Unpaid Health Care Work: A Challenge for the Region 

In the last decade, the debate on caregiving work—its gender inequality and impact on development—has gained increasing relevance on the public policy agenda in Latin America and the Caribbean. The origin of this debate dates back to concerns about the sexual division of labor, which places an unequal share of unpaid caregiving work on women. According to ECLAC, this division is a structural knot of inequality, and can be seen in the fact that, prior to the COVID-19 health crisis, women in the region spent between 22 and 42 hours per week on caregiving activities, three times more than men. 

In the health field, this presents a dual challenge: on one hand, it is necessary to understand the unpaid health-related caregiving work that falls on households (primarily women)—which PAHO refers to as unpaid health care work—and at the same time, understand the role and responsibility of the health sector in caregiving tasks. The relationship between these aspects is essential for various reasons, and we’ll explore them in this blog. 

Health Care and Unpaid Health Care Work: An Essential Distinction 

One of the concerns in debates about caregiving systems and policies is the fine line between health care services and unpaid health care work (TNR-S), the complementarity between both, and the specific responsibilities of each. 

First, it is crucial to highlight that, while it is undeniable that timely and quality access to health services reduces caregiving burdens in households in the long term, health care and public health actions do not constitute, in the broadest sense of the term, a form of care. 

In most countries in Latin America and the Caribbean, health care is provided within formal institutional systems, comprised of both public and private entities. These systems offer a variable set of benefits—which generate different levels of out-of-pocket spending across countries—with the goal of promoting health, preventing and treating diseases, and rehabilitating individuals. Thus, health care is a specialized job with specific characteristics, carried out within the framework of a paid employment relationship, subject to the rules and conditions of the health systems, whether public or private. This type of care is part of a set of benefits generally agreed upon as part of the contract for protecting and guaranteeing the right to health, which may vary by context, though part of this work may be done informally in different settings. 

In contrast, unpaid health care work encompasses activities that generally take place in the home, such as caring for chronically ill individuals, supervising or assisting with medical treatments, and managing health. These responsibilities, mostly assumed by women, may be generated by the health sector’s efforts to contain public spending or improve health outcomes, for example, with “hospital at home” programs. When the burden is shifted to households, these strategies often have negative impacts on the quality of life and health of caregivers and, of course, on the health of patients themselves. 

Burdens and costs of unpaid health care work, a challenge to be solved in the region and in Colombia 

Measurements in countries like Uruguay indicate that more than 60% of unpaid health care workers work over 40 hours a week. In Colombia, according to the National Time Use Survey (ENUT) (2020-2021), only 0.4% of households with a sick member receive external assistance for care. Additionally, women spend considerable time on these responsibilities, highlighting gender inequality in caregiving. 

In Colombia, for specific caregiving activities—such as administering medication, conducting therapies, rehabilitations, or treatments—men spend an average of 35 minutes per day, while women spend 48 minutes. The time spent accompanying sick family members to medical appointments (including conditions such as diabetes, cancer, hypertension, among others identified in the survey) can reach up to 3:12 hours for men and 4:17 hours for women. 

A clear distinction between health care and unpaid health care work is essential, as these are not sporadic situations but a constant challenge in areas such as financing, time use, women’s quality of life, and economic autonomy, among others. And just as this distinction is clear, it is urgent to define how and which sector assumes its costs. After all, the debate involves a public policy choice to determine which part of caregiving work is assumed by the health sector, which part by the caregiving sector, and which part by households. 

Next Steps: Technical Meetings and Roadmap to Define Care Guidelines for the Health Sector 

To analyze the links between the health and caregiving sectors in Colombia, the IDB coordinated a working table aimed at designing a roadmap to define caregiving guidelines. The meeting brought together public actors and experts in caregiving and health to incorporate different perspectives into the conversation. 

One of the agreements was to highlight the need to recognize the health sector not only as a provider of health care but also as a generator of unpaid health care work in households and, at times, as a financial contributor to some of these activities. While this is an ongoing legal debate in Colombia, the interrelation between these sectors is essential to coordinate tasks that require support, such as home health care, health management (appointments and paperwork).  

Additionally, the importance of distinguishing the specific responsibilities of each sector and clarifying which financing corresponds to health care and which to caregiving was emphasized. These steps are crucial to addressing the burdens that health systems have shifted to households and, particularly, to women, and most importantly, to ensure the right to health itself. 

Some of the most relevant conclusions were: 

1. In general, there is little information on the burden of care related to unpaid health care work in Colombia.  

2. It is important for the State to ask itself how the health care work that households (mainly women) assume today is financed, taking into account that there are at least two sectors involved: health and care.  

3. Although the jurisprudence of the Colombian Constitutional Court and other judicial instances have addressed the debate on care, today many of the care tasks financed by the health sector are the result of citizen demands through tutelas and it is necessary to seek institutional mechanisms to provide a solution to this debate. 

4. There is an information gap on both the savings that health care represents for households, as well as the savings it represents for the health sector and also the costs that would be incurred if the latter were to assume them.  

5. It is essential to diagnose the effects of unpaid health care work on caregivers in order to determine the type of support and ensure the recognition they require.  

What measures are being implemented in your country to coordinate the relationship between health and care services? We invite you to tell us in the comments.