GenderAge ClassEmploymentcondition

Expert meeting on the Future of Work in Asia:

Skills development strategies to promote employment-rich and equitable growth in the care economy

ITC ILO, 17 - 19 September 2018, Turin, Italy

Development of job opportunities in the caregiver services:

The case of Italy

P. Checcucci/R. Fefè

Contents

Contents

Demographic evolution and Public Welfare resources

Long Term Care and Disability

Family caregiving and work-life balance

The evolution of professions in the social sector

Conclusions

Contents

Demographic evolution and Public Welfare resources

Long Term Care and Disability

Family caregiving and work-life balance

The evolution of professions in the social sector

Conclusions

Contents

Population and the life course

Demographic evolution and Public Welfare resources

6 25 28 29 30.8 31.3 34.2 57.8 58.4 80.3 84.9

0 90

Primary school

First job men

First job women

Exit from the family of origin women

Exit from the family of origin men

First marriage men

First child

First marriage Women

Retirement men

Retirement women

Life expectancy

men Life expectancy women

Source: Eurostat, 2017

Population by age classes. 2017-2045 (%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-64 65+

Population and disability onset

In 2016 the population 64+ showed a healthy life expectancy of 3.6 years among men and 5.6 years among women.

In 2015, about 8.051.000 over the age of 65 have some kind of chronic disease or functional limitation which limit the ability to carry out daily tasks of life (do the cleaning, leave the house, take a bus, carry out housework, ecc…)

74,8% of people between the ages of 65 and 74 had at least one chronic disease, and 47.9% said they had at least two chronic conditions (growing trend among over 75: 85,2% with at least one chronic disease, and 65.4% with two)

1,6 0,7 0,7 1,2

1,5 2,8

5,1 9,3

18,2

43,3 5,6

0 10 20 30 40 50

6-14 15-24 25-34 35-44 45-54 55-64 65-69 70-74 75-79 80+

Total

Persons with disabilities by age classes (%)

Source: Istat, 2018

Functional limitations by age classes (%)

Source: Istat Social inclusion of people with functional limitations, disability or severe chronic disease, 2015

Demographic evolution and Public Welfare resources

Care needs, chronic disease and functional limitations

• Women tend to age in worse conditions than men

• Autonomy in daily life tends to reduce as people age; 25,9% of elderly people feel to count on a solid social support while the 58% of serious dependant elderly claim they need an help

• The most of the over 65 aged live in couple without children (43%) or alone (29%); with serious disease in daily life the main condition is living alone 46,6% (women 55%).

• There is also a trend that links dependancy with poor living conditions

• Even if , due to the pension system, older people is better protected than other generations by poverty risk, during the economic crysis families with dependent member and with care spending exceding more than 20% the household income, were more exposed to poverty risk.

Source: ISTAT, Social inclusion of people with functional limitations, disability or severe chronic disease, 2015

a.v. % a.v. % a.v. %

Male 1019 33,0 4944 49,0 5963 45,3

Female 2066 67,0 5147 51,0 7213 54,7

15-34 90 2,9 594 5,9 684 5,2

35-54 244 7,9 1950 19,3 2194 16,6

55-64 215 7,0 2033 20,1 2247 17,1

65-74 458 14,8 2680 26,6 3137 23,8

75-84 1117 36,2 2256 22,4 3373 25,6

aged 85 and

over 963 31,2 578 5,7 1541 11,7

University or upper secondary school

355 11,5 2579 25,6 2934 22,3

Lower secondary school

591 19,1 3310 32,8 3900 29,6

Primary school or no title

2140 69,3 4203 41,6 6342 48,1

Good conditions

1539 49,9 5683 56,3 7223 54,8

Poor conditions

1546 50,1 4408 43,7 5954 45,2

TOTALE 3086 100,0 10091 100,0 13177 100,0

SEX

AGE CLASS

EDUCATION

ECONOMIC RESOURCES

People with serious People with mild Total

Demographic evolution and Public Welfare resources

Public resources for care

Support to family care

Disability Poverty

Care services 380.8 4.9% 521.1 2.6% 2,617.9 31.8%

Benefits 5,032.5 64.4% 18,854 95.3% 5,619 68.2%

Tax

expenditures

2,405 30.8% 418.6 2.1% 0.0 0.0

Total 7,818.3 19,703.7 8,236.9

Welfare public resources. Millions of Euros and %. Year 2018

Source: IRS elaboration on Italian Budget Law 2018

Demographic evolution and Public Welfare resources

Contents

Contents

Demographic evolution and Public Welfare resources

Long Term Care and Disability

Family caregiving and work-life balance

The evolution of professions in the social sector

Conclusions

Long – term Care

Long Term Care and Disability

people provided by the National Health Service

• 40% of spending

• Home health-care services (integrated domiciliary care) and other health services provided in residential settings

• National Health Service is responsible for assessing the degree of disability of citizens

•Home health care Coverage rate 4,8%

(17 h per user); 2,3% of 65+

•Residential structures Coverage rate 2.2%

Social component of LTC provided by

municipalities

• 14% of spending

• In kind care provisions, at local level

• Personal social services, both domestic and personal care tasks provided at home

• Mainly means-tested

• National Health Service is responsible for assessing the degree of disability of citizens

•Coverage rate of in-home assistance 1,2%

(65+); decreasing trend in use vs increasing costs (+21%)

Attendance allowances (indennità di

accompagnamento)

• 46% of spending

• Cash benefit

• Not means-tested

• Local Health Authorities examine eligibility criteria

• National Social Security Institute (INPS) provides benefits

•Users in 2015: 11,5% of italian population;

decreasing trend in access

Expenditure accounted for 1.7 % of GDP in 2017.

2/3 of the expenditure are directed at 65+

Long-term care is delivered by both public and accredited private providers of health and personal social care (private providers for-profit and not-for-profit have 65% of all institutional long-term care beds)

Source: Ministry of Economy and Finance, Le tendenze di medio-lungo periodo del sistema pensionistico e socio-sanitario, Rapporto n. 19, 2018;

European Commission, Italy Health Care & Long-Term Care Systems, An excerpt from the Joint Report on Health Care and Long-Term Care Systems

& Fiscal Sustainability. October 2016

Long-term care projections

Long Term Care and Disability

20

24 23

48 58

0% 20% 40% 60% 80% 100%

2010 2040

0-64 65-79 80+

Distribution of LTC spending by age classes

Source: Ministry of Economy and Finance, Le tendenze di medio-lungo periodo del sistema pensionistico e socio-sanitario, Rapporto n. 19, 2018

Dementia

Long Term Care and Disability

Italian National Plan on Dementia (2014) – Strategy for the promotion and improvement of quality and pertinence of interventions and assistance on dementia

The Italian context:

Projections estimate that cases of dementia could triplicate during next 30 years, due to ageing population

Current offer of services is based on 500 “memory clinics”, which started their activity after 2000, within the national Project CRONOS, especially addressed to Alzheimer evaluation and treatment

The National Plan objectives :

Objective 1 – health and social interventions and measures

Objective 2 –Integrated network of services

Objective 3 –Strategies and intervention for care pertinence

Objective 4 – Awareness raising and stigma reduction for improving the quality of life The main interventions aim at :

updating services, enhancing excellence experiences and addressing a better integration between health and social services

developing public health policies and measures to fight social stigma and aimed at

empowering patients and their caregivers, starting from a correct and updated knowledge of the disease

Disability - Education

Long Term Care and Disability Students with

disabilities Students (total)

Students with disabilities (%)

Nursery school 28.138 1.518.843 1,9

Primary school 90.845 2.792.414 3,3

Middle school 69.470 1.729.226 4,0

High school 65.913 2.664.967 2,5

total 254.366 8.705.450 2,9

Visual impairments

Hearing impairments

Intellectual or Learning

Disabilities

Physical

disability Others Nursery

school 1,5 2,9 58,3 5,5 31,8

Primary school 1,3 2,2 70,7 2,8 23,0

Middle school 1,2 1,9 71,6 2,6 22,7

High school 1,9 2,8 64,2 4,2 26,9

total 1,5 2,4 67,9 3,4 24,8

Students with disabilities. SY 2016/2017 (a.v., %)

Students with disabilities. Type of disability. SY 2016/2017 (%)

Source: elaboration on data Ministry of Education, University and Research, Statistical Office

Disability – Support teachers

Long Term Care and Disability

• Support teachers are learning facilitators and tutors, working with/in the classroom.

• Skills and knowledge: pedagogy, organization, legislation,

communication, psychology, relationship management

• He/she designs the student’s individual educational plan, in collaboration with the other teachers, the family, the local health authorities and social services

8,6 9,1 10 9,7 10 10,6 10,6 10,8 11,2 12,1 12,8 13,2

14,4 15,1 15,1 16,3

0 2 4 6 8 10 12 14 16 18

Share of support teachers on total number of teachers (%)

1,88

1,96 2 1,99 2,03

1,99 1,97 2,02

2,09 2,08

2,03 2

1,9

1,85 1,85 1,8

Students with disabilities per support teacher

Total number of teachers 2016/2017

% Nursery school 97.781 11,4 Primary school 273.804 32,0 Middle school 194.688 22,8 High school 289.461 33,8

Total 855.734 100,0

Disability – Self determination policies

Long Term Care and Disability

• Persons with disabilities 18-64

• Project duration 12 months, max Eur 80,000 (National funding)

• Personal budget and case management

• Personal assistant funding and training

• NGOs involvement

• Community welfare support

Independent living

• National funding of innovative projects for autonomous living solutions (also co-housing) and self-help groups

• Personal budget

• Awareness raising and empowerment programs for persons with disabilities

• Tax relief for insurance schemes, trusts, goods and assets devoted to independent living of single persons

After us

• A person designated by a Judge to assist, support and represent a person with disability in legal matters during daily life

• He/she must observe the persons’s needs and aims and keep him/her informed

• Regularly reports to the Judge

• Charged for at least 10 years

Support

administration

Contents

Contents

Demographic evolution and Public Welfare resources

Long Term Care and Disability

Family caregiving and work-life balance

The evolution of professions in the social sector

Conclusions

Italian Families and Caregivers 1

Family caregiving and work-life balance Who and How many care givers are ?

• In 2010, more than 15 million people undertook care functions of some kind.

More than 3 million (8.4% of the Italian population) took regular care of older adults.

• Considering also people who cares persons with problems due to aging, chronic diseases or disabilities, in 2015 the care givers population exceeded 8 million people (8.5 milions providing assistance – 7.3 milions providing care mainly to family members).

• Women and the older generations (25-44 and 55-64) play an important role both in the care of the youngest, as in that of older adults who are not self- sufficient.

Caregivers Providing care mainly to family members

Countries 15-64 65-74 75 e più 65 e più Totale 15-64 65-74 75 e più 65 e più Totale

Italy 18,5 17,4 10,4 14,1 17,4 16,1 14,1 8,4 11,5 14,9

Female 21,3 18,9 10,0 14,5 19,5 17,9 15,7 8,2 12,0 16,4

Males 15,6 15,6 11,0 13,6 15,2 14,1 12,3 8,7 10,7 13,3

Eu 28 16,0 16,5 11,6 14,3 15,6 13,4 12,0 8,3 10,3 12,7

Females 18,8 17,9 11,1 14,6 17,8 15,5 12,8 7,7 10,3 14,3

Males 13,1 14,9 12,4 13,9 13,2 11,1 11,0 9,3 10,3 10,9

Source: ISTAT 2015 – Data on 2010, II trimester

Italian Families and Caregivers 2

Source: ISTAT 2015 – Data on 2010, II trimester

Incidence on population % Composition %

Population Caregivers (any kind)

…of cohabitating

children

…of other children

…of adults (elderly

and/or disabled persons)

Caregivers

…of cohabitating

sons

…of other children

…of adults (elderly

and/or disabled persons)

Care givers

…of cohabitating

children

…of other children

…of adults (elderly

and/or disabled persons)

Total 39.520 15.182 10.944 2.665 3.329 38,4 27,7 6,7 8,4 100,0 100,0 100,0 100,0 Age class

15-24 6.070 613 127 379 169 10,1 2,1 6,2 2,8 4,0 1,2 14,2 5,1

25-34 7.689 2.794 2.437 322 271 36,3 31,7 4,2 3,5 18,4 22,3 12,1 8,1

35-44 9.740 6.255 5.786 482 678 64,2 59,4 4,9 7,0 41,2 52,9 18,1 20,4

45-54 8.668 3.612 2.418 514 1.200 41,7 27,9 5,9 13,8 23,8 22,1 19,3 36,0

55-64 7.353 1.908 176 969 1.011 25,9 2,4 13,2 13,7 12,6 1,6 36,4 30,4

Employment Condition

Employed 22.614 9.738 7.849 1.109 1.796 43,1 34,7 4,9 7,9 64,1 71,7 41,6 54,0

Unemployed 2.089 745 518 153 179 35,7 24,8 7,3 8,6 4,9 4,7 5,7 5,4

Inactive 14.817 4.699 2.577 1.403 1.354 31,7 17,4 9,5 9,1 31,0 23,5 52,6 40,7

• Considering the employment condition of care givers, in the case of dependant adults the care is carried out by employed persons (54%), almost as much as by people who are inactive (40.7%)

• Caregivers are mainly employed, but inactive people still play a relevant role in the care of children and adults (52,6% - 40,7%).

• Even though family structures are more and more fragmented, the family still plays an important role in managing care

Family caregiving and work-life balance

Gender specific trends in unpaid care work

44,20

75,20

54,30 65,40

78,30

65,20 65,00

78,20

63,80

0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0

Both employed partners Employed man - Unemployed woman

Couple in other conditions

Asimmetry Index in unpaid care work (2014)

without children with children Total 24,7

19,1 22,4

1,0 0,2 0,5

13,5

6,6 9,9 6,0 15,4 9,8

9,0

21,1 16,3

7,4 19,2 13,5 16,7 13,3 15,3

28,3

20,4

23,5 22,2 18,0 20,0

Men Women Total Men Women Total Men Women Total

Employed Unemployed Total

2013

Use of the time (% on 24 hours)

Paid work Unpaid care work Free time

During the time the employment rate of women raised the 52,5% (vs 85,8% men’s), but both employed and unemployed women still spend more time in unpaid care work than man.

High incidence of women in part time and atypical work (32,7 W.; 8,2% M); the employment rate of women decreases with the increase of the number of children (from 51,9 with 1 children to 43,8 with more than 3 children); the unemployment rate of women is still at 12,3% (10,2% men’s u.r.) in a raising trend. The inactivity rate of women (43,7%) is twice the men’s rate (25,2): even the gender balance is growing women are still the main caregiving providers.

Due to the crisis, unemployed fathers tend to dedicate more time to the care, so that the asimmetry Index is reducing, in particular when there are more than one children, in high qualified couples and in dual earners households

More than one million of inactive people (24% of those with children under 15 or with other care responsibilities) would be willing to work if they could reduce the time involved in assistance and caregiving.

Source: ISTAT 2016 – Data 2014 – Indagine Multuscopo sulle famiglie: uso del tempo - Multi-purpose survey on families: use of time

Family caregiving and work-life balance

The «rifamiliarization» process in caregiving

Family caregiving and work-life balance

• From 96,8% to 97,5% of the cases, the care recipient is a relative

• About 74% of caregivers are providing care directly without any services support

• 54% of older caregivers and 69% of

younger care givers use working leaves to provide care

(PLUS, 2016)

• Only 5,9% of families with an older member use a nurse service or ask for an informal or professional support in providing caring activities; the percentage raises the 28,3% when the member has serious difficulties in daily life activities

• 6,6% of 65+ get help from an informal caregiver

“Badante”

(ISTAT, 2015)

• Decreasing trend in the use of family assistant

(COLF) in regular domestic workers: from 1.012.988 in 2012 to 864.526 in 2017

• Increasing trend in the use of informal carers (Badante)

(INPS 2017)

0 10 20 30 40 50

Flexible working hours

Regular working hours

Distance from place

of work

Care services availability

Lower cost for care services

Other What would make it easier to combine work with care tasks?

Age class 18- 29 Age class 30-39 Age class 40-49 Age class 50-64 Age class 65-74

Contents

Contents

Demographic evolution and Public Welfare resources

Long Term Care and Disability

Family caregiving and work-life balance

The evolution of professions in the social sector

Conclusions

The qualification of Care function

The evolution of professions in the social sector

Families and caregivers

Family assistants (Badante)

(Colf)

Qualified professions in

health and social services Unpaid care work ---- Paid Care Work

• What tasks / what skills?

• Migrants; Regular/Irregular Employment

• Gray job and fuzzy qualification process

• Changing in use of thecnologies/rules/organizational model of services

• Changing skill needs Social

attitudes and care cultures

Social

mandate on care

function:

From cure to Care

Norms and laws that institute

services and professions Changing in care demand for services

Public spending and private investiments

The informal domestic&care work

The evolution of professions in the social sector

• In 2017 the National Institute of Social Security (INPS) accounted about 864,000 domestic workers with regular contract. More than 73% were foreigners and the 88,3% were women (INPS)

• About 39,478 (43%) had regular contracts with the families as personal assistant (badante). The main profile is foreign woman working as badante (72%). It is estimated 1 milion “informal” domestic workers undeclared.

• Prevalence of low salaries (from 3,000 to 10,000 euro per year)

• Household spending in private solutions is estimated around 9.352 billion euro; around 29% on the family income.

Assistant’s tasks:

• A) to live in the same home of assisted people; to work 16 hours a day to offer a multi- faceted care (to keep company, giving nursing care, house cleaning, cooking, less frequently doing the shopping or paying bills)

• B) After the economic crisis there is a raising trend in time work

(Pasquinelli and Rusmini, 2013-2018)

 Informal workers as a surrogate of the traditional role of women, assimilated into a family component without a clear difference between internal and external aid

 “SHORT CIRCUIT of the REPLACEMENT FUNCTION”*, when the professional action chosen to deal with the problem is not technical, but is in lieu of emotional acting outs which characterize the culture of the family as client.

*Paniccia, 2012

The “care” professions ‘ training in Italy

The evolution of professions in the social sector

Function

Healthcare professions Social Professions

Prevention, Diagnosis, Treatment Care and relational dimension of health and coexistence demand

Lack of definition in job profiles due to the changing asset of organisational

models

LTC services to dependent people provided by the National Health Service

Social component of LTC provided by

municipalities

Higher education qualification

Lower

qualification

Care professions trends in Italy 1

The evolution of professions in the social sector

Function

• Employed people in health, healthcare and social services are about the 8,5% of the total employment in Italy

• High gender segmentation and pay gaps: lower wages than in other technological sectors; more than 88% of social professions is performed by women (in particular within qualified professionals, family assistant and domestic workers, but also between educators, social workers, teachers). During the crisis the public spending cuts in public administration (education, health services) have lead to a wage drop.

• High presence of foreigners: in 2010 they were about the 46% of total social workers; in 2017 foreigners were the 77,6% of domestic workers (family assistant and personal caregivers)

• High rate of irregular employment in particular when services is provided directly to families (47.6%

in 2015, 0.2 percentage points more of 2014; the total irregular employment rate is 15,9%).

58%

41%

35%

64%

75%

24%

16%

83%

30%

69%

97%

2%

0% 20% 40% 60% 80% 100%

Male Female

<40 40>

Dependent work Indipendent work

GenderAge ClassEmployment condition

Employment composition by age,sex,working condition (mean 2014-2016)

Qualified professions in health and social services

Total Employment

Source: ISTAT, Sistema informativo sulle professioni, 2014-2016

Care professions trends in Italy 2

The evolution of professions in the social sector

Function

• In 2016-2020, the health and personal care sector will greatly contribute to employment in the coming years, with an average annual rate of 3.8% (Excelsior 2018), boosted both by replacement and the expansion of demand

• In 2020 estimations forecast the major contribution among graduates from doctors and paramedics (31,000) and teachers (almost 19,000). Due to population ageing, the demand for health specialists will grow by 60%, that for qualified professions in health and social services by 34%, and for health technicians by 14%.

BUT

• There could be a mismatch between high skilled technical and health professions and the demand for relational skills from families, due to changing demand from dependant adults

• Due to the old age of healthcare professionals and to budget restrictions in the public sector, there will probably be labour shortages

INAPP Audition on the Skill demand expressed by employers (2016-2018)

Social Professions + Nurses, home care workers, educators Healthcare professions Care and relational dimension of health and coexistence demand Prevention, Diagnosis, Treatment

The ageing of care professionals

The evolution of professions in the social sector

49 49

National Health Service

School Regions and Local Authorities

Average age of workers in selected Public sectors. 2011

Source: ARAN, 2013

1,7 8,5

10,7 12,2 18,3

27,8

18,9

1,8 0,2 0

5 10 15 20 25 30

30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-67 68+

Age of Physicians in the NHS. 2013 (%)

Source: ANAAO, Assomed, 2013

Contents

Demographic evolution and Public Welfare resources

Long Term Care and Disability

Family caregiving and work-life balance

The evolution of professions in the social sector

Conclusions

Contents

Conclusions

The evolution of professions and policies in the care sector

•

Population ageing and family changes transformed the reproduction of Italian society

•

Efforts to adapt welfare systems often resulted in the provision of cash benefits instead of care services

•

Public resources and care professions markedly concentrated on older population cohorts, with the exception of Education and (partially) the Health system

•

Initial overcoming of the medical model in favour of the adoption of a bio-psico-social model of care (especially disability)

•

Multidimensional evaluation of individual situation and individual tailoring of care (disability, older people, poverty)

Challenges

• Family overload of care responsibilties

• Both family care givers and care professionals and workers are ageing at a fast pace ( risk of labour shortages)

• Formal recognition of the Caregiver function in service planning and managing

• Gender imbalances in the distribution of family care

• Gender segregation in some professional sectors

• Institutional fragmentation of Public

care organizations (National, regional,

local)

Bridging the gap

The evolution of professions and policies in the care sector

Function

• Medicalization of health and aging

• Aging is an individual issue is someting to “cure”:

• Tension between isolating the illness/patient and returning him to the social health system once healthy again

• Access to the public services only in emergency condition

• Compensatory approach: the goal of the home care service is to guarantee the survival needs

• Care Policies aimed to correct deficits

• Medicalization of health and aging

• Aging is an individual issue is someting to “cure”:

• Tension between isolating the illness/patient and returning him to the social health system once healthy again

• Access to the public services only in emergency condition

• Compensatory approach: the goal of the home care service is to guarantee the survival needs

• Care Policies aimed to correct deficits

29

• Health and aging are a relational issue of the life course

• The enviroment might represent a resource for the care process

• From technical/diagnostic approach at care in a clinical context to a transformative approach of social coexistence

• Integrative functions and skills with a focus on the family & individual/context demand

• Active care paradigm – co-creation and co-implementation of public services

• Transformative care policies and skills aimed to develop contextual and relational resources

• Health and aging are a relational issue of the life course

• The enviroment might represent a resource for the care process

• From technical/diagnostic approach at care in a clinical context to a transformative approach of social coexistence

• Integrative functions and skills with a focus on the family & individual/context demand

• Active care paradigm – co-creation and co-implementation of public services

• Transformative care policies and skills aimed to develop contextual and relational resources

Pietro Checcucci-p.checcucci@inap.org Roberta Fefè –r.fefe@inapp.org

Il presente prodotto è stato sviluppato da INAPP in qualità di Organismo Intermedio del PON SPAO con il contributo del FSE 2014-2020

Azione 8.5.6 Ambito di attività I/8i/8.5.6/2