The primary concern with current spending at community level is that very few older persons benefit, and then only the very frail, with inconsistent reach across provinces. There is very little support for older persons who have high care needs and are at home, nor for active older persons.
How do we support elder care in South Africa, and how do we ensure equitable care for all our elders? Two reports recently published by the Family Caregiving of Older Persons in Southern Africa Programme outline how funding for elder care is structured and changing in South Africa, and the related experiences of older persons, caregivers, as well as careworkers.
"Understanding the landscape of elder care in South Africa is not straightforward. That was the first challenge we wanted to unpack as we investigated how different pieces of the caring landscape fit together," said Dr Elena Moore, an associate professor of Sociology in the University of Cape Town's (UCT) Faculty of Humanities.
Several different state departments have obligations to older persons, but the Older Persons Act of 2006 mandates the Department of Social Development (DSD) to implement the act, taking account of the responsibilities of other relevant departments.
"Our investigation therefore looked at DSD spending, while remaining cognisant of the fact that the Department of Health also funds programmes and provides services to older persons," Dr Moore added.
Overview
The Funding Elder Care in South Africa report, released on International Day for Older Persons on 1 October, seeks to provide an overview of spending on the country's older persons over the past two decades. According to its findings, most DSD spending on older persons was in respect of the Older Persons Grant which, in 2022, benefited 3.8 million older persons, or about 75% of South Africa's total older person population. This totalled about R92.13 billion (2022), representing about 98% of all DSD's spending on older persons.
The increase in the number of older persons led to an increase in the overall cost to the state of older persons' grants. For example, the number of these grants increased from 2.2 million in 2006, to 3.8 million in 2022.
The remaining 2% of DSD funding (about R1.6 billion) was spent mostly on subsidies and transfers paid to non-profit organisations (NPOs) that provide residential care for community-based services to older people. In 2022, DSD provided subsidised beds for 18 011 people across the country. Community-based care services reached about 78 477 people attending community services centres, which provide vital food, social and health services to older people. The report highlights the experiences of NPOs, and documents how funding shortfalls impact service providers, their services and the older people they serve.
Key findings
Among the key findings was that while the economic value of support to older persons in South Africa has grown, the increase has been insufficient to meet the needs of this growing population.
It has also not been adequately linked to inflation. While spending per person, adjusted for inflation, is 5% higher in 2022/2023 compared to 2006/2007, provincial funding has decreased by 13% during the same period. Spending on community-level care, which includes both community-based services and residential care homes, increased from R460 million to R1.6 billion during the review period, representing a 13% decrease in funding when adjusted for inflation and increased numbers of older persons.
Additionally, the report reveals that the current structure of community support reaches only about 100 000 older persons nationally, a tiny fraction of the total population in need of assistance with daily activities. Based on estimates, it is believed that more than 1.5 million people, or at least 40% of South Africa's total older person population, require support with daily activities.
In effect, community care is not reaching the vast majority of older persons who need it. This is compounded by the fact that they are also barred from accessing care due to factors, including the inability to attend a service due to mobility or health-related challenges, or because there is no service centre near their homes.
The report also revealed vast regional disparities in provision of community-based and residential care. Some provinces also receive significantly more funding than others. For example, the Western Cape receives R259.5 million in funding, and KwaZulu-Natal only about R181 million, even though the latter is home to more older people. The funding is based on the number and reach of care services that meet DSD operational requirements, and on the number of people assisted. In effect, this means that the availability of elderly care support depends on where people live.
"Families and caregivers need much more support."
While this report provides evidence of a decrease in funding for community care services, a second report, the Older Persons and Community Care in South Africa Report, highlights how this is experienced by older persons, caregivers and care workers. It provides insight into how families interact with services, policies and infrastructures of care at the community level. The findings reveal that families and caregivers need much more support, including information about certain conditions, and support with training and cost of care.
The report reveals that management of conditions, disabilities and care for older persons occurs mostly within families and communities. There is an increasing focus on non-communicable diseases, such as strokes, cancer and diabetes, with a lot of concern around healthcare costs and decreasing support for family caregivers, as well as the impact that strokes, amputees or blindness has on older persons, their families, caregivers and the community.
Care implications
The care implications presented by various conditions are significant. Many older people have difficulty with walking, accessing public transport, getting dressed or preparing food. In partnership with several NPOs, such as Grandmothers Against Poverty and AIDS (GAPA), the Association for the Aged (TAFTA) and Silver Stars, several forums were hosted in the Western Cape and KwaZulu-Natal to hear from community members, home-based carers, older persons and family caregivers.
One younger caregiver said: "Before I leave in the morning, I have to make sure everything is close to her [grandmother]. She takes insulin, so that has to be ready as well. Every morning I prepare her needles, food etc, things like that, before I leave to attend my classes because she can't see properly and her knees also give her issues. It's challenging because when I'm not home, I'm always worried about her and I have to come back as soon as possible. I have to accompany her everywhere because she is not able to travel alone."
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"It's challenging because when I'm not home, I'm always worried about her and I have to come back as soon as possible."
It also detailed challenges, such as limited community support services for older people, including senior clubs, and lack of access to social workers and home-based carers. When services are available, they are often inaccessible as transport is expensive, and unsuited to older people with high-care needs. Moreover, many essential services that older people need to access, such as clinics, SASSA offices or banks, are ageist and rarely cater to the needs of older people.
The report details what is required to address the challenges and close the gaps in funding and service provision, with authors, Moore and Dr Gabby Kelly, making several recommendations. At the very least, they urge the state to commit to developing an expert working group on elderly care to secure the sustainability of supporting an expanding older person population, and improving the reach and quality of care. A trans-disciplinary team, including members from government, civil society, NPOs that currently serve older people, and academia, is required to effectively plan for South Africa's future of older care, they argue.
