Saraceno, 2008; Ciarini, 2011; Ranci & Pavolini, 2015).
In accordance with Chiara Saraceno (2008: 20)
The need to develop policies of reconciliation between family responsibilities and participation in labor market becomes important in conjunction with the expansion of female
employment. Such a positive trend deserves to be supported both on a political and cultural level.13
Esping-Andersen (2002: 19) recommends “rewriting the Social Contract”, given the mutation of at least two conditions that were among the basis of post-war family policy. Indeed, the dominant family structure of the past is no longer valid, and the increase in female employment requires new caring institutions (ibid.). Thus, a new family policy is urgent because “the ongoing gender revolution is both irreversible and desirable” (ivi ).
The male breadwinner model family seems to erode itself (Saraceno, 2008: 13 Translation by the author
4) leaving space to the dual adult worker model (Ranci & Pavolini, 2015: 103), even if there is not a real respective “increase in men's care work and housework” (Saraceno, 2008: 4). Indeed, except for the Scandinavian countries that are the closest to a dual-earner family model, “supported by the state via paid parental leaves and extensive formal care services” (ibid.), the most widespread trend shows polarized situation in Southern Europe (women who are working or not employed at all), and the emergence of a “one-and-a-half” earner model in north-western Europe (ibid.). Therefore, this simple overview reveals a general increase of the female employment in western Europe, although it is largely part-time. The following 2.1 table (European Commission, 2011) shows the percentages, grouped by age and divided between males and females, related to the reasons of part-time employment. In this context, the interesting evidences to underline are those relating to women.
Table 2.1 Options warranting part-time employment in EU (%)
Source: Eurostat, 2011
A first glance suggests a higher percentage of male workers than female ones.
Moreover, focusing on the option defined “lookingafterchildren/incapacitated adults” in the first group age (15-64), there have been significant differences: the percentage points referred to women are four times higher than men. Not least, if the second group (50-64) is also included, it is clear that most of the women who take care of their in-need family members (as are the children and the elderly) are at a rather young age, the one that should be “planned” for seek employment or carry on own occupation, thus allowing independence and autonomy. Based on EUROFAMCARE statistics report, Sundstrom et al., refer that “in country like Sweden […] it is
estimated that one employee in five is also a carer. British strudies report that between 14% and 19% of the workforce have caring duties and German estimates indicate even higher gifures at about a third of the employees” (Sundstrom et al., 2008: 261).Thus a large amount of care work still remains in the family, but innovative elements emerge which outline a different system of social policies in the direction of a more adequate redistribution of care responsibilities between family and public intervention (Ciarini, 2011: 257). The ascending level of “care going public” means that the provision of specific care services is formalised as part of the provided social care package (Saraceno, 2008: 8).
Going back twenty years, Anttonen and Sipila (1996) conduced a study on the theme, mapping out different welfare models based on available care services, both for children and for the elderly.
The evidences contain different “caring regimes”, considered as institutional forms of services provision or support. “Care regimes have been firstly defined in relation to the extension of State responsibility to provide care in contrast with family obligations” (Pavolini & Ranci, 2013: 10). Basically, the author “distinguished between Scandinavian countries (where care is made available to people by State) and continental countries (characterized by the privatization of care)” (ibid.). Furthermore, the study compared to the composition of services, as well as in their levels of coverage: some countries had good services for older people but not for children, and vice versa (Naldini 2006: 56). Further and more recent comparative studies have found (Saraceno, 2009), most European countries provide financial aid and measures for reconciling professional life and houseworks, mainly through parental leave (for childcare) and specific facilities (both for childcare and elderly care), cushioning “the strong contrast between state-led regime, and family-led regime” (Pavolini & Ranci, 2013: 11). However, although several countries (it would be possible to say all Europeans) have recognized the legal right to take a leave, among them there are important variations between paid or unpaid and in term of time restrictions (Sundstrom et al., 2008: 260). Without going into the details of each of the policy instruments that followed the significant reforms occurred in the last few years, it should be emphasized that they have led to a decisive extension both on the side of monetary transfers' measures and on that of public services (Ranci &
Pavolini, 2015; Saraceno, 2009; Ciarini, 2011). In particular, in regard to the childcare, it is interesting to underline the role of parental leave, added to the maternity and paternity leave (usually shorter). Nowadays, such a new policy instrument are split between mothers and fathers, with the purpose to encouraging men to take greater part of responsibility in the family, directly affecting the division of care work. According to Saraceno (2009: 10-11), “it is the more recent innovation, reflecting the increase of the women's presence in the labor market”.14 As it had already been
partially discussed following the Esping-Andersen categorization (in the first chapter), the concept of “de-familisation” becomes important by specifying to what extent the welfare system is able to reduce the members' degree of dependence on their families, and the way in which the caring issue has been solved (Esping-Andersen, 2002; Naldini, 2006). The resulting continuum reveals at the two ends situations of familisation and de-familialised models, also identifying two intermediate points, one called financially supported familisation; and the other of optional familism (Saraceno, 2009: 25-26). These recent developments allow Saraceno (2008: 4) to raise the issue in terms of “re-familisation of men and de-familisation of women”. Actually, she continues “state sponsoring of fathers' care via paid parental leave schemes is a novelty, and represents, at least in principle, a radical re-definition of caring obligations and rights, as well as a form of re-familialisation of men” (ivi ). Instead, the analysis of the main political instruments and programs introduced to deal with the care-dependent older people will be dealt with more extensively in the following paragraph, focused on long-term care policies.
Concluding, as Saraceno (ivi ) synthesized:
[...] the many threads which make up the relational, symbolic, political and practical tapestry of care and caring relationships have been progressively unraveled […]. In this process, different actors have emerged, both on the side of caregivers and of care receivers. Interests and conflicts of interest have been acknowledged, named, and contrasted. Locations of care giving and care receiving ha been identified. And there is increasing debate about the rights and
responsibilities both of the care dependent and of care providers.
Currently, and more and more in the future it is clear that “we must recast the nexus between work, welfare, and the family. […] Women's employment improves family welfare and at the same time […] means improving the collective welfare of society at large” (Esping-Andersen, 2002: 20).
2.2 New profiles of social risk link to the demographic changes The recent inter-European diagnoses define the incoming challenge of population ageing. In fact, the demographic process that is appearing in several European countries is socially and politically relevant.
It includes various elements, among which the change in the composition of the population that is progressively getting old, and the decrease in the birth rate, contributing to transform the shape of the population structure. Ageing is bound to have a strong impact in various sectors of welfare state. In particular, public administrators will be required to take measures in the pension field, and to provide increasingly adequate and complete responses in the case of social and health services, as it will be seen later in detail. As indicated in the figure 2.2 (source Eurostat, 2017)15, the forecasts for the
near future up to over half century, show a considerable increases in the 80+ and 65-79 age groups, coupled with a corresponding reduction of working-age persons (15-64 age group).
Fig. 2.2 Projections on the composition of the EU population (%)
Source: Eurostat, 2017
The development referred to the growth of the number of elderly people, explained by increased longevity, is defined as “ageing at the top” of the population pyramid. Otherwise, the process known as “ageing at the bottom” is referred to the assessment of the fewer births, that leads to a decline in the proportion of young people in the total population (ibid.) . Longevity, although it represents the progress of medical research and the result of a general improvement in the economic and social conditions of the entire population, it is also combined with the presence of various diseases and chronic conditions. To summarize, a precedent European Commission (2011: 7) document remarks:
A steady increase in life expectancy across the EU during the last century led to increased longevity, while in more recent decades – from the 1970s onwards – the EU has experiences falling fertility rates. These two developments impact upon demographic ageing, a process that has become established in the EU in the last 30 or 40 years and which is expected, by many, to become further
entrenched during the next half century, as the absolute number and the relative importance of the population of older persons continues to grow.
A broader look requires to mention the ratio of elderly population against the one of the working-age persons. As a result of the population movement between age groups, the EU-28's old-age dependency ratio is projected to almost double from 29.3% in 2016 to 52.3% by 2080, as the projection shown in the figure 2.3 (source Eurostat, 2017)16.
Fig. 2.3 Projected old-age dependency ratio, 2016-80 (%)
Source: Eurostat, 2017
“In the midst of economic upheaval” (Esping-Andersen, 2002: 2) these adverse demographic conditions trouble individuals, families and governments as well. While, on the one hand, scientific and medical progress has allowed a considerable increase in life expectancy, causing important revolutions both in the individual and collective attitudes, it is equally true that the key element to which politics, as well as society itself should look, it is represented by the general living conditions that will be experienced during old age (which are often critical and of distress). The two components, the first of increasing life expectancy, and the second of good quality of life in old age, are not said to go hand in hand. The “good health” concept is very extensive, encompassing lifestyle and other relational, economic and environmental aspects. Conversely, from a strictly medical, health point of view an indicator of healthy life “it is based on the concept of disability-free life expectancy” (European Commission, 2011: 28).
The data in the following table 2.4 (OECD/EU, 2016: 59) retrieve the entanglement among these items.
Fig. 2.4 Life expectancy (LE) and healthy life years (HLY) at 65, by gender, 2014
In the analysis of welfare state in this precise historical phase, the concept of life expectancy is not so relevant as life expectancy in good health.
In fact, living longer does not necessarily entails meeting old age in good health. “One projection which does have a potentially significant impact is the number of people with chronic illnesses” (NORDEN, 2014: 5).
Indeed, in most European countries, ”the number of elderly people with chronic diseases increases, putting at risk the most significant condition that characterize a good quality of life, that is independence”17 (Istat, 2010: 24).
Other forecasts state that “during the coming 25-30 years the number of people suffering from dementia will double, and other chronic illness like diabetes […] have similar gloomy predictions” (NORDEN, 2014: 5).
It is a real “epidemiological transition”18, which sets new priorities alongside
the extension of life expectancy. Among them, surely, it appears the issue related to the healthy life and that of the development of patients' autonomy (Farmafactoring, 2015: 45).
Looking at the fig. 2.4 in all countries life expectancy is higher for women, with important peaks between 22-23 points reached in Italy, Spain and France; although generally the number of healthy years for both sexes does not differ significantly (at most one point). Furthermore, the highest ratios were recorded in the Nordic countries, while for example Italy, as well as other countries of Mediterranean Europe and Eastern Europe register lower proportions. This means that older people in these countries, with more frequency will encounter situations of illness and unease, thus reducing the life years in good health, or manifesting situation of reliance and fragility. However, “frail elderly people's need for care is not attributable to a particular age, if not as a statistical risk. Its emergence and its closure are not predictable in advance”19 (Saraceno, 2008: 16).
It is precisely in this sense and for this reason that since the 1990s “LTC emerged in the public discussion, when population ageing became a more widespread and growing problem” (Pavolini & Ranci, 2013: 6-7). As Esping-Andersen (2002: 24) states: “increased life expectancy means also a major challenge to health care systems and growing demand for services to the frail and disabled”. In particular, the so-called long-term care (LTC) defines 17 Translation by the author
a form of personal care and health care of a continuous nature (Pavolini & Ranci, 2013: 3). By uniform definition of international institutions (European Commission, 2015: 142; OECD, Eurostat, WHO 2017; European
Commission, 2017: 128-129) and according to Pavolini and Ranci (2013: 3) Long-term care is […] defined as a range of services required by
persons with reduced degree of functional capacity (physical or cognitive) and who are consequently dependent for an extended period of time on help with basic and/or instrumental activities if daily living (ADL), such as bathing, dressing, eating, getting in and out of bed or chair, moving around and using bathroom. The personal care component is frequently provided in combination with help with basic medical services such as […] medication, prevention, rehabilitation or services of palliative care. LTC services can also be combined with lower-level care related to help with instrumental activities of daily living (IADL), such as help with housework, meals, shopping and transportation. The notion of long-term health care services usually refers to services delivered over a sustained period of time, sometimes defined as lasting at least six months.
Caring demands of an ageing population point out the insufficiency and inadequacy of the current policies, by placing under pressure the public system because “old institutional solutions no longer fit new needs and problems” (Pavolini & Ranci, 2013: 6). “If left unchecked, these increases will have a potentially devasting effect on the healthcare cost” (NORDEN, 2014: 5). Thus, the goal of social policies in tackling the demographic challenge is to allow a growing number of elderly people to live a dignified and as autonomous life as possible, by strengthening the care service infrastructure as well. If this purpose should not be pursued seriously, facing the manifold dimensions of old age, then the complexity of the situation of dependent people in need for care will not be addressed and welfare programs will never fill the so-labelled “care deficit” (Pavolini & Ranci, 2013: 8). Governments have long recognized the need for elders to enjoy income even in the period following the working age, through the pension scheme; while care needs have been recognized belatedly and less extensively. (Saraceno, 2008: 15). Indeed, “while the care needs of little children […] are at least partially taken account of in public discourses and policies, […] this is not so far for the caring […] of the frail elderly and generally of the disabled, although, differently from children, this population group is growing” (ivi ). If the term “care”, doesn't refer only to the medical aspect, then it is clear that the need associated with it also has significant
social implications, both on the network of each elder, and on the community itself. Actually, Pavolini & Ranci (2013: 7) adopt a holistic view of care activity, referring to the “multiple dimensions attached to providing “care” (personal help, social interaction, support for mobility or basic everyday life activity, and so on)”. Lastly, in fact, according to the System of Health Accounts classification (SHA, 2011; European Commission, 2017: 128)
public expenditure on long-term care is defined as the sum of the following publicly financed items: services of long-term nursing care (which is also called “the medical component of long-term care” […] and includes both nursing care and personal care services); social services of long-term care […] which represents both the “assistance services” part, relating primarily to assistance with IALD tasks as well as related cash benefits.
2.3 Institutional development about long-term care (LTC) policies in Europe
“LTC has historically been a less “institutionalized” policy field” (Pavolini & Ranci, 2013: 6), but now it represents “a key sector in the new welfare systems” (Pavolini & Ranci, 2008: 256).
Care-dependency explodes as a new social risk in the 90s, reaching the top of social policy's agenda as a consequence of at least three parallel phenomena. The first, the demographic one, mainly caused by the increase in the number of elderly people, that according to Manton's theory of “equilibrio dinamico” (“dynamic equilibrium”), carries with it the expansion of the absolute number of the oldest old with severe disabilities (while the rate of mild disability decreases) requiring more continuous forms of assistance, as confirmed also in the recent comparative study conducted by Lafortune and Balestat (Pavolini & Ranci, 2013: 25; Ranci & Pavolini, 2015: 240). The second, sees a progressive increment in female employment (even if women tend to be just part-time employed) that causes changes in the traditional support system. Although “an increasing rate of employment participation […] does not necessarily mean a proportionate decrease in the number of care givers within family” (Osterle, 2017: 20), the care givers require some support measures “to combine formal employment and informal care-giving” (ibid.). Evidences suggest that there is a decrease in the amount of time spent on informal care-giving, “making home care
