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Systematic Review or Meta-Analysis
INQUIRY: The Journal of Health Care
Organization, Provision, and Financing
Volume 58: 1–17
© The Author(s) 2021
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DOI: 10.1177/00469580211062426
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Aging, Dependence, and Long-Term Care: A
Systematic Review of Employment Creation
Roberto Martinez-Lacoba
1,2
, Isabel Pardo-Garcia
1,2
, and
Francisco Escribano-Sotos
1,2
Abstract
Population aging is an economic and social challenge in most countries in the world as it generates higher dependency rates and
increased demand for long-term care. Undertaking the care of older dependent adults can result in new opportunities for job
creation. There is limited knowledge of the impact of dependent care and long-term care on employment. We examined this
impact through a systematic review. Countries with conditional cash benefits show job creation, and countries with un-
conditional economic benefits reveal the development of a grey care market with high participation of migrant labor. Migrant
employment in developed countries affects the development of the labor market in the countries of origin. The employment
created to care for dependent persons is generally precarious. In conclusion, global aging will increase long-term care worker
demand, but the variations in policies can determine what kind of employment is created.
Keywords
aging, dependence, employment, long-term care, systematic review, aging, dependence and long-term care
Introduction
Global population aging is a challenge for welfare states, es-
pecially for long-term care systems (LTC). Since aging will
significantly increase the absolute number of older people who
are care dependent, demand for care and care cost will increase
in the next decades.
1,2
The world of work is also changing
because of aging, among other factors,
3
and it is necessary to
readjust the workforce to meet the needs of dependent people.
Developed countries have elaborated different measures and
policies to satisfy growing care needs and to contain social and
economic care costs. There are different ways to cluster
(1) What do we know about this topic?
Long-term care can result in new opportunities for employment creation.
(2) How does your research contribute to the field?
Through a systematic review, this research shows that employment is created in countries with conditional cash
benefits and countries with unconditional cash allowances encourage a grey market.
(3) What are your research’s implications towards theory, practice, or policy?
The proportion of migrant labor in care provision increases with unconditional cash allowances and the use of
the migrant workforce impacts on the labor market in their native land.
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1
School of Economics and Business Administration, Castilla-La Mancha
University (UCLM), Albacete, Spain
2
Sociosanitary Research Center, Castilla-La Mancha University (UCLM),
Cuenca, Spain
Corresponding Author:
Roberto Mart´
ınez Lacoba, Facultad de Ciencias Económicas y Empresariales,
Universidad de Castilla-La Mancha, Plaza de la Universidad, 1, Albacete
02071, Spain.
Email: roberto.mlacoba@uclm.es
countries based on LTC systems. On the one hand, focusing on
the European welfare state classification—suitable for all de-
veloped countries, there are 3 care regimes.
4
First, the social
democratic care regime provides universal access to care ser-
vices for all people in need. Second, the liberal care regime is
characterized by a developed care market in which services are
purchased and the state provides care for people without re-
sourcesand funds, outsourcing services. Third, the familistic
care regime relies on family as caregivers for dependent
relatives, with the state providing care in their absence.
Countries adopt these three models to differing degrees. In
other words, no country can be defined as practicing a
purely social democratic, liberal, or family regime. On the
other hand, focusing on public long-term care coverage for
personal care, there are three broad country clusters:
universal coverage within a single program, mixed sys-
tems, and means-tested safety-net schemes.
1
This classi-
fication is based on two criteria: the scope of entitlement to
long-term care benefits and whether LTC coverage is
through a single system or multiple benefits, services, and
programs. Other classifications rely on characteristics re-
lated to governance and financing, supply of formal care
services, cash benefits for the care of dependent persons,
and the role of informal care or marketization of LTC.
5
However, despite the differences among LTC systems,
countries are changing or developing their LTC systems in
a similar direction: the search for consumer choice, moving
away from residential care towards home care and com-
munity care, flexibility, financial sustainability and im-
proving access to, and affordability of, care.
1,5
Demographic changes imply a greater pressure on health and
social public expenditure,
6,7
but caring for dependent people can
generate new employment opportunities. The demand for formal
care is increasing as a result of aging societies, higher care
dependency ratios, and changing family structures—increase in
the number of single households, and the growing participation
of women in the labor market.
5,8
Projections on labor market
evolution show that long-term care workers demand will in-
crease in the decades to come.
9
According to the International
Labor Organization (ILO), the employment needs are estimated
at 4.2 formal long-term care workers per 100 individuals aged 65
years or above.
8
The employment created in this sector may not
have similar working conditions in all countries; quantity and
quality of job will depend on the policies applied. It is important
to ensure good working conditions in LTC employment to create
an attractive professional environment in the sector
10
and then
improve care quality. The attractiveness of the formal care sector
to potential workers is often undermined by negative perceptions
related to poor working conditions, stressful working environ-
ments, lack of clearly defined career paths and lack of devel-
opment opportunities, and quality of care is vital to maintaining
and improving the quality of life of the elderly.
5
The literature has studied the LTC sector from different
perspectives. Some studies have examined the implications of
informal care for the job market
11,12
and female supply,
13-15
and others have studied whether employment affects informal
care choice.
16,17
Other works have examined the opportunity
cost of informal care or caregiving in general,
18-20
the features
of LTC systems in different countries,
21-23
or how to make
care systems efficient, equitable and sustainable.
24
There is little evidence on the dynamics of the LTC work-
force and consequences associated with aging and dependence
in different care models. Thus, the aim of this paper is to analyze
the impact of long-term care on employment creation in the care
sector.
Method
This systematic review followed the guidelines of the PRISMA
statement for reporting systematic reviews and meta-analyses.
25
A narrative synthesis to present the results has been used.
26
The
graph was constructed using Gephi software.
27
The study used the definition of dependence provided by
the Recommendation of the Committee of Ministers of the
Council of the European Communities in 1998.
28
The Rec-
ommendation considered dependence as a state in which
persons, because of lack or loss of physical, psychological, or
intellectual autonomy, require significant assistance or help in
carrying out their usual day-to-day activities.
Data Sources and Searches
The literature search was conducted during February 2018. We
included all the publication period. Due to the multidisciplinary
approach of the review, the databases of PubMed, Web of
Science, and Scopus were consulted. Tab l e 1 shows the search
strategy and the included terms. To reduce the potential pub-
lication bias, the literature review was completed with a sec-
ondary search of the bibliographical references from the studies
identified in the search strategy.
Study Selection
Articles meeting the following requirements were included: (1)
they were published in English; (2) they were an original article;
and(3)theywerefocusedonemploymentorlong-termcare.
Articles were excluded if: (i) they focused on informal
care; (ii) they provided no information about labor force or
markets, or workforce or employment in care sector; (iii) they
focused on caregiving intensity or probability of being em-
ployed; and (iv) they focused on gender-related topics. Study
design and empirical approach were not exclusion criteria.
Given the wide variety of studies on dependence, it was
necessary to take into account the results of the studies re-
gardless of their design or empirical approach.
Quality of the Manuscripts
Methodological quality was assessed using three critical
appraisal tools. One tool was used for the evaluation of cross-
sectional studies,
29
the second was used for the evaluation of
2INQUIRY
qualitative research,
30
and the third was used for the eval-
uation of mixed research (both quantitative and qualitative).
31
Two researchers (IP and RM) independently used the mea-
surement tool. The checklists work with a different number of
questions. Each component scores one point if the answer is
“yes”or zero if the answer is “no,”“unclear,”or “not
applicable/could nottell.”The cross-sectional study checklist
comprises 8 questions, the qualitative research checklist
consists of 10 questions, and the mixed research checklist has
13 questions. Any differences in the quality assessment of a
particular study were resolved by consensus.
Data Extraction
The study selection and data extraction process comprised
two phases. First, two researchers (IP and RM) screened all
the records to eliminate any duplicates. Both researchers then
independently reviewed the titles and abstracts of the 2217
records obtained. Finally, they selected the articles to be fully
reviewed. The results were compared, and a third researcher
(FE) was consulted to resolve any discrepancies in the in-
clusion criteria and so reach a consensus agreement.
Second, the two researchers (IP and RM) read all the articles
obtained following the application of the inclusion and ex-
clusion criteria. A full-text review of 55 articles was conducted.
Of these, 41 were discarded by applying the exclusion criteria.
The references of the 14 articles accepted were reviewed in
case any relevant study had not appeared in the search process.
The researchers found 4 studies in the secondary search. A total
of 18 articles were finally included in the review.
Results
Brief Description of Included Articles
Given the wide range of topics involved in dependence, care,
and employment, a narrative synthesis of the full-text articles
was undertaken.
The selection process identified 2929 articles. After
eliminating duplicates, 2217 remained. Only 18 met the
inclusion and exclusion criteria—primary and secondary
search. The flow diagram for the search procedure and study
selection is shown below (Figure 1).
Eleven of the studies included have a quantitative, ob-
servational, descriptive, and analytical design.
23,32-41
The
studies refer to the following countries or regions, in al-
phabetical order, Australia, Austria, Canada, Europe, France,
Germany, Greece, Ireland, Italy, Japan, Korea, Luxembourg,
Netherlands, Norway, Portugal, Sweden, United Kingdom,
and United States of America. On various occasions, Spain,
Greece, Italy, and Portugal are grouped together as southern
European or Mediterranean countries.
32,41,42
Six studies employ a mixed methodology, including
quantitative information drawn from observational
Table 1. Search Strategy.
“Depression"
OR
“Dementia"
OR
“Schizophrenia"
“Aging population" “Employment" OR
OR OR “Alzheimer"
“Aging population" “Labor force" OR
OR OR “Drugs"
“Disabled people" “Health workforce" OR
OR OR “Influenza"
“Long-term care" AND “Labor force participation" AND NOT OR
OR OR “HIV"
“Elder care" “Health care work" OR
OR “Nurs*"
“Caregiving" OR
OR “Rehabilitation"
“Care regimes" OR
“Psychosocial"
OR
“Physical"
OR
“Teacher"
OR
“Arthritis"
Martinez-Lacoba et al. 3
studies and qualitative information using different
methodological tools in Austria, England, France, Ger-
many, Ireland, Italy, the Netherlands, Norway, Spain,
Sweden, Taiwan, and United Kingdom.
42-47
One of these
studies includes empirical research conducted using de-
scriptive techniques and also based on the results of
qualitative research comprising semi-structured recorded
interviews, informal recorded interviews, unrecorded
informal interviews, and non-participant observation of
employees, employers, and care agencies in Madrid,
London, and Stockholm.
47
One work
48
utilizes qualitative methodology and studies
how migrant controls compromise migrant care workers’
exercise of choice and control over their employment, ana-
lyzing the findings of 56 in-depth interviews with migrant
care workers from the United Kingdom.
49
The main characteristics and results of each study are
presented in table form (Table 2). In order to facilitate the
interpretation of the results, in the following paragraphs, the
reader will find “EU”for studies focused on European
countries, and “US”for studies focused on the United States.
Other specifications have also been used on certain
occasions—for example, Mediterranean countries.
Narrative Synthesis of Results
The world population is aging and the need for care services
has increased,
37,42
while the LTC labor demand
33,34,38
and the
social and economic costs of care have risen.
41
Meanwhile,
the need for elderly care services has increased, but the share
of the population that is of working-age and can potentially
provide these services is decreasing.
35,38,42
Figure 1. Flow diagram.
4INQUIRY
Table 2. Descriptive Summary of Included Studies (n = 18).
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Bettio, Simonazzi,
and Villa 2006
Greece, Spain, Italy, and
Portugal
Informal Migrant care workers crowd out the
supply of specialized care
A new care model is generated by the
arrival of female migrants: “Migrant in
the family”model. It is cheap and
flexible, resolving the deficiencies in
public provision, while reducing the
cost of the service
4
Browne and
Braun 2008
US NA The need for LTC workers is
increasing
Globalization, population aging, and
immigration impact on the LTC
workforce, which, in turn, affects
global poverty and economic
inequalities, the feminization and
colorization of labor, and
empowerment and women’s rights
4
Cangiano et al.
2014
Europe Formal and informal Demographic aging has led to growing
reliance on migrant workers in the
provision of older adult care in most
European countries
Demographic aging and the shrinking of
intergenerational care support have
themselves been a powerful impetus
for employment creation by generating
additional labor demand within specific
sectors of the economy. In many
European countries, this labor demand
cannot be met without migrant care
workers
5
Chen 2016 Taiwan NA There is occupational segregation in
care labor market
The gap between the dual care system
and workforce regulations has clearly
resulted in occupational segregation in
the secondary care labor market.
Foreign home caregivers should be
made insiders, equally protected by
labor regulations. This will allow
service receivers to choose caregivers
without exploiting foreign caregivers
and will therefore guarantee more
employment opportunities for local
caregivers and an improvement in the
overall quality of care
12
(continued)
Martinez-Lacoba et al. 5
Table 2. (continued)
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Da Roit, Gonz´
alez
Ferrer, and
Moreno-
Fuentes 2013
Italy and Spain Informal The lack of development of LTC
policies and services have
encouraged the use of migrant care
workers
LTC policies in Italy and Spain have been
aimed at neither the socialization of
risks of dependency nor the creation of
employment in the sector. A
combination of factors has created a
situation in which migrant labor plays a
central role in the working of the
Southern European welfare regimes,
with predominantly female migrants
filling roles in the low-paid and informal
domestic worker market, while the
growth of formal care employment has
been more modest. This situation is
likely to interfere with future
development in care policies in these
countries but may also affect the
opportunity to develop a properly
regulated care sector
4
Da Roit, Le Bihan,
and ¨
Osterle
2007
Austria, France, and Italy Mixed: Austria and France Informal:
Italy
Unconditional cash benefits develop a
grey care market. They reduce
employment creation
Countries differ in: 1) how cash benefit
programs have been developed, and 2)
how the benefits can be used to obtain
care. In France, the benefits serve to
fund specific care packages,
encouraging a formal market. In Italy
and Austria, beneficiaries are free to
use the benefit as they wish, facilitating
a grey market. In the three countries,
the benefits are used to pay for care in
the informal sector, which continues
to be the largest source of LTC
provision
4
Da Roit and Le
Bihan 2010
Germany, Austria,
France,Italy, the
Netherlands, and Sweden
Largely unregulated cash benefit
system: Germany, Austria, and Italy
Highly regulated cash benefit system:
France
Social services model: The
Netherlands and Sweden
In Sweden and the Netherlands, cash
benefits are an attempt to bring care
back to the family.In France, the
cash payments are intended to
boost employment. In other
countries, cash payments allow and
sustain the partial removal of care
from the family through the reliance
on an unregulated care market
The common trend is for cash benefit
programs for care provision. The
allowances have been used to maintain
or increase informal care, contain costs
and support the market. The benefits
have created new forms of
employment and have affected both
informal care and the organization of
care work and caregivers
4
(continued)
6INQUIRY
Table 2. (continued)
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Da Roit and
Weicht 2013
Austria, France, Germany,
Italy, Netherlands,
Norway, Spain, Sweden,
and UK
NA The intersection of care, migration,
and employment regimes shapes
different patterns of migrant care
work
This research studies two main
outcomes: Migrant-in-the-family and
migrant-in-formal-care. The migrant-
in-the-family outcome depends on two
necessary conditions: Limited public
expenditure on LTC services and a
high proportion of migrants in low-
skilled jobs, but there are different
paths in different countries. The
migrant-in-formal-care outcome
depends on four conditions: High
expenditure on services, lack of
expenditure on uncontrolled cash-for-
care schemes, allocation of
predominantly low-skilled jobs to
migrants, and absence of an
underground economy
9
Di Rosa,
Melchiorre,
Lucchetti, and
Lamura 2012
Italy Familistic The use of migrant care workers has
relieved many families of care tasks
but partly “crowded out”formal
care services
The findings show that the private
employment of migrant care workers
by families of dependent older people
in Italy has relieved them of the most
burdensome care activities, especially
in case of live-in solutions. Professional
services are being partly crowded out
by migrant care workers in most usual
care tasks, and they are reacting only
very slowly to the growing request for
more targeted investments and
expertise to better train and properly
integrate these new actors into the
existing formal care network
5
(continued)
Martinez-Lacoba et al. 7
Table 2. (continued)
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Lundsgaard 2006 Australia, Austria, Canada,
Germany, Ireland, Japan,
Korea, Luxembourg,
Netherlands, Norway,
Spain, Sweden, UK, and US
Informal: Korea, Spain, Japan
(mandatory insurance provides
substantial formal services), US
(informal, but now paid), and
Canada (informal, but now paid)
Mixed: Austria, Luxembourg,
Germany, Ireland, UK, and
Australia
Formal: Netherlands, Norway, and
Sweden
Payments for informal care can
undermine formal care employment
and normal labor market
Giving older adults a budget or cash to
pay informal caregivers can help tap
into a wider pool of human resources
where there are shortages of
professional care workers. On the
other hand, a functioning market for
formal home care services (or public
supply of such services) is essential to
allow relatives of older people in need
of care to maintain their attachment to
the normal labor market. Payments for
informal care can risk creating
“incentive traps”that attract informal
caregivers away from the normal labor
market, if the interaction between
informal care payments, taxes,
unemployment benefits, and other
transfer incomes is not well-
controlled. After having been away
from a normal job for a period, it can
prove difficult to return
4
Pavolini and Ranci
2008
Germany, France, Italy, the
Netherlands, UK, and
Sweden
Mixed and integrated: France and the
Netherlands
Mixed, services oriented: UKServices:
Sweden
Informal: Germany and Italy
Low quality employment may still
increase due to the separation of
funding and supply. This has made it
very difficult to control the level of
quality of both employment and
care
Long-term care reforms have resulted in
a general trend towards convergence
in social care at three levels: a) macro:
the continental countries have
increased the number of people in
receipt of care, but the northern
countries have reduced the degree but
not the intensity, of service provision.
Italy continues to rely on families and
the market; b) meso: a larger range of
providers has been implemented,
citizens have been empowered with
the capacity to choose, but a major
percentage of acquisition and control is
in the public sector; and c) micro: the
new forms of support for informal care
have favored the regularization of
caregiver employment and promoted
the recognition of informal care as
quasi-professional. Benefits have not
helped to eradicate gender inequality in
care provision
4
(continued)
8INQUIRY
Table 2. (continued)
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Shutes 2012 UK NA The employment of migrant care
workers has emerged in the context
of growing demand for care
alongside processes of cost
containment
Migrant mobility is conditioned by
immigration controls, in both access to
the labor market and job changes.
Migrant care workers find employment
in the care sector due to lack of
opportunities in other sectors,
accepting it out of necessity and not by
choice. It is also difficult to change
employer as the immigration
authorities may view this negatively.
On occasions, employers hold back, or
do not pay, wages to migrant care
workers. Their working days are
longer than those of native workers
are, and they are often used to cover
staff shortages
7
Shutes and Chiatti
2012
England/UK and Italy England/UK: Formal
Italy: Informal
State policies in care and migration
shape demand for migrant labor
across both informal and formal
models of care, and regular and
irregular care labor markets
In England and Italy, marketization
(contracting-out of services to private
providers and the provision of cash
transfers to older people to directly
purchase their care) has contributed to
the increasing employment of care
workers in private sector services and
in private households directly by older
people and their families. However, the
extent of these types of employment
varies according to differences in levels
of public provision and in types of
provision, between services and cash
transfers
9
Shutes and Walsh
2012
England and Ireland Formal Market-oriented and cost containment
policies have created divisions of
race, ethnicity, and citizenship in
LTC provision
Market-oriented policy aims for
personalization, as well as for cost
containment, thus raising implications
for divisions of race, ethnicity, and
citizenship in increasingly marketized
and privatized systems of long-term
care, as regards the financing,
purchasing, and delivery of services. By
framing the provision of care in terms
of the responsiveness of providers to
the preferences of the individual
service user, racialized hierarchies for
the selection of care workers and their
allocation to individual users are
potentially legitimated
11
(continued)
Martinez-Lacoba et al. 9
Table 2. (continued)
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Simonazzi 2009 Germany, Austria, Greece,
France, Italy, UK, and
Sweden
Mixed, continental: Germany and
Austria,
Formal, continental: France
Formal, Northern European: UK and
Sweden
Informal, Mediterranean: Greece,
Italy, and Spain
Regulated markets secure an adequate
supply of native workers.
Conversely, unregulated markets
have not been able to produce a
sustainable solution in terms of the
quantity and quality of care labor
France, United Kingdom, and Sweden
have fostered the creation of a formal
market. In Sweden and France, the
workforce is native and in the United
Kingdom, the workforce is mixed—
native and migrant. Germany and
Austria have used cash transfers to
promote family and informal care.
Germany depends on a native
workforce and Austria on a mixed
workforce—native and migrant. The
Mediterranean countries have
developed an extensive irregular
supply of migrant care workers in an
informal market
4
Spetz, Trupin,
Bates, and
Coffman et al
2015
US NA Demographic and utilization changes
will have little effect on projections
of robust long-term care
employment growth between now
and 2030
Given the movement toward non-
institutional care for the coming
generation of older adults, and the
resulting forecast growth of the
number of direct care provider jobs,
now is the time to develop and
enhance training and education
programs for all direct care workers
6
Van Hooren 2012 Italy, the Netherlands, and
England
Familistic: Italy
Social democratic: the Netherlands
Liberal: England
Cutbacks and need for elderly are
likely to further increase the
demand for migrant labor in care
services
Social care policies and the way in which
the state organizes the social care
sector were found to have a
considerable impact on migrant care
work. The availability of public services
crowds out the demand for private
(migrant) care services. Moreover, a
large public investment in public
services makes the social care sector
attractive for native employees and
decreases the dependence of care
providers on foreign labor. A familistic
care regime induces a “migrant in the
family”model of care, while a liberal
care regime leads to a “migrant in the
market”model of employment and a
social democratic care regime creates
no particular demand for migrant
workers in elderly care
9
(continued)
10 INQUIRY
Table 2. (continued)
Reference Geographical area Long-term care system by authors Effect of dependence on employment Summary of results
Quality
score
Williams 2012 Spain, UK, and Sweden Spain: Informal, Mediterranean
UK: Liberal
Sweden: Social democratic
The number of migrant care workers
is increasing
The intersection between care,
immigration, and employment regimes
generates variations between
countries. In Spain, hiring migrants for
care provision is a result of welfare
payments, immigration policies and the
worse working conditions make
migrant employment accessible. In
Sweden, migrant employment in health
and social care is a reflection of cost-
effectiveness and increased
outsourcing in a modernized welfare
state. In the United Kingdom, the
increased use of au pairs and nannies
reflects class preferences in home care,
consumer discourse, and logistical
difficulties in care responsibilities when
there is more than one child in the
household. The provision of elderly
care, however, is dominated by the
private sector
11
Martinez-Lacoba et al. 11
Our review shows that in the US and EU, the care sector is
characterized by low wages and bad working
conditions.
34,36,37,41,46,48
One study on the EU showed that
outsourcing of services has encouraged the deterioration of
working conditions.
47
Another work on Mediterranean
countries added that the care service market is especially
poorly regulated and the working conditions are considerably
different from those of other markets.
32
These changes generated by aging have favored the reform
or development of LTC systems.
32,36,37,40,41,48
These reforms
or developments, despite being applied in different countries,
share certain characteristics: (i) intention of creating a care
market,
32,36,37,40,45,48
(ii) fostering user empowerment, giv-
ing individuals the capacity to choose between services and
cash benefits—for example, cash benefit schemes allow
families a “free choice”of care providers,
36,37,40,41,47,48
(iii)
promoting home care,
36,37,40,41,48
or (iv) the promotion of
cash benefits.
23,36,37,39-41,47,48
In the US, EU, and other OECD countries, the intro-
duction of cash benefits for the care of older adults has
favored home care, affecting both the formal and informal
care workforce—for example, attracting informal caregivers
away from the formal labor market.
37,39-41,47,48
In other
words, cash benefits have promoted user empowerment,
increasing the capacity to choose,
36,37,40,41,47,48
and these
benefits have encouraged the creation of a care
market.
36,37,40,41,48
The use of cash benefits was also used to
contain care costs.
23,37
However, promoting user choice not
only affects users, but it can also have an impact on the care
workforce,
41,48
and payments for informal care can risk
creating “incentive traps”that could attract informal care-
givers away from the regular labor market.
39
This review has also found that care has been
commodified.
23,36,37,40-42,45,47,48
There are various points of
view explaining the rise of commodification of care. First, the
policy of cash benefits,
36,37,48
and, second, the reliance on the
private and not-for-profit sectors.
47
This latter perspective
argues that this reliance has fueled the commodification of
badly paid home care and that this commodification trend has
accelerated the intervention of the private sector in the health
and social care market, turning care provision into a large-
scale international business, thus affecting care workforce
conditions. Furthermore, a critical line on care system re-
forms states that, by separating funding from provision, the
creation of a market has given rise to the commodification of
care.
40
However, this critical line argues that what has ac-
tually happened is that this commodification has been ac-
companied by greater coverage and public regulation.
In addition, our results show that western EU welfare
states are increasingly dependent on migrant labor to meet
care needs and cover the demand for native labor.
23,32,34,35,42,48
Migrant care workers are helping to contain the social and
economic costs of care
37,48
and have also relieved many
families of care tasks. However, they have also partly
crowded out formal care services.
38
Our findings suggest various factors might explain the rise
in the reliance on migrant care workers. First, the development
of cash benefits, especially when the allowance is
unconditional—as in Germany, Austria, and other southern
European countries—has encouraged the use of migrant care
workers—mainly women—hired in the grey market, for the
provision of home care.
37,40-42,44,48
It is worth noting that the
migrant and gender gap is not only common in EU; in the US,
the workforce in the domestic service and care sectors mainly
comprises women, and, furthermore, migrant women.
34
Ad-
ditionally, in Italy, although benefit payments have been
conditioned to hiring regulated caregivers in order to reduce
the size of the informal market, the prevalence of cash transfers
in a poorly regulated labor market with an extensive informal
economy has favored a large supply of unregulated, and often
undocumented, migrant care workers.
41
If we focus on
southern European countries, our results show that the tradi-
tional and family-based care model—or familistic, where the
burden of care falls on the family, mainly the female members,
is shifting to a “migrant-in-the-family”care model.
32,41,44,47
On the other hand, the use of migrant labor for care services
can be explained by the difficulty of hiring and retaining
national caregivers, and migrant workers may be convenient
employees because they are even more vulnerable and, as a
consequence, willing to accept poor employment conditions
and low pay.
42
For example, in Taiwan, occupational segre-
gation was reported between local, foreign institutional, and
foreign home caregivers, the latter being the cheapest, most
obedient, and most adaptable product in the market.
43
As previously mentioned, user choice has not only af-
fected users. In this situation, the capacity for choice should
also be extended to the migrant care workforce, which is
compromised by immigration controls; the need to work—
they do not choose a job in the care sector, and they need it;
and the possibility of employers’reporting negatively to
immigration authorities if their employees want to change
jobs.
48
Our results also show that the development of the grey care
market is due to three factors.
36
First, being cheap, it is a cost-
effective solution for families, as indicated by several
studies.
32,36,40,41,43,47
Second, the migrant care workforce
earns more than in their country of origin because agreements
with families tend to include full board, as indicated in other
studies.
32,36,41
Third, the grey market has reduced the pres-
sure on social service demand.
37
Moreover, another consequence of the use of migrant
labor to meet care demand is a partial undermining of the
development of a formal care market,
32,36-38
while it has also
encouraged the commodification of care.
40
Discussion
To the best of our knowledge, this systematic review is the
first to offer a synthesis of the scientific evidence provided by
the studies available on the impact of dependence and long-
12 INQUIRY
term care on employment in the care sector. The wide the-
matic variety and heterogeneity of the studies necessitated
determining the causal chain connecting the topics addressed
in the studies with the aim of the review. Figure 2 shows a
conceptual map depicting the interrelation between the dif-
ferent topics analyzed in the studies.
Due to global aging, LTC systems have had to be re-
formed, or developed wherever they were lacking, to confront
the increase in demand for care, the need for labor, and the
costs associated with care. Based on long-term care worker
projections, the paid long-term workforce would need to
grow to avoid serious future labor shortages.
5,8,9
However, to
date, the reforms proposed have encouraged the creation of a
care market and the maintenance of home care, be it with
formal or informal employment. The purpose of this was to
contain care costs rather than to manage the labor care market.
One of the measures used is the introduction of cash
benefits, the aim of which is to give families the financial
power to choose how to spend the money, thus fostering
competition in the sector. In countries where the cash benefit
is conditioned to hiring personnel or services, formal em-
ployment has been created. However, as our results have
shown, the main problem of this measure arises when the
allowance is unconditional, that is, when proof of con-
sumption is not required. In countries with an informal
services market, families use this market due to the low cost
and high flexibility of extensive migrant labor.
8
This has led
to a crowding out of other, more costly alternatives.
32
Consequently, the first effect on employment in the care
sector has been employment creation, albeit of poor quality,
in countries with conditional cash allowances. The second
effect, in countries with unconditional cash benefits and a
grey economy, is dual in nature: an increase in the weight of
migrant workers in the total provision of care and increased
precariousness of labor in the care sector. However, the
migrant care worker phenomenon is currently emerging in
countries with well-developed formal services, as a result of
cutbacks in the care sector.
50
The migrant care workforce, which is mainly women,
23,51
has been a cheap and flexible solution for families. It has also
Figure 2. Conceptual framework.
Martinez-Lacoba et al. 13
enabled migrant care workers to earn more than they would in
their own countries and has served to contain the pressure on
the demand for caregivers.
37,51
The long working hours to
which migrant workers are exposed, together with the inse-
curity involved in immigrant status, undermines the ability of
these caregivers to develop affective relationships with the
people they care for.
48
Furthermore, female migrant care
workers have been especially vulnerable to exploitative
working conditions since domestic services are often paid
under the table and in poor conditions.
8,34
Consequently, the
exploitation of migrant labor limits the quality of care as
quality care is dependent on relationships of affection, not
exploitation.
48
Thus, given the precarious situation in the care
sector, the incorporation of migrant labor has not enhanced the
pay and working conditions, but actually the contrary; the use
of migrant labor has undermined the development of the
formal care market.
32,36,37
Furthermore, limiting the analysis
of the effect of dependence and care on employment to a
Eurocentric point of view significantly reduces the perspective
of a global problem. Some countries of origin have specialized
in “exporting”migrant care workers to specificdestinations.
32
Remittances—money sent home—are a relatively stable
source that often help to raise family income, may improve
living conditions, and encourage economic development.
52
However, the migration of nurses, nursing assistants, and
other long-term care workers has created a care deficit in the
countries of origin.
34
In addition, this is important because the
infrastructures in place in less developed countries are in-
sufficient to meet this need.
2
The assignment of care to the
private realm of the home, while generating job opportunities,
however limited, for female migrants as domestic workers in
developed countries, means they leave their own care re-
sponsibilities in the country of origin to their families.
48
In
other words, while female migrant care workers serve as
caregivers in richer countries, they create care needs which are
covered by their partners, other relatives, or they may even use
a domestic worker themselves—which at the same time is
often an internal or an international migrant, and often another
woman.
53
This phenomenon of a series of personal links
between people across the globe, based on the paid or unpaid
work of caring, is known as the “global care chain.
8,54
Thus, in
the target countries, employment in the domestic and care
sector, albeit precarious, is being created,while in the countries
of origin, the development of the job market is restricted since
part of the active population is working in other countries.
The studies analyzed do not provide sufficient information
to determine the limit of a care system in countries depending
strongly and increasingly on migrant labor, with the ex-
ception of two studies suggesting that the sustainability of the
system will depend on the time the countries of origin take to
recover economically.
32,34
Another perspective shows that
large public investments in public services make the social
care sector attractive for native employees and decreases the
reliance on migrant care workers.
42
One interesting policy
could be to protect migrant care workers by means of labor
regulations, avoiding differences between native and foreign
care workers.
43
Others policies to support caregivers could be
to encourage leave from work, a flexible work schedule, or
respite care, among others.
1
Hence, it is of great importance to
ensure that both native and migrant care workers and care
recipients have a decent life. In general, a large majority of
long-term care workers feel that their work is useful, but
many are not satisfied with their working conditions.
55
On other hand, better working conditions are necessary in
order to guarantee the quality of care. As our review has
shown, over the last few years, the commodification of care
has favored growth in private service provision, which could
create additional difficulties. As stated by the ILO, public
provision of care services tends to improve the working
conditions and pay of care workers, whereas unregulated
private provision tends to worsen them, irrespective of the
income level of the country.
8
Despite the many efforts to
improve the quality of care—notably through accreditation
systems and the constant refinement of standards—the
quality of LTC still remains a problematic issue in Euro-
pean countries.
5
For this reason, it is necessary for LTC to be sustainable: it
must be accessible, fair, and flexible.
24
This means that care
policies must be designed with a mixture of freedom of choice
of provider, state responsibility to provide care for families
who are unable to obtain it themselves, and the development
of an efficient private sector for those who wish to find
another form of care. Care policies should consider different
national contexts and the developmental stage of their care
systems, and in this sense, from Southeast Asian countries to
the US and EU, LTC systems are being reformed.
55,56
Moreover, despite care systems being an expense, they can
produce an economic return through the formalization of
employment.
Limitations
This study has some limitations that need to be considered.
The main limitation is a possible selection bias resulting from
the databases consulted, the search strategy, and the exclusion
of articles not published in English. Furthermore, despite
having included grey literature, other similar studies or ar-
ticles from non-indexed journals have likely not been de-
tected. In addition, as the included studies are focused on
specific regions, their findings are applicable to these regions.
We added the tag “EU,”“US,”or other country/regional
quotes to facilitate the reading and the interpretation. How-
ever, it must also be considered that the challenges, changes,
and reforms in different long-term care national systems are
frequently common.
55
Finally, the limitations and quality of
the studies included could condition our conclusions.
However, the main strength of this work is the use of a
systematic and structured search methodology for the studies
published, as well as a specific methodology for preparing the
narrative synthesis.
14 INQUIRY
Conclusions
This review shows that, due to global aging, LTC systems
have had to be reformed, or developed wherever they were
lacking, to confront the increase in demand for care, the
need for long-term care workforce, and the costs associated
with care. However, the main policies and reforms have
encouraged the creation of a care market and the main-
tenance of home care, creating two kinds of employment.
On the one hand, in countries with conditional cash al-
lowances, formal employment has been created. On the
other hand, in countries with unconditional cash allow-
ances and an informal services market, there has been an
increase in the weight of migrant workers in the total
provision of care and increased precariousness of labor in
thecaresector.
The variations in policies may determine what kind of
employment is created. Therefore, future care policies and
reforms should address three main objectives. First, they
must be designed with a mixture of freedom of provider
choice, state responsibility to provide care for families in
need, and the development of a private sector for those who
want to find another kind of service. Second, they should
take advantage of the economic return that formalization of
employment can produce. Third, they must ensure that both
native and migrant care workers and care recipients have
decent living conditions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
research has been funded by the University of Castilla-La Mancha
Research Group “Economy, Food, and Society.”(Project 2019-
GRIN-27194.). The funder had no role in study design, data col-
lection and analysis, decision to publish, or preparation of the
manuscript.
ORCID iDs
Roberto Martinez-Lacoba https://orcid.org/0000-0001-5543-2191
Isabel Pardo-Garcia https://orcid.org/0000-0003-4391-6011
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