The paradox

To address everyone’s care needs, care must be scaled and formalized. Though embedded in wider political and cultural phenomena, including appetites for social control, care institutions typically arise out of necessity: the medicalization of childbirth sought to curb unacceptably high maternal mortality, the creation of day care to facilitate women’s access to employment, and the advent of nursing homes to provide an alternative to family support in old age amid rising life expectancy and family isolation. Institutions allow family caregivers to pursue varied sources of meaning—education, art, work, friendships—and help shift some of the heavy responsibility that interdependence places on women.

Care is, at its core, a relational process. Trying to standardize it into a replicable and minimally costly service acts on relationality like Roundup on a patch of green grass. It is structural care-icide.

Yet the very characteristics necessary to provide care at scale are also those most antithetical to good care. There lies the paradox. Public funding for facilities helps keep them accessible to a wide range of people regardless of income, but that also makes them vulnerable to austerity measures. Privatization can relieve pressure from state budgets and create a greater variety of options, but also subjects care to potentially deleterious profit-seeking calculations. One-size-fits-all models are easier to roll out nationally, but they risk leaving no space for individual needs and experiences.

Care is, at its core, a relational process. Trying to standardize it into a replicable and minimally costly service acts on relationality like Roundup on a patch of green grass. It is structural care-icide.

***

It therefore feels as though we are faced with a binary choice. We can completely disengage from formal structures to preserve the spontaneous and organic nature of care—but that is only an option for a few, and families are by no means exempt from domination and violence. Or we can “give in” to institutions that inevitably strip care of its relational essence.

But this status quo is not, in fact, inevitable. Formal care structures don’t have to be soulless vessels we are forced into due to a lack of viable alternatives. When built correctly, they can also be places of beautiful connection and joy. The way care institutions are designed today has little to do with the nature of institutions per se: it is the product of cultural norms and policy incentives. It is a choice, and we can make a different one.

A way forward

How, then, do we overcome the paradox? How do we formalize care in a way that provides much-needed structure to social life and relief to caregivers, without manufacturing disconnection?

As is often the case, the boring, nuanced answer is the most promising one: compromise. We can build institutions that allow enough space for the natural porousness of care to freely manifest—that institutionalize fluidity. There must be, of course, substantial support, resources, and recognition for those who do want to “opt out”: give birth at home, stay home with their young children , or live with aging parents to support them in later life. Making fluidity the norm implies making room for all choices. But formal facilities that preserve the essence of care should be widely available for those who need them.

Pioneering obstetrician Michel Odent’s concept of home-like birth centers is one such compromise, which brings both the benefits of a familial, organic-feeling environment and the safety of an institutional setting. A similar logic was applied by the Ethiopian Ministry of Health in the early 2010s to design maternal care facilities respectful of cultural customs. 

Puzzled as to why maternal mortality rates were barely moving despite significant investment in primary health centres and community health staff, the Ministry held informal discussions with women in rural areas to understand what the barriers were. It turned out the new facilities did not allow women to give birth in the way they wanted. Loved ones could often not be present, and traditional rituals such as drinking coffee and porridge with neighbours to welcome the new baby could not be observed. Following these conversations, health officials gradually reformed maternal care infrastructure to be more flexible, allowing each community to adapt it to their own cultural practices.

Fluidity is also the driving principle behind the emergence of intergenerational sites that bring together child and elder care. Pioneered in Japan in the 1970s, these facilities come in a variety of forms: a preschool or a day care inside a nursing home, for instance, or a residence for older adults next to an afterschool community center for kids. Children might simply play in a designated area within the nursing home’s garden or have dedicated shared activity times with elderly residents, such as reading, creative writing, theater, or cooking. 

The elderly participants, meanwhile, are healthier, less isolated, and live longer, feeling helpful and valued.

These sites have nothing but benefits for everyone involved: the young are more tolerant and more comfortable around people with disabilities and physical or mobility differences; they learn skills, hear life stories from their elders, and develop creative pursuits under their elders’ coaching. They learn to be around adults who aren’t family, with diverse lived experiences. The elderly participants, meanwhile, are healthier, less isolated, and live longer, feeling helpful and valued. The sites encourage prosocial behaviors, sensory stimulation, and intellectual development in both age groups. One paper highlights that “the nurturing presence of older adults helps bring a familial aspect to the preschool setting,” potentially offsetting some of its more anxiety-generating aspects for young kids.

***

Shared sites are also attractive to staff, giving their work more meaning while making it logistically easier to meet their own caregiving responsibilities. French startup Tom&Josette, a network of micro-creches implanted within elder care facilities, built its organizational model around valuing the field expertise of day care workers. On top of their day-to-day responsibilities with the children, early childhood professionals design joint activities with the elderly residents and have their say in the recruitment of incoming staff.

Founders Astrid Parmentier and Pauline Faivre say they were inspired by Dutch at-home health care company Buurtzorg, founded in 2006 by Jos de Blok and a team of professional nurses. Frustrated with years of reforms that impoverished their profession, stripped humanity from their relationships with patients, and removed opportunities for connection, they set up Buurtzorg (whose name translates to “neighborhood or community care”) “to look after people at home, in a way their values and craft demanded.”

The Buurtzorg model has three core principles: 

• a holistic view of the human person and their needs beyond the physiological, 
• an emphasis on the quality of the caregiver-patient relationship (notably by minimizing the number of individuals caring for a single person), and 
• a priority on the patient’s autonomy, through therapeutic education and mobilization of their social support network. 

Buurtzorg nurses also have a much greater latitude than is the norm in decisions on timetables and patients’ needs.

After only a couple of years, the company revolutionized in-home care in the Netherlands, rising to the top of patient satisfaction rankings and reducing spending by about 40% per accompanied person, which translated to an average of 3000€ in savings for the patients themselves. It showed that heavy bureaucracy and aggressive management styles are not vital, but rather detrimental to the economic health of good care organizations. Five times between 2010 and 2016, Buurtzorg was voted the country’s Employer of the Year.

***

While we should keep radically rethinking the way we structure care in our societies, there is also hope in building desirable innovations within existing constraints. 

These are all examples of formalized caregiving, both public and private, that don’t completely drain care of its relational essence. They show that the spectrum of social change around caregiving is not zero-sum: while we should keep radically rethinking the way we structure care in our societies, there is also hope in building desirable innovations within existing constraints. 

There is, then, a path out of the paradox. We should be critical of flawed institutions and strive to foster organic spaces and community outside of economic equations. We should also build resilient institutional alternatives that future generations will have the luxury of taking for granted.

Mélina Magdelénat is a Visiting Fellow at Capita.