Hierarchies of Care Work in South Africa: Nurses, Social Workers and Home-Based Care Workers

Article excerpt


This article examines care-worker hierarchies in South Africa, notably since the HIV/AIDS pandemic and the structural changes it has brought. The nurses, social workers, home-based care workers and volunteers are mostly women, of varying racial, socio-economic, demographic and educational backgrounds; they work in the public, private, and not-for-profit sectors. Recent changes in care provision have brought improved earnings for some, but the "care penalty" remains, and task-shifting because of the epidemic has been mostly downwards, increasing the burden on the lowest paid - or even unpaid - in the worst working conditions, thus increasing inequality between women.


An overarching concern in the welfare regime analysis pioneered by EspingAndersen (1990) is the extent to which social provision moulds class formation in society as a whole. Subsequent analysis by others has tended to focus on the recipients of welfare benefits and services, especially in health, education and the social services, all of which influence care. Esping- Andersen (ibid.) further held that welfare regimes also mould class formation through policy decisions about, and fiscal allocations to, the providers of benefits and services.

To take a simple example, if a policy reform results in the growth of tertiary-level health care, that has consequences for the types and levels of nursing and other staff who will need to be trained. Since nurses are typically female, the policy decision will in turn have an impact on the potential for women's career mobility. Similarly, differences in the working conditions in the public, the private, and the private not-for-profit sectors will lead to consequences for inequality of treatment between different groups of women in paid work, and also between those in paid care work and those in unpaid care work.

Korpi argued in favour of focusing on the impact of care provision on the labour force: "behind the distinctions between paid and unpaid care work, between the public and the private spheres, looms the fact that the labor force is the arena for the major socioeconomic stratification processes in modern societies, processes where agency is crucial" (2000, p. 139). He also stressed the importance of a combined gender and class analysis. Pascali and Lewis (2004) analysed gendered trends and differences within countries in the newly expanded European Union, looking at household composition and at which household members are earners, i.e. the change from the "male breadwinner" to the "dual earner" model and other models. Ungerson (2003) pursued a different theme with her "routed wages" concept, exploring how policy reforms in different European countries have involved a shift from a model where the State directly provides services, to one where money is given directly to the person cared for, who can then buy support from carers. In these important feminist critiques of welfare regime analysis, little attention is given to the social stratification dynamics between female care providers, and between occupational groups. Pascali and Lewis (2004) examine class (and age) differences in the ability of households to buy in care (wealthier households can buy private care, for example), but their overall analysis considers women as a whole, and men as a whole.

This article focuses on relationships between different groups of care providers - or care workers - most of whom are women from a variety of social classes. It uses the lens of HIV/AIDS to explore the changing dynamics of care work. The context is South Africa, 15 years after the country's transition to democracy in 1994.

The following section provides a brief background to the racially and spatially discriminatory patterns of settlement and access to land, and to social services in South Africa. …