Equity Choices and Long-Term Care Policies in Europe: Allocating resources and burdens in Austria, Italy, the Netherlands and the United Kingdom
... Austria has traditionally been viewed as a strong social-democratic state with an emphasis on a gendered division of labour and the 'male breadwinner' model of welfare provision, resulting in low levels of provision of formal care services (Bettio and Plantenga, 2004). In 1993 the long term care allowance ('Pflegegeld') system was introduced, a tax-financed non-means tested benefit paid directly to the disabled or older person (Oesterle et al, 2001). It is generally used to purchase care from either organisations, individuals, or to reimburse family members (Hammer and Oesterle, 2003). ...
... It is generally used to purchase care from either organisations, individuals, or to reimburse family members (Hammer and Oesterle, 2003). They have tended to be used to fund informal care or migrant/'grey' labour market workers (often from neighbouring accession states), reinforcing traditions of lowpaid workers (often women) with very little employment protection whilst also reinforcing gendered divisions of labour within the familial sphere (Kreimer and Schiffbaenker 2005;Oesterle et al 2001). ...
Draft only Abstract There are moves across many countries away from state-led provision of services for disabled people towards cash-based systems, which have been welcomed by disabled people as increasing choice and control over services and support, and increasing independence and social participation. However, feminist scholars have long warned about the implications of commodifying care for women, and the implications of substituting cash for services for social citizenship have remained underexplored, for both disabled people generally, disabled women and mothers more particularly, and for personal assistants/care workers. This paper will attempt to address that gap by carrying out a comparative literature review and policy analysis of the role of policy development and outcomes in cash-for-care schemes, looking comparatively across policy developments in several European countries* as well as developed welfare states beyond Europe to examine: a) the impact of the tensions between various governance levels, particularly local and national government, in the development and implementation of cash-for-care policies and b) the gendered impact of such policies on (for example) gendered divisions of paid and unpaid work, citizenship and social participation c) the impact such policies have, or are likely to have, on different groups of men and women across the lifecourse and across different social and economic groups d) how such policies can contribute to the wellbeing and/or detriment of different groups of women (and men) within different social, political, economic and historical contexts The paper will conclude with a critical discussion of the usefulness and complexity of carrying out a comparative analysis of policy developments across various governance schemes, and particularly the role that tensions between local and national government play in developing and implementing policies that have direct and indirect impacts on social citizenship outcomes for different groups of disabled people, and the intended and unintended gendered outcomes of such policies.
... Austria has traditionally been viewed as a strong social-democratic state with an emphasis on a gendered division of labour and the 'male breadwinner' model of welfare provision, resulting in low levels of provision of formal care services (Bettio and Plantenga, 2004). In 1993 the long term care allowance ('Pflegegeld') system was introduced, a tax-financed non-means tested benefit paid directly to the disabled or older person (Oesterle et al, 2001). It is generally used to purchase care from either organisations, individuals, or to reimburse family members (Hammer and Oesterle, 2003). ...
... It is generally used to purchase care from either organisations, individuals, or to reimburse family members (Hammer and Oesterle, 2003). They have tended to be used to fund informal care or migrant/'grey' labour market workers (often from neighbouring accession states), reinforcing traditions of lowpaid workers (often women) with very little employment protection whilst also reinforcing gendered divisions of labour within the familial sphere (Kreimer and Schiffbaenker 2005;Oesterle et al 2001). ...
There are moves across many countries away from state-led provision of services for disabled people towards cash-based systems, which have been welcomed by disabled people as increasing choice and control over services and support, and increasing independence and social participation. However, feminist scholars have long warned about the implications of commodifying care for women, and the possible consequences of substituting cash for services for social citizenship have remained underexplored, for both disabled people generally, disabled women and mothers more particularly, and for personal assistants/care workers. This article will attempt to address that gap by carrying out a comparative literature review and policy analysis of the role of policy development and outcomes in cash-for-care schemes, looking comparatively across policy developments in several countries, as well as developed welfare states beyond Europe to examine: (a) the impact of the tensions between various governance levels, particularly local and national government; (b) the gendered impact of such policies on (for example) gendered divisions of paid and unpaid work, citizenship and social participation; (c) the impact such policies have, or are likely to have, on different groups of men and women across the life course and across different social and economic groups; and (d) how such policies can contribute to the well-being and/or detriment of different groups of women (and men) within different social, political, economic and historical contexts.
... But if the recipient's income (including care allowance) and assets are insufficient to cover the costs of these services, the social welfare plan will cover this difference. [21,22] The need to care and protect older people is no longer an exception and has become a central issue in Austrian social policy. Not only those in need of care, but also their families and caring relatives need support because they carry a heavy burden and a very valuable share in society. ...
Background: Population aging leads to change of population structure and increase care needs. Lack of proper planning in this field
will lead to occur increasing problems. In this paper, the review of the elderly care plans at various levels in some European and
Asian countries, comparing these countries with Iran with the goal of using their experiences to enhance elderly plans have been
done. Methods: This research was a review study of library documents and resources and systematic search. Data were collected
using the resources, databases, scientific databases and websites of the Ministry of Health and Welfare of the studied countries.
Results: Based on this research in the studied countries, the care services of the elderly is based on the important principle of
coordination between different organs of the country, followed by the creation of LTC insurance and provision of health and social
services for the elderly and mainly the type of home care. In Iran country, providing appropriate services and cares for the elderly
with existing plans and policies is not possible and the need to provide appropriate service packages based on the different systems
of successful countries and applying the experiences of these countries is essential. Conclusion: Given the current status of the
Iranian elderly population in terms of policies and plans and the types and methods of providing services, quality, access and
financial resources allocated to this age group, compared to the studied countries, there is a well and integrated plan is essential.
... But if the recipient's income (including care allowance) and assets are insufficient to cover the costs of these services, the social welfare plan will cover this difference. [21,22] The need to care and protect older people is no longer an exception and has become a central issue in Austrian social policy. Not only those in need of care, but also their families and caring relatives need support because they carry a heavy burden and a very valuable share in society. ...
Background:
Population aging leads to change of population structure and increase care needs. Lack of proper planning in this field will lead to occur increasing problems. In this paper, the review of the elderly care plans at various levels in some European and Asian countries, comparing these countries with Iran with the goal of using their experiences to enhance elderly plans have been done.
Methods:
This research was a review study of library documents and resources and systematic search. Data were collected using the resources, databases, scientific databases and websites of the Ministry of Health and Welfare of the studied countries.
Results:
Based on this research in the studied countries, the care services of the elderly is based on the important principle of coordination between different organs of the country, followed by the creation of LTC insurance and provision of health and social services for the elderly and mainly the type of home care. In Iran country, providing appropriate services and cares for the elderly with existing plans and policies is not possible and the need to provide appropriate service packages based on the different systems of successful countries and applying the experiences of these countries is essential.
Conclusion:
Given the current status of the Iranian elderly population in terms of policies and plans and the types and methods of providing services, quality, access and financial resources allocated to this age group, compared to the studied countries, there is a well and integrated plan is essential.
... Individual care payments (the use of which is not governed) have been developed are used to pay family members or employ care workers (Hammer and Oesterle, 2003;Oesterle, 2001), in often on the black (unregulated) labour market or employing migrant workers (Gori and Da Roit, 2007;Ranci, 2007;Kreimer and Schiffbaenker 2005). Lack of regulation means that payments are not always used for care, and workers have very little employment protection ...
Purpose
There are clear theoretical, policy and practice tensions in conceptualising social or long-term care as a “right”: an enforceable choice. The purpose of this article is to address the following questions: Do disabled and older citizens have the right to long-term care? What do these rights look like under different care regimes? Do citizens have the right or duty to *provide* long-term care? It is already known that both formal and informal care across all welfare contexts is mainly provided by women and that this has serious implications for gender equality.
Design/methodology/approach
In this article, the author takes a conceptual approach to examining the comparative evidence from developed welfare states with formal long-term care provision and the different models of care, to challenge feminist care theory from the perspective of those living in care poverty (i.e. with insufficient access to long-term care and support to meet their citizenship rights).
Findings
Drawing on her own comparative research on models of long-term and “personalised” care, the author finds that different models of state provision and different models of personalised care provide differential citizenship outcomes for carers and those needing care. The findings indicate that well-governed personalised long-term care provides the best outcomes in terms of balancing potentially conflicting citizenship claims and addressing care poverty.
Originality/value
The author develops new approaches to care theory based on citizenship and care poverty that have not been published elsewhere, drawing on models that she developed herself.
... The availability of public services on the territory is the more relevant contender of SE deprivation. Indeed, the cost of services, if sustained by general taxes and/or by limited forms of copayment, significantly reduces the economic possibilities of the single individual or of the familial nucleus [5,43,46]. More specifically, regional distributions show how regions with a higher system answer capability invest more in LTC in terms of resources and services than others [47,48]. ...
The sustainability of European Long-Term Care systems faces the demographic and socioeconomic circumstances, mainly the increasing ageing of the population, with its chronic disease conditions, and the simultaneous economic general crises, exacerbated by the recent COVID-19 pandemic. Beyond the increase in the general rate of relative poverty, there is a higher risk of poverty among the elderly and families in high demand of care, especially if situations of Activities Daily Living (ADL) disability are present. Italian welfare, which is based on family care regimes and regional strategies, and is oriented to private or public care, is a relevant case study with which to analyze such a relationship. This paper aims to study the relationship between ADL disability and the socioeconomic deprivation of families, that is, household poverty. Variables came from the ISTAT Health for All Italian Database and the INAIL Disability Allowance Database. A pool of statistical methods, based on bivariate and multivariate analyses, from bivariate correlation, through multiple linear regression to principal component factor analysis, were used to reduce the number of the variables and compute the indicators. The multivariate analysis underlines how ADL disability impacts a household's poverty, confirming the existence of statistical correlation between them. Moreover, the study identifies and measures two answer capability models to cope with household poverty. The answer capability of the formal system is the main tool for reducing poverty due to one family member's ADL disability. Integration and collaboration between the formal system and family capabilities remains the main solution.
... The welfare state caring regime has for a while now been under pressure due to fnancial constrains and also other social-cultural changes surrounding old age-related needs. In particular, care-dependency emerges as a new social risk in the 90s, increasing the demand for long-term care (LTC) measures and asking for a restructuring process of the healthcare policy feld, throughout all the European countries (Pavolini & Ranci, 2013;Österle, 2017Österle, : OECD, 2017. The LTC reforms followed the frst, the second and the third policy change's order 4 . ...
... Such interest derives from welfare systems having to face the ageing of populations and looking abroad for evidence regarding effective policies and practical implementations. In conducting cross-national research on long-term care of the elderly, many researchers have relied on existing literature or secondary quantitative data to explore the provision and cost of care (e.g., Glendinning, 1998;Ősterle, 2001). Only a small number of countries were studied qualitatively, by a few researchers equipped with intimate knowledge of the countries under study, so that a concrete, welldefined issue could be investigated in two or more national contexts (e.g., Jani-Le Bris, 1993;Ungerson, 2004). ...
The issue of the elderly people’s rights has been discussed more and more often in the broader context of human rights. There is much evidence from social life that these rights are not being respected to the extent they should be. Securing and respecting the rights of older the elderly is becoming a challenge for state authorities that uphold human rights and create the directions of social policy for the rights protection. It is especially important as the elderly people due to their age, health status, weakened social position, rarely become advocates of their own interests. They are victims of an unobvious and often invisible process of marginalization and self-exclusion from an active social life. The aim of this article is to sketch the phenomenon of the marginalization of the elderly in the context of mechanisms related to their functioning on the one hand, and age, and on the other to social attitudes towards seniors. There are presented the elderly people’s rights and basic conditions for the rights to be respected..
... Such interest derives from welfare systems having to face the ageing of populations and looking abroad for evidence regarding effective policies and practical implementations. In conducting cross-national research on long-term care of the elderly, many researchers have relied on existing literature or secondary quantitative data to explore the provision and cost of care (e.g., Glendinning, 1998;Ősterle, 2001). Only a small number of countries were studied qualitatively, by a few researchers equipped with intimate knowledge of the countries under study, so that a concrete, welldefined issue could be investigated in two or more national contexts (e.g., Jani-Le Bris, 1993;Ungerson, 2004). ...
... Arguably, limited and unequal access to childcare services perpetuates social inequalities, whereas investment in early education can protect children from further social disadvantages and contribute to more equality. Elderly care has emerged as a major social policy concern in OECD countries more recently (Da Roit, Le Bihan, & Österle, 2007;OECD, 2011b;Österle, 2002;Pavolini & Ranci, 2008). The proportion of GDP spent on long-term care is especially high in the Nordic countries, Australia and Japan (more than 1% of GDP) and it is estimated to at least double and possibly triple by 2050 (Comas-Herrera et al., 2006;OECD, 2005). ...
... Micro-level Daly and Lewis (2001) have observed for social care, I argue that this issue has remained underdeveloped in mental health care so far. Notably, the framework incorporates the role of the informal sector which has all too often been neglected in current welfare state reforms and their analyses (Osterle 2001). Not least, the framework's beauty lies in the fact that it connects the changes on the macro level with the micro level, thus making visible the relationship between financing arrangements and individual social relations within mental health care provision. ...
... In conducting cross-national research in the long-term care of older people, many researchers have used literatures and/or secondary quantitative data to explore the issues of paying for and providing care (e.g. Glendinning, 1998;Ö sterle, 2001). Some have researched a small number of countries qualitatively, where researchers can look at a well-defined issue in two or more national contexts with an intimate knowledge of all the countries under study (e.g. ...
This paper aims to fill an important gap in cross-national comparison conducted by a solo-researcher through an example of a three-nation study of the long-term care of older people, in order to make transparent some of the key issues—time and space, comparability, culture and language—involved in the practical implementation of cross-national qualitative research. It is argued that cross-national comparison is very demanding in terms of language skills, cultural understanding, resources and time to provide a rigorous comparative instrument and outcome. Key approaches that address challenges for solo-researchers are: careful attention to geographical location and flexibility in timetable and programmes for gathering data; employment of multi-disciplinary knowledge to address the complexity of the research topic; application of a multi-method and multi-layer approach in data collection and analysis; recognition of the caring culture; and sensitivity of national as well as local language. In contrast to the challenges, the paper concludes with an analysis of the added value of solo-researcher activity in cross-national research.
... Until 1993 the public support system in Austria was characterised by a decentralised responsibility for care support, cash benefit structures, and home-based and residential service offers. Decentralisation resulted in considerable regional disparities with regard to eligibility criteria, levels of payment and a limited offer of both home-based and residential service provisions (Österle, 2001; Da Roit et al., 2008). The 1993 reform incorporated two main parts. ...
... Elderly care has emerged as a major social policy concern in OECD countries more recently (Österle 2002;OECD 2005b and2011b;Da Roit et al. 2007;European Commission 2006;Pavolini and Ranci 2008). The proportion of GDP spent on long-term care is estimated to at least double and possibly triple by 2050 (OECD 2005b;Comas-Herrera et al. 2006). ...
This paper looks at how the income distribution in countries changes when the value of publicly-provided services to households is included. We consider five major categories of public services: education, health care, social housing, childcare and elderly care. On average across OECD countries, spending on these “in-kind” benefits accounts for about 13% of GDP, slightly more than the spending on cash transfers – but with considerable cross-country variation. Broadening the income concept to account for in-kind benefits considerably increases households’ economic resources: in a typical OECD country, the average annual household income would be close to USD 28 000, rather than USD 22 000 in purchasing power parities. But public services also contribute to reducing income inequality, by between one-fifth and one-third depending on the inequality measure. Mexico and, according to most inequality measures, the United States, Portugal, Ireland, and the United Kingdom record higher reduction rates, while Slovenia records lower ones. Across all countries, redistributive effects are stronger among specific population groups at higher risk of poverty. Between 2000 and 2007, the redistributive impact of public services remained stable overall. However, the impact became stronger in countries where the share of services in household income increased significantly, while it weakened in those countries where this share decreased. The paper suggests that publicly provided services fulfil an important direct redistributive role in OECD countries.Ce document examine la façon dont la distribution des revenus varie dans les pays lorsque la valeur des services publics fournis aux ménages est inclue. L'imputation de la valeur de ces services dans les revenus des ménages et l'analyse de leur potentiel redistributif posent des défis méthodologiques importants, tels que l’estimation et l’allocation de ces services aux bénéficiaires, ou l'ajustement de l'échelle d'équivalence aux besoins associés à ces services. Nous présentons des analyses de sensibilité, en utilisant deux approches innovatrices mises en avant dans la littérature. Le document considère cinq grandes catégories de services publics : éducation, santé, logement social, garde d'enfants et soins aux personnes âgées. En moyenne, dans les pays de l'OCDE, les dépenses relatives à ces prestations «en nature» s’élèvent à environ 13% du PIB, soit légèrement plus que les dépenses relatives aux transferts en espèces - mais avec beaucoup de variations entre pays. Elargir le concept de revenu pour tenir compte des avantages «en nature» augmente considérablement les ressources économiques des ménages : dans un pays typique de l'OCDE, le revenu annuel moyen des ménages serait proche de 28 000 USD, plutôt que 22 000 USD en parité de pouvoir d’achat. Mais les services publics contribuent également à réduire l'inégalité de revenus, d’un cinquième à un tiers en fonction de la mesure d’inégalité. Le Mexique et, selon la plupart des mesures d’inégalités, les États-Unis, le Portugal, l'Irlande et le Royaume-Uni enregistrent des taux de réduction plus élevés, tandis que la Slovénie enregistre des taux de réduction plus faibles. Dans tous les pays, les effets redistributifs sont plus forts parmi les groupes de population spécifiques à risque de pauvreté plus élevé. Entre 2000 et 2007, l'impact redistributif des services publics est resté globalement stable. Toutefois, l'impact est devenu plus fort dans les pays où la part des services dans les revenus des ménages a augmenté de manière significative, alors qu'il s’est affaibli dans les pays où cette part a diminué. Le document suggère que les services publics remplissent un rôle de redistribution directe important dans les pays de l'OCDE.
International research on long-term care (LTC) can valuably inform LTC policy and practice, but limited transnational collection of data on key LTC issues restricts the contributions of international LTC research. This special collection of Gerontology and Geriatric Medicine helps close the gap between the status quo and the potential for international LTC research by cultivating a transnational common ground of internationally prioritized measurement concepts and sowing the seeds of international LTC common data elements. The articles in this special collection address both adaptive and technical challenges to international LTC measurement, build on and complement existing LTC measurement systems, and provide diverse international perspectives on the measurement of LTC across four overarching domains: LTC contexts, workforce and staffing, person-centered care, and care outcomes. From large transnational teams of scholars specifying the meanings of central LTC concepts, to smaller subnational research teams testing new measures of person-centered care across diverse local LTC settings, contributors spark new insights and point in new directions for a LTC measurement infrastructure supportive of person-centered care and lifelong thriving.
Market-oriented restructurings of long-term care policies contribute significantly to the aggravation of care workers’ situations. This article focuses on the effects of broader long-term care policy developments on market-oriented reforms. Germany, Japan and Sweden are three countries that have introduced market-oriented reforms into home-based care provision embedded in distinct long-term care policy developments. Conceptually, this article draws on comparative research on care to define the institutional dimensions of long-term care policies. Empirically, the research is based on policy analyses, as well as on national statistics and a comparative research project on home-care workers in the aforementioned countries. The findings reveal the mediating impact of the extension and decline of long-term public care support and the corresponding development of the care infrastructure on both the restructuring of care work and the assessments of the care workers themselves.
This chapter analyses policy paradigms in the area of long-term care for older people in France, Spain, England, Sweden and Germany2 since the mid-1990s. The chapter identifies three paradigms that do not have much in common and that have not converged in any essential respects. While the statist paradigm (to which Sweden continues to adhere) and the familialist/individualist paradigm (to which care policies in England and Spain belong) have experienced only minor changes, the ‘state pays, others provide’ paradigm to which France and Germany adhere has undergone extensive changes. Contrary to some other recent accounts of the development of social care systems, this chapter argues that there are no signs of significant convergence towards universalisation, individualisation and formalisation in the long-term care policy paradigms in the five countries analysed here. Despite the absence of significant convergence between the paradigms, there are two common themes that the long-term care policies in all five countries share, namely the emphasis on homecare (domiciliary or ‘community’ care) and the increased inclination to turn to the market as a source of care (marketisation).
In den alternden europäischen Gesellschaften entwickelt sich seit einigen Jahren transnational praktizierte Altenpflege. Der wachsende Pflegebedarf für Ältere wie auch die abnehmenden Pflegepotentiale der mittleren Generation einerseits und die Zunahme der temporären weiblichen Arbeitsmigration in Haushaitstätdgkeiten andererseits münden in graue Pflegemärkte. Tätigkeiten der Versorgung, Pflege und Haushaltsarbeit - eben ‚Care‘ - werden zunehmend von Frauen übernommen, die von ärmeren in reichere postindustrielle Länder wandern und auf einem informellen transnationalen Pflegearbeitsmarkt landen (Sassen 2001; Gather et al. 2002).
This chapter analyses the reform developments that took place in Austria in the long-term care (LTC) sector over the last two decades. The first section provides a brief overview of the history of LTC policies (culture, values, actors, policies) and a description of the field of LTC as it has been institutionally defined in Austria. In the second section, the 1993 cash for care reform is presented and discussed, looking in particular at the content of the reform, at the concrete mechanisms that have facilitated institutional change, and at the coalitions of actors who have pushed for change. This is followed by an analysis of the developments after 1993, characterised by only gradual changes. In the next section, the chapter examines a new major reform, which has been introduced in the last few years, focusing exclusively on the regularization of migrant care in the private household. In studying the developments from the establishment of long-term care as a separate social policy field in 1993 up to the present, this chapter focuses on two major aspects: (1) it analyzes the aims, tools, and effects of the major reforms and gradual changes in that period; and (2) it studies the driving forces behind the changes, including the role of the various actors involved and the specific reform mechanisms. The final section provides a broad interpretation of such innovation. © 2013 Springer Science+Business Media New York. All rights reserved.
Since the 1990s, two distinct processes of marketization in long-term care provision can be found in Sweden and Germany. First, professional long-term care services were restructured inspired by ideas oriented towards New Public Management. Second, tax deduction policies were established to create a new mix of (ir)regular domestic and professional care services. Despite the international character of the development, the existing structure of professional and (ir)regular domestic services at the beginning and the approaches selected, their effects on the infrastructure and on the situation of care (and domestic) workers differ significantly between both countries. In both countries, research findings indicate – however country-specific - patterns of a worsening of working- and employment conditions of care workers embedded in distinct processes of hierarchisation among care workers. The paper aims to compare pre-existing service structures, policy approaches, their effects on service restructurings and the situation of care workers. Based on a comparison, it will reveal and explain the effects of country-specific policies and restructurings on processes of hierarchisation among care workers.
Conceptually, the paper combines international comparative research on care policies and marketization and intersectional approaches developed within sociology to relate the effects of marketization to the emerging patterns of inequalities within the care work force based on gender, social class (training levels and positions) and ethnicity. Empirically, it will include documents and laws, literature review and representative statistics to analyze policy changes and existing- and changing infrastructure. Findings of a German-Swedish research project on the situation of professional carers with approx. 600 care workers in each country, will be used to reveal the country-specific restructurings and processes of hierarchisation within formal care provision, which is complemented by research on the developments within domestic service provision.
With the introduction of the Long-term Care Insurance in Germany, a universal coverage scheme was established on the national level. Despite the universalistic orientation and clearly-defined care rights of this law, unequal care arrangements have emerged depending on gender, socio-economic class, living situation and ethnicity. The emergent care patterns are explained based on a conceptual approach to the impact of care policy designs on the construction of formal and informal care work as determined by life situations. Assessments and the use of types of benefits, care arrangement patterns, informal care-giving and the emergence of migrant carers within the family context provide the empirical basis for the analysis. The findings show that universal coverage on a medium level and the offer of cash benefits and services interact with social, economic and cultural factors of the life situations of beneficiaries and informal carers, and result in the unequal patterns of care arrangements.
This volume is a collection of research papers presented in three international conferences organized by the Athens Institute for Education and Research (ATINER), in 2005. The majority of papers were presented at the Health Conference, organized by the University of Athens in collaboration with ATINER. Some research works relative to health issues from Conferences on Education and Business, organized also by ATINER, are included in the present volume. The book is organized into three parts that deal with issues on the economics of health care, on health care management, and health policy and other health care related issues.
Health Economics
This part consists of 6 papers, which comes from 4 different areas. The first two presentations refer to public finance of health care services and its direct and indirect effects on health status for people living in a middle and a low income country: Turkey and Botswana. The third paper comes from the area of pharma-ceutical expenditures in Greece. The next paper deals with the productivity and economic efficency and quality of care of nursing homes in Finland. The final two papers are in the area of econo-mic evaluation.
Zafer Caliskan, from Turkey, investigates the effects of stru-ctural adjustment programmes (SAPs) on health outcomes and health care system. From the literature review, it becomes clear that there is no an exact relationship between SAPs and health status. The latter is measured with the indices of infant mortality rate (IMR) and child mortality rate (CMR). Thus, the empirical model used examines how health outcomes are affected by the changing socio-economic conditions in the process of structural adjustment policies. The author regresses the dependent variable of health outcomes on a number of explanatory variables. Cali-skan found that factors such as real per capita income, antenatal care, infant visits, and the female employment reduce both infant and child mortality rates. However, the failure to access data on rural-urban disparity and population subgroups within each province is a limitation of the paper.
Oluyele Akinkugbe, from Botswana, examines the extent to which the health status of the people of sub-Saharan Africa (SSA) may have benefited from the government interventions through increases in public health ecpenditure and other social services. Even though health care expenditures in SSA as a percentage of GDP have increased from 2.7 in 1997 to about 6.0 in 2000, the health status of the Africans declined over the same period. These developments have been attributed to some extend to the declining socio-economic conditions in the sub-region, and the recent upsurge in the HIV/AIDS pandemic. Three measures of health status were used: life expectancy at birth (years), infant mortality rate (per 1.000 live births), and under-five mortality rate (per 1.000). Akinkugbe found statistically significant rela-tionships between health status and number of physicians, female literacy, and immunization.
Dimitra Lambrelli and Owen O’Donnel measure the impact of the switch to new and more expensive drugs on aggregate drugs expenditure in Greece during the 1991-2001 period. Measured in real terms (adjusted for general inflation) drug expenditures increased by 78 percent between 1991 and 2002. In addition, the Greek reimbursement systems weaken the incentives for con-sumers to be price conscious. Consistent with other studies car-ried out in different countries, like Sweden, Spain and Canada, Lambrelli and O’Donnel demonstrate that the switch from in-expensive to expensive drug therapies constitutes the most im-portant factor explaining the rising pharmaceutical expenditures in Greece. The promotiom of generic prescribing, the integration of cost-effectiveness evaluations into price and reimbursement policies and the introduction of a monitoring system are some of the issues that require attention in order to secure that scare economic health care resource are allocated efficiently.
Juha Laine explores the productivity, technical and cost effi-ciency, and quality of care of nursing facilities for the elderly in Finland, in the 2000-2003 period. The main internal and external factors that nesseciate the discussion on productivity and effi-ciency issues in Finland are the continuously increase of ageing population, the cost of health and social care services, and the emergence of a new ideology, stressing that publicly financed and produced health care services are inefficient, and that Finland cannot afford to maintain the traditional Nordic welfare state mo-del. She used a “quality adjusted” stochastic frontier cost function model. Laine concluded that productivity of nursing services has decreased, whereas quality of the output has been stable between 2000 and 2003. Future policies of Finish government should focus to increase productivity and diminish efficiency differences of the nursing home facilities. To apply these, a nationwide quality mo-nitoring and quality assurance systems need to be introduced.
Aftab, Saint-Jean, and Fournier evaluate the performance of Fournier cervical self-sampling device in developed and develo-ping countries. Cervical cancer remains one of the leading causes of women mortality worldwide, and a major financial burden to health care system and society in general. The widespread deve-lopment of Papanicolaou (PAP test) smear screeing programme has allowed a substantial reduction in morbidity and mortality, during the past four decades in North America. However, the problem of cervical cancer remains huge in the developing coun-tries. Recent bio-medical and technological advances have resul-ted to the development of new screening methods for cervical ca-ncer and other sexually transmitted diseases. Regardless of these recent developments of screening programmes, the implementa-tion of such methods is very difficult in developing countries due to lack of sufficient and trained clinicians, cytologists and patho-lists to conduct these tests. In their paper, Aftab et al used a sample of women in both Haiti and Miami in the USA to evaluate the performance of a new self-sampling device for cervical ca-ncer and other diseases. From their analysis, it was found that the self-sampling device performed at least as well as the traditional methods. Self-samplinmg methods could improve the cost-effe-ctiveness of cervical cancer screening programmes in both the developing and industrialized countries. Also, these can produce one of the lowest cost benefit ratios of $27 per year of life saved.
Wilson, Strosberg and Barrio examine the costs and benefits of several current and potential strategies for the eradication and treatment of Chagas disease in Latin America and Caribbean- LAC. The prevelance of Chagas disease in these regions today is estimated to be 10-14 million, while the mortality estimates also range widely, from 13 to 50 thousands. They use a steady state Markov cohort simulation model and available literature on costs and benefits to model Chagas disease in LAC with and without the benefits and costs of the vector control programs and with and without the benefits and costs of a potential new drug treatment for Chagas disease in addition to these vector control programs. Thus, the authors compare the cost and effectiveness of these different options. It is concluded that the best strategies for the control and treatment of Chagas disease in LAC are a combined vector control plus new drug treatment approach. Such strategies result in earlier beneficial effects on morbidity and mortality and are highly cost-effective.
Health Care Management
The second part of this volume deals with issues on health care management. The first two papers focus on health care educational management in nursing and public health in two Euro-pean countries – the UK and Germany. The second presentation concerns service users’ perception and to what extend health care organizations in the UK can be promoted, and improve their performance. The next two papers use hospital services as a background and deal with the strategic management in Spainish public hospitals, and NHS managers’ views and beliefs towards recent health care reforms in the UK. The last three papers of this part are about disaster management in Turkey, management decision tools for resource allocation in Canada, and risk mana-gement decisions, in terms of international food standards in the WTO member states.
Sue Dyson examines the factors influencing undergraduate students from Zimbabwe to leave their country and study nursing in the UK. She uses a life history approach to understand their experiences and to make suggestions for improving their educa-tional management. Her sample includes nine nursing students in a UK university. The economic cricis, corruption, lack of health care, and the emergence of AIDS and HIV are the main reasons for Zimbabweans to leave their country. Choosing to study nur-sing in UK universities was one way to do this. Some recom-mendations for improving the educational management of such students should include greater facilitations in terms of the ele-ctronic information provided by the UK universities to those stu-dents. Educational leaders should provide Zimbabwean students with more information about occupational health services, and advice them on matters of personal health and safety. The UK gοvernment should take efforts to support newly qualified and existing practitioners from Zimbabwe working in the NHS. Future planning of the Zimbabwean nursing students should take into ac-count that they are likely to remain in the UK for some conside-rable time, and will probably bring their families to join them in the UK rather than returning to Zimbabwe.
Kreuter and von Stünzner from Germany present the public health education programmes developed by Magdeburg University at Applied Sciences, and compare it with the European dimension of public health education. The existing situation at Magdeburg University is that there exist programmes of continuous education and distance learning at four levels: singular courses, certificate offers, bachelor degree, and master programmes. For the scope of their paper, the authors analyze the last three categories here. Health oriented programmes in the Magdeburg University include two certificate, four bachelors, and three master degree pro-grammes. Except from three programmes that run by other uni-versity economic oriented departments, the remainings are dire-cted to public health education. Despite the fact that all pro-grammes offered at Magdeburg University, they include – more or less – a European oreientation, none of them can be characterized as a specific European health module. According to a community action plan (2003-2008), public health education programmes should be focused on the development of cooperation between European countries in general and specifically between educa-tional institutions.
David Rea examines the ability of organizations to learn from service users, and specifically the way that a team may change practice and policy as a result of a service user evaluation of care management. In practice, users’ involment into the management may affect positively the quality of health care provided. Rea uses a service provided for 720 people with learning diabilities. He results that knowlegde of user views cannot alone “trigger” orga-nizational change. It is, however, necessary leaders or managers to recognise that there are different learning approaches that make “service user” a key player in the whole process. However, the ability of provider organizations to adapt and learn from the experience of user involvement will depend crucially on their ca-pacity for organizational and management change.
Madorran-García and de Val-Pardo from the University of Navarra in Spain identify the strategic practices employed in a sample of general public hospitals and evaluate their performa-nce. Forty-eight public hospitals participate in this survey. The analysis shows that strategic practices are employed mainly in the areas of Human Resources and Marketing. When the hospitals are classified according to their strategic practices, two groups are emerged. In the first group, strategic actions in the area of Human Resources Marketing are taken, while in the second group such actions do not exist. There are significant differences in performance with regard to occupancy rate, with the first group presenting a higher rate. Madorran-García and de Val-Pardo conclude that the use of strategic practices is a way of improving performance, and it would be necessary to progress in this dire-ction. This would allow public hospitals to improve and adapt to new challenges and threats posed by existing environmental con-ditions.
Faruk Merali with a work in progress study provides an in-sight into the views, beliefs, and attitudes of some of the NHS managers towards the various reforms, and also how the mana-gers perceive their roles and functions within the NHS. Mereli uses a sample of 20 NHS managers, half of an Acute Care Trust and half of a Community Care Trust in London. In this paper, the author presents only the views of the 10 of the NHS managers. From the analysis arises that the majority of the managers sought the opportunity to work in an environment, which was under-pinned by altruistic values. Although NHS managers receive very low public recognition, they answered that would repeat their decisions to join the NHS. To the question whether they per-ceived any differences in relation to being an NHS manager rather than a manager in the private sector, they believe that the principles of management are similar both in the NHS and in the private sector, and they also acknowledge that there are some key differences regarding the skills required to manage within the NHS system. Regarding those managers with a medical related background, they found benefits and synergies between their me-dical knowledge and their managerial role, but they pointed out that there was poor support, training and education in terms of their management skills. The majority of the managers considered positively the recent NHS reforms, although they explained these reforms as a way to foster and develop a collaborative rather than a competitive spirit within the internal health market.
Nilgun Sarp from Ankara University focuses on the level of disaster management in Turkish health care services, especially in hospitals. Earthquakes, floods, and tropical storms are some of the disasters that unexpectetly happen. Planning for such a situation should be done at three different levels: before the disa-ster, with the hearing of the disaster, and when patients reach the hospital. At the first level, the existance of well staffed emerge-ncy departments at hospitals, and a completely disaster plan are the basic actions. The provision of accurate information to both the patients and the personnel of hospitals, and the secureness of enough supplies, like food, blood and vaccinations are some of the main things to do with the news of the disaster. At the third level, when injured patients arrive to the hospital, health personnel classify the patients, in terms of the seriousness of their injury, and the less serious cases are transferred to other health centers. No in-patients cases are treated to those hospitals for the whole period that there is increased demand due to disaster. Hospitals in Turkey are not ready for disasters. From a reasearch that has been conducted to 31 hospitals in Ankara it is concluded that al-most all hospital administrators are not well informed on disaster management, while they have only fire fighting plan.
Decision makers all around the world face the fundamental problem of scarcity of resources for satisfying infinite needs. Ro-ger Chafe reviews a number of available tools for making health resource allocation decisions at the institutional meso-level in Canada. He firstly presents a fictional decision problem, based on the type of multi-factor resource allocation dilemmas that deci-sion makers regularly face. Chafe examined five decision support tools, decision analysis, screen models, cost-effectiveness analy-sis, programme budgeting and marginal analysis, and Daniel’s ac-countability for reasonableness. He concluded that although all of these tools have some limitations, a mixture of programme bud-geting, and Daniel’s accountability for reasonableness could re-solve more appropriately the four fictional alternative requests presented here. In a general context, the value of any decision support tool ultimately depends on its being used and adapted by a health care institution.
Tracy Murray addresses the question to what extend socio-economic determinants are a part of a risk management decision, in terms of international food safety standards. The introduction of such determinants, like animal welfare, the environment, and biodiversity into the food regulatory system is a controversial is-sue. From the analysis, it is concluded that there is no consensus among the WTO member states regarding the extend to which socio-economic concerns should be included in the decision making process. Anecdotal evidence confirms that member go-vernments use socio-economic consideration on an ad hoc basis. Moreover, the positions of individual governments change from case to case. In many cases it is difficult to determine whether socio-economic concerns are central to an issue or are smo-kescreens to justify an outcome, which has a different desired outcome. For example, a consumer concern may be used to justi-fy a food standard designed to protect domestic producers.
Health Policy and Οther Ιssues
The third part of this book relates to health policy and other health care related issues. It consists of seven presentations. The first two papers refer to recent health care reforms in Germany and Norway. The next one presents an evolution of French health system, using a lexical analysis. The fourth paper deals with the evaluation of existing policies, regarding the aged in seven Euro-pean countries. The last three papers have economic and policy implications, and they discuss the issues of personality of smo-kers and non-smokers adolescences in Turkey, obesity among African American women in the USA, and antenatal screening for sickle cell/thalassaemia in Egland.
In view of considerable health care reforms all around the world over the last thirty years, Anton, Klautzer, Toenshoff, de Vries and Kahan present the results of a seminar game carried out by the RAND Europe in Germany. In this seminar participated representatives of all health care stakeholders, like providers, insurers, government, and social partners. The aim of the discus-sion was to explore feasible reform options in the German health care system, in terms of consumer responsibility and choice. They concluded that any health care reform should include the issue of quality assurance, while the issue of personal responsi-bility in the form of taking charge of one’s own health is viewed favourably, with no consensus on how to define appropriate indi-vidual behaviours to differentially ration health care services. Also, there is merit in supplamentary general tax financing to ba-lance future health care expenditure. Such a system would ensure solidarity, and stabilise the general economic climate.
Finnvold and Svalund from Norway estimate the effects of the implementation of a list-patient system in general practice on patients with chronic conditions. This regular general practitioner scheme was introduced in 2001. About 3,000 individuals were in-terviewed. They were asked about existing diseases, living con-ditions, and visits to their general practitioner both in 2001 (prior to the reform) and in 2003 (after the implementation). Only pa-tients with chronic condition were targeted. A general conclusion is that the implementation of the Norwegian regular general practitioner scheme was of benefit of this particular group.
Abecassis, Batifoulier, Bilon, Gannon and Martin present an evaluation of French health system using a lexical analysis. They focus on recent reforms, in terms of increasing competition bet-ween actors of the health care system in France. Their analysis is based on texts, and words, more than on data and figures. Deon-tology texts, which describe the relations between medical colle-agues and between doctors and patients, and legal texts, which deal with the relations between medical professionals and their administrators, are used for the lexical analysis. They conclude that the French health system is largerly presented as ruled by logic of rival blocks: political power versus medical power. The last reform project of the system in 2004 gives a measure of medical power. The French state seems to be unable to induce or force the physicians to admit the principles of orthodox mana-gement. The profession holds out the chart of liberal medicine or the ethical argument of the quality of medical care. Thus, as the authors conclude competitive regulation needs the state’s invi-sable hand, but the least that can be said is that it is trembling, compared with doctors’ iron first.
Vincent Coutton evaluates the processes of care for cogni-tive dependence in old age in seven selected European coun-tries: Belgium, Denmark, France, Germany, the Netherlands, Spain, and the UK. These seven countries are classified into three different models. The Beveridge system includes Denmark and UK, the Bismark system includes Germany and the Netherlands, and an intermediate system of social assistance which includes France and Spain. Belgium has characteristics of both Beveridge and the intermediate system. His study found that systems of care for cognitive dependence in old age in the European Union show a great diversity in the choice of concepts, measuring instruments and methods of financing and care.
Gürsoy and Biçakçi aim to determine the personality design of smokers and non-smokers adolescents in Turkey. Their sample includes 300 adolescences, which half are smokers and half are not. The variables they use are age, SES, educational background of parents, relations with friends and family members. The findings of the study indicate a statistically significant diffe-rence in personality scores of smoking and non-skoking indivi-duals. Personality scores of smoking participants are found to be lower than those on non-smoking participants. Statistically signi-ficant effects are produced by SES, parents’ educational level, peer and family relationships. Gender has not any significant ef-fect on personality scores of adolescences.
Shirley Blanchard examines the relationship between dep-ression, psychosocial issues and obesity among African American women, who live in Omaha, Nebraska. Obesity is a primary risk factor for disease for many Americans. African American women present the highest level of obesity (66 percent are overweight and 37 percent are obese) across all ethnic groups. In this rese-arch, a sample of 378 African American women was used. From the analysis, it is concluded that both psychosocial factors and depression were positive correlated with obesity. This puts Afri-can American women at high risk for disease.
Simon Dyson focuses on the ethnic question and antenatal screening for sickle cell/thalassaemia in England. Such a disorder mainly affects people of African, Caribbean, Midle Eastern, South Asian, South East Asian and Mediterranean descent, while rarely found in the Northern European population. Antenatal screening is routinely practised in the UK, with the aim of a) identifying mot-hers with sickle cell disease, b) distinguishing between iron defi-ciency anaemia and being a carrier of thalassaemia, and c) infor-ming couples at risk of having a baby with a significant problem at an early stage in pregnency. Dyson concludes that in order to minimize the number of real carriers not afforded early antenatal care with regard to screening for sickle cell and thalassaemia should use the evidence-based screening question, create sus-tained educational opportunities for health professionals (primary midwives), who carry out the screening depends, allocate suffi-cient time within routine service provision to administer a screening question based on full consultation with the mother about her needs, and expand the number and use of the skills of specialist counsellors.
The diversity of subjects covered in this book, the results of ATINER’s conferences, is of great interest to both specialists and non-specialist of the field covering a wide range of issues and topics. Health policy makers’ will find the book extremely useful because it gives them up-to-date research on themes that deal in the everyday implementation of policies. The lack of focus on a specific subject is more than compensated by the importance of the spread of issues covered that even the professionals and specialists will find it very interested to read. Professors and teachers of health courses may use this book as an additional reading in their course work, particular for postgraduate students.
Wie Wohlfahrtsstaaten mit der Etablierung sozialer Rechte das Zusammenspiel von Pflegebedürftigkeit und sozialer Ungleichheit
beeinflussen, ist systematisch noch ein weitgehend unterbelichtetes Thema. Der demografische Wandel führte seit den 90iger
Jahren des letzten Jahrhunderts in vielen europäischen Gesellschaften zu einer Einführung sozialer Rechte für das Risiko der
Pflegebedürftigkeit, die in der Regel Geldleistungen oder professionelle ambulante Dienste bzw. institutionalisierte Versorgung
einschließen. Der Trend zu einer verstärkt öffentlich finanzierten Pflege ist — abgesehen davon, dass man die insbesondere
durch die schrumpfende jüngere Generation knapper werdenden Pflegepotentiale stützen will — auch ein Ausdruck der Absicht,
das Risiko der Pflegebedürftigkeit und dessen Folgen gleicher auf viele Schultern zu verteilen. Gleich ob man steuerfinanzierte
oder durch Sozialversicherungen finanzierte Leistungen für Pflegebedürftige und ihre Angehörigen betrachtet, sie bilden einen
kollektiven Pool, der partiell die privaten Pflegerisiken und Ressourcenausstattungen an Einkommen und Vermögen angleicht.
Über die horizontale Gleichheit hinaus, die ein sozialstaatlich organisierter Absicherungspool bietet, stand bisher die geschlechtsspezifische
Ungleichheit in der Pflege und ihre wohlfahrtsstaatliche Einbettung im Fokus der sozialwissenschaftlichen Debatte. Aber welche
Möglichkeiten der sozialen Ungleichheit gibt es überhaupt in der Pflege und welche Rolle spielen dabei Wohlfahrtsstaaten mit
den von ihnen definierten sozialen Rechten?
Purpose
– The paper compares the introduction of universal long‐term care schemes and the regulations of migrant care work within the framework of multi‐level governance in Austria and Germany. The aim of the paper is twofold. First, it reveals the characteristics of country‐specific universal policy schemes and second, it explains their designs – the new type of universalism and its completion by regulations of migrant care work within the family framework – by the policy‐making process.
Design/methodology/approach
– Conceptually, the paper combines approaches within long‐term care research to define dimensions of universalism, as well as on multi‐level governance and new‐institutionalism to examine the policy‐making process. Empirically, Austria and Germany are selected as two cases.
Findings
– The findings reveal the significant dimensions of the new type of universalist policy design and of policies towards migrant care work. The country differences are explained by the policy‐making process within countries and with cross‐border effects. In particular, the impact of the disability movement in Austria and the coalition between the political parties in Germany resulted in a country‐specific definition of universalism. The integrated approach towards migrant care work in Austria is contrasted with the fragmented approach in Germany. In both countries, the regulations of migrant care work question the idea of universalism.
Originality/value
– The impact of societal actors and their ideas on the creation of a new type of universalism and the interrelated regulation of migrant care work has only rarely been examined. The analysis contributes to an understanding of the policy‐making process and its interrelationship with selected policy designs.
Throughout the developed world, countries are facing the challenge of developing long-term care systems and policies that will meet the basic needs of disabled older people. At the same time, it is trying to achieve good quality and economical care provision by finding a balance between the state and the family. To assess these countries' long-term care systems, this paper compares the similarities and differences between demographic and social issues, and the cultural and political differences shaping policy objectives, economic constraints and long-term care services. The statistical data for this article has been collected from supra-national institutions and national governments. While such indicators need to be treated with care because of a lack of consistent data, they, nevertheless, supply us with a basic understanding of social, political and economic circumstances. Nonetheless, this paper evidenced some conversion trends that are showing a closing in of the gap of welfare and long-term care systems between the East and the West.
Die europäischen Wohlfahrtsstaaten stehen vor gro\en sozialen, ökonomischen und politischen Herausforderungen. österreich
stellt dabei keine Ausnahme dar. Im Hinblick auf das Ausgabenvolumen ist der österreichische Wohlfahrtsstaat vergleichsweise
gro\zügig dimensioniert. österreich rangiert bei den Sozialausgaben als Anteil am Bruttoinlandsprodukt an sechster Stelle
innerhalb der EU-25 (29,5% des BIP im Jahr 2003), in absoluten Zahlen gemessen sogar an vierter Stelle (7700 Kaufkraftparitäten
pro Kopf). Neben den soziodemographischen Entwicklungen und einem veränderten polit-ökonomischen Umfeld, ist nicht zuletzt
dieses hohe Ausgabenniveau Auslöser und Kern vielfältiger Debatten zur Zukunft des österreichischen Wohlfahrtsstaates. In
diesem Beitrag sollen die historischen Entwicklungen, die wesentlichen Charakteristika des österreichischen Wohlfahrtsstaates
sowie aktuelle Trends aufgezeigt und analysiert werden. Kapitel 1 widmet sich zunächst der Entstehungsgeschichte des österreichischen
Wohlfahrtsstaates, der dann im Rahmen der vergleichenden Wohlfahrtsstaatsliteratur verortet wird. Zudem wird die Rolle und
Bedeutung von öffentlichen und privaten Trägern in der Wohlfahrtsproduktion verdeutlicht. Nach einer kurzen Charakterisierung
von aus quantitativen Informationen ablesbaren Prioritäten des österreichischen Wohlfahrtsstaates, werden die zentralen Sozialpolitikbereiche
in Kapitel 2 im Detail präsentiert. In der Folge werden in Kapitel 3 dann ausgewählte Gestaltungsprinzipien und Ergebnisse
der Wohlfahrtspolitik politikfeldübergreifend untersucht. Abschlie\end wird in Kapitel 4 ein kurzer Ausblick auf die Entwicklungsperspektiven
des österreichischen Wohlfahrtsstaates gegeben.
Der soziale und demografische Wandel führte in den westlichen Ländern zu einer (Neu-)Definition sozialer Rechte zur Absicherung des Risikos der Pflegebedürftigkeit und damit zu einer Neuregulierung der Care-Arbeit. Care- oder Fürsorgetätigkeiten wurden zunehmend in öffentlichen Sektoren – Markt, Staat oder Zivilgesellschaft – verortet, während gleichzeitig informelle, familiäre Care-Aktivitäten vermehrt direkt auf der Basis von Geldleistungen unterstützt wurden. Ausgehend von dem theoretischen Konzept „Social Care“ wird der Zusammenhang zwischen der (Neu-) Definition von sozialen Rechten und der Etablierung eines regulären und grauen Care-Arbeitsmarkts sowie die damit einhergehende Entwicklung unterschiedlicher Formen von Ungleichheit – nach Geschlecht, sozio-ökonomischer Klasse und Ethnizität – in einem empirischen Vergleich zwischen Schweden, Deutschland und Italien untersucht. Die Ergebnisse des Ländervergleichs zeigen, dass insbesondere die in sozialen Rechten definierten Zugangskriterien zu Leistungen und deren Umfang und Form entscheidend werden für die Ausformung eines regulären oder grauen Care-Arbeitsmarkts und einer darauf aufbauenden Hierarchisierung dieses nach wie vor weiblich konnotierten Arbeitsbereichs nach sozio-ökonomischer Klasse und Ethnizität.
This article discusses the development of the home care sector in Austria. It analyses what impacts the interplay of the traditional family orientation to care, a universal cash-for-care scheme (reaching about 5% of the population) and a growing migrant care sector have on formal home care in Austria. The article is based on an analysis of research papers, policy documents and statistical data covering the period from the introduction of the cash-for-care scheme in 1993 up to 2011. Some authors have argued that generous cash benefits with no direct link to service use - as in the case of Austria - limit the development of home care, particularly in countries with a traditionally strong family orientation towards long-term care. Additionally, a tradition of family care and an emphasis on cash benefits may be conducive to the employment of migrant carers in private households, as a potential substitute for both family care and formal care. Despite this context, Austria has seen a substantial increase in formal home care over the past two decades. This has been driven by clients using their increased purchasing power and by policy priorities emphasising the extension of home care. Migrant care work was regularised in 2007, and the analysis suggests that while migrant care has usually worked as a substitute for other care arrangements, migrant care can also become a more integral element of care schemes. The article concludes that family orientation, unconditional cash benefits and the use of migrant carers do not necessarily preclude the development of a strong social service sector. However, there is a risk that budgetary limitations will primarily affect social service development.
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