In Strategies of Care Barbara da Roit compares two contrasting health systems: Italy and the Netherlands. Italy has a care system where care for elderly people is firmly rooted in intergenerational solidarity, and where children have a legal obligation towards their parents. In the Netherlands these obligations are much weaker: care is institutionalised and professionals manage the care for elderly people in co-operation with the family (if there is a family present). Da Roit's choice to compare these extremely different care systems is original. It confronts the student/reader with the fact that care systems develop in a complex and dynamic context of family values, the availability of informal and monetary resources, and the presence of cheap labour. Da Roit argues that to understand the position of women, social research and reflection on the social organisation of care and intergenerational relations are very relevant.
In order to analyse the changes in elderly care in the two countries, Da Roit elaborates on the dynamics in the care systems that took place between the years 1990 and 2003–04. She looks at trends in the incidence of dependence over time in the two counties by analysing socio-demographic and institutional factors. The risks of dependence on others increased in the Netherlands as a consequence of the deinstitutionalisation, whilst in Italy the risk remained stable over time. But in the end dependence in old age is a much stronger challenge for Italian than Dutch society. Da Roit also discusses the macro-transformations in the two care systems, in particular the changing of care packages and the combination of different sources of support. She concludes that the Dutch care system is mostly based on formal care, with a decrease in the availability of informal care. The Italian care system makes a shift to an increasing dependence on market solutions, yet at the same time there has been a dramatic decrease in the availability of informal, family-based care. As a result the Dutch system has remained relatively resilient whilst the Italian system shows significant transformations.
From the quantitative macro analysis in Chapters Three and Four Da Roit moves in Chapters Five and Six to a qualitative micro analysis of the social mechanisms that constructed the care packages in The Netherlands and Italy. These care packages result from social interactions of individuals and families with relevant social actors, such as social services, care professionals, and various organisations. The qualitative study was conducted in Amsterdam and Milan and is a reconstruction of the specific local contexts via policy documents and conversations with key actors, informal care-givers and care professionals. The micro analysis gives insight to the actual content of the care packages, the context of institutional and structural constraints and the relevant actors who contribute to the care packages. In addition, it shows us how key choices in care for elderly people are made in the two care systems. These two chapters are the most interesting part of the book. They highlight the struggle of families to realise a care package that is acceptable for the older person and the family. In Italy the family, and mostly the women, play the key role in decision-making processes. In the Dutch care systems decisions are made by the older person in interaction with care professionals and members of the family.
Da Roit is conclusive in her argument that in Italy it is not only family values and traditions that play a major role in the choices that are made, but that decisions are also affected by the absence of, and the distance to, institutional care. Moreover, care institutions have a poor reputation in Italy. The condition of most of these institutions and the population of elderly people who depend on heavy care confirms this situation. Families in Italy prefer market solutions, made possible by the cheap labour of immigrant workers. As a consequence the informal and material resources of the family are central to the construction and form of the care packages. In the Dutch care system formal care remains the key resource. It is remarkable that the strong position of formal care in the Dutch care system and the individual approach which is dominant in professional care acts to strengthen the position of the older person. Da Roit concludes that the growing pressure on the families in the Dutch care system to contribute to the care for the elderly questions the independence of older people themselves with respect to their relatives. It is a pity that she could not evaluate the changes that took place after the introduction of the Social Support Act (in force from January 2007) which emphasises the role of informal care and restricts the claims on formal care.
Strategies of Care offers important insights on the interaction between changing health systems and family life, when health problems for older people occur and dependency increases. This book will be particularly useful to students and policy makers.
