B. Taking care of paid caregivers
2. Continuity of health care
domestic workers are paid less than the minimum wage for manual labour (ILO, 2021b). Despite the progress made regarding the minimum wage, remuneration for domestic workers is still low.19 As a result, one in every five women in paid domestic work is living in poverty.20
Paid domestic work is a source of employment for much of the working elderly population: one of 10 women workers in this sector is over 60 years old. It is considered an “ageing” sector, as the average age has been increasing at a faster rate than for the rest of employed women. Between 2000 and 2017, the average age of paid female domestic workers in the region increased by almost eight years (from 34.5 to 42.2 years). Whereas in 2000, paid female domestic workers were, on average, almost two years younger than women in other occupations, in 2017 they were almost two years older than other employed women. This trend is caused by two phenomena: the low level of social security coverage and the consequent inability to retire force these women workers to remain employed until an advanced age.21 Furthermore, the younger generations, who have a higher level of education, opt for other types of jobs. In addition to the large proportion of older workers, the percentage of very young paid female domestic workers (between 15 and 24 years of age) is also of concern in some countries, such as Honduras (36.6%), Paraguay (30%), Guatemala (29.5%), Nicaragua (26%), the Plurinational State of Bolivia (20%), El Salvador (17%) and Peru (16%) (Valenzuela, Scuro and Vaca Trigo, 2020).
It is clear that the sexual division of labour, the reproduction of patriarchal cultural patterns and the undervaluation of domestic and care work directly affect the working conditions of those who provide these services. While the precariousness of employment in this sector is structural, the COVID-19 pandemic highlighted the urgent need for State intervention and the reaffirmation of international conventions on labour legislation to further improve current conditions. Full appreciation of the care work carried out by paid female domestic workers, their professional development and representation and the improvement of working conditions would create a virtuous circle that would benefit the people in need of care and those who provide it.
The time-use surveys conducted in some countries enable analysis of the time spent by households on unpaid work associated with the health of household members (see figure IV.4). In all countries for which information is available, women’s participation in care work is higher than men’s. Regarding the time spent on these tasks, except for Colombia and Ecuador, the burden of care in the countries reviewed is also greater for women. The heterogeneous nature of regional dynamics largely stems from the questions included in each survey and the way in which the data are collected. Thus, although figure IV.4 enables us to observe the average time in each country in broad terms, it is not possible to draw comparisons between countries.
Figure IV.4
Latin America (10 countries): time spent providing health-related care to household members by population aged 15 years and over, by sex
(Hours per week and percentages)
Time spent by women providing health-related care to household members (left axis) Time spent by men providing health-related care to household members (left axis) Women’s participation in providing health-related care to household members (right axis) Men’s participation in providing health-related care to household members (right axis) 5.6
9.0
3,3 4.8
16.5
12.6
6.8 6.6
4.8
9.9 5.3
10.8
2.4
5.2
8.0
11.6
4.6 5.2
3.8
9.0 22.0
3.3
20.5
13.8
4.2
2.9
14.2 13.3
18.4
5.8 10.9
1.0
9.7
4.3
1.9 0.7
10.6
6.8
10.3
2.7 0 5 10 15 20 25
0 5 10 15 20 25 30 35
Chile,
2015 Colombia,
2017 Costa Rica,
2017 Ecuador,
2012 El Salvador,
2017 Guatemala,
2019 Mexico,
2019 Paraguay,
2016 Peru,
2010 Uruguay, 2013
Participation rate
Hours per week spent providing health-related care
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of the Repository of information on time use in Latin America and the Caribbean.
Note: Given the diversity of data sources, which precludes comparison between countries, the aim of this figure is to illustrate the trends within each country. The hours per week are calculated based on the total hours spent providing health care relative to the population participating in this activity. Participation in health care activities is calculated based on the percentage of persons of each sex reporting participation in these activities of the total population aged 15 years and over. In the case of dependent or disabled persons, in addition to time spent providing direct health care, it included time spent preparing special foods, assisting with feeding, bedtime, helping to move, going to the bathroom and getting dressed. It does not include being available while doing something else or being present during the night. Costa Rica, Ecuador and Peru provide information on the number of hours spent staying awake or monitoring health during the night. When this variable is included, participation increases between 0% and 2.8%, and weekly hours spent on care increase by 0.2 and 1.36 hours. In Colombia and Guatemala, the questions do not ask specifically about caring for dependent or disabled members of the household.
In order to develop public policies and create comprehensive care systems or strengthen existing ones, it is important that the countries in the region improve the information collected on the time dedicated to health care in urban and rural areas. The distribution and scope of the various activities associated with this type of care should be examined, taking into account activities such as administering medicines; providing supervision, treatment, therapy and rehabilitation services; temporary and permanent care, as well as the time spent making arrangements, traveling and accompanying people to health centres (Durán, 2006; ECLAC, 2017b).
This last aspect can be crucial, as limited mobility and transport time can often influence the care received.
The health sector workforce demonstrates considerable diversity and marked occupational segregation that reflect the existence and persistence of gender gaps. In 2020, 7.5% of employed women worked in this extremely feminized sector, in which 72.6% of workers are women. The wage gap in relation to men stands at 39.2%, the highest among the paid sectors of the care economy (see infographic IV.3).
Infographic IV.3
Latin America: characteristics of the health sector workforce, around 2020
Nursing and midwifery (mid-level) Other mid-level
health occupations
Medicine and pharmacy Nursing and
midwifery (professional level)
Health professionalsMid-level health occupations
Other health professionals
Medicine
Women Men
Distribution of persons employed in health subsectors, by sex
(Percentages)
Share of public employment in the health sector (Percentages)
Women employed in health, by subsector (Percentages)
Average hourly wage, by sex (Dollars at purchasing power parity)
25.5
10.3 19.6 17.1 4.3 30.1 18.6
19.4 6.5 9.4 14.4 24.8
Medicine
27.1 23.7
Other health professionals
15.1 13.7
Nursing and midwifery (professional level)
10.4 10.0
Medicine and pharmacy
7.0 7.4
Nursing and midwifery (mid-level)
5.9 5.1
Other mid-level health occupations
6.1 4.5 Other mid-level health occupations
Nursing and midwifery (mid-level) Mid-level health
occupations
Health professionals Medicine and pharmacy
Nursing and midwifery (professional level) Other health professionals
Medicine
63.9
83.2 52.2
86.1 70.6
48.8
Bolivia (Plur. State of) 51.2
Chile 51.6 Peru 64.0 Ecuador 37.9 Colombia 5.8 Mexico 49.5Guatemala 37.8El Salvador 46.8
Venezuela (Bol. Rep. of) 58.4 Panama
55.4 Costa Rica 61.1 Honduras
33.6
Brazil 35.8 Dominican Rep.
58.0
Uruguay 25.0 Argentina 35.9
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of the Household Survey Data Bank (BADEHOG).
Note: The share of public employment in the area of health care activities and social assistance was calculated based on the International Standard Industrial Classification of All Economic Activities (ISIC), Rev. 4. The following countries were considered: Argentina, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, Peru, Plurinational State of Bolivia and Uruguay, using data from 2020; Honduras and Panama, using data from 2019 and the Bolivarian Republic of Venezuela, using data from 2014. The occupational categories were developed based on the International Standard Classification of Occupations (ISCO-08), according to the disaggregated data available in each country. Occupational data from the following countries were considered for this process: Brazil, Chile, Costa Rica, Dominican Republic, Ecuador, El Salvador, Honduras, Mexico, and Uruguay, using data from 2020, and Panama and Honduras, using data from 2019. The categories of health professionals include: health professionals (22), physicians (221), nursing and midwifery professionals (222), traditional and alternative medicine professionals (223), paramedical practitioners (224), other health professionals (226); mid-level health professionals (32), medical and pharmaceutical technicians (321), mid-level nursing and midwifery professionals (322), mid-level traditional and alternative
Health-related occupational categories are divided into two levels, namely, health professionals and mid-level health occupations. Men represent 51.4% of staff in the first level, while women primarily occupy the second, where they represent 53% of staff. The first level comprises those engaged in medicine, nursing and midwifery and other health-related professional activities. The second level corresponds to occupations related to technical careers in medicine, pharmacy, nursing and midwifery, along with other mid-level health occupations (see infographic IV.3). The detailed distribution by type of occupation shows that 25.5% of men employed in the health sector are medical professionals, compared to only 10.3% of women in this category.
The majority of women (30.1%) are concentrated in mid-level occupations related to nursing and midwifery, which accounts for the gender stratification evident in the qualifications, functions and earnings of occupations in the sector. Indeed, the hourly wage of medical professionals is, on average, 4.9 times higher than that of the mid-level nursing and midwifery occupations. Similarly, there are gender gaps within each occupational category. The highest gender gap is noted in “other mid-level occupations,” where women earn 84.8% of the wages paid to men (see infographic IV.3).
The gender stratification in health occupations detailed above has implications for the roles that women occupy within health systems. Despite the higher proportion of women in the health sector, women are underrepresented in jobs involving leadership and decision-making, as they hold fewer managerial positions (only 2% of women are in managerial positions, compared to 3.6% of men) (see infographic IV.3). This discrepancy assumes greater importance in the context of the COVID-19 pandemic since, considering the preponderance of women in primary health care activities, it is concerning that they do not play a more central role in decision-making about health measures. Women’s daily work and their proximity to communities makes them well placed to detect the onset of outbreaks and monitor the overall health situation. It is important to include women in decision-making processes within health institutions, capitalizing on their potentially positive influence on the design and implementation of prevention and community-related care activities (UNFPA, 2020).
Another key dimension of the analysis of working conditions in the health sector is the distinction between different types of employers as this largely determines the degree of formalization and the access to social protection available to workers. While work in public or private health care institutions allows for a high degree of formalization of the workforce, this does not necessarily imply decent conditions for all staff.
As mentioned above, the health sector is characterised by its heterogeneity and by the existence of gaps and occupational hierarchies. These have a negative impact on the least skilled staff , who have to deal with precarious contractual forms that hinder access to decent work, especially for migrant workers (ILO, 2020).
Moreover, some health-related services (nursing, palliative care, therapies, among others) are often arranged directly with households and, in these cases, the work is often carried out under conditions of informality and uncertainty, with variable agreements and limited or no access to social security (ILO, 2020).
Trends in home health care work in Latin America and the Caribbean are mixed, although formalization rates remain above 80% for most occupations within the sector. Given that informal health care work takes various forms and includes the provision of diverse services, it is difficult to establish clear criteria to identify the workforce engaged in these activities (ILO, 2020). Unlike other private actors, informal health care providers are not covered by national laws and often lack formal certification of training in the services they provide (Kumah, 2022).