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Try out PMC Labs and tell us what you think. Learn More. An estimated 58 million persons aged plus live in sub-Saharan Africa; by that will rise sharply to million. Older Africans traditionally get care in their old age from the middle generation. Simultaneously, the burden of disease among older persons is changing in this region.

The result is a growing care deficit. We advance a conceptual framework of gendered identities — for both men and women — and intergenerational social exchange to help focus and understand the complex interdependent relationships around carework, which are paramount in addressing the needs of older persons in the current care deficit in this region, and the Global South more generally.

There are currently about 58 million persons aged plus in sub-Saharan Africa, and their is growing. First, these older persons will need care.

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But, particularly in East and Southern Africa where so many younger kin have been lost to HIV and related illnesses, informal care systems are strained. Third, there are important shifts and variation in the burden of disease among older persons in this region with an increase in non-communicable disease, as well as variation in the resources available to older persons. Informal carework for the sick and ageing might include assisting with transportation to medical appointments, getting and giving medicines, feeding, bathing and toileting.

Informal carework for children might include feeding, bathing, and support with school needs. What we do know is that those who fill the care deficit are often women, and in many cases, older women Akintola,; Schatz, In northern Uganda, Oleke and colleagues found that older women headed the majority of households where orphans received care.

The complexity of the situation in East and Southern Africa demands attention to both care for and by older persons, with consideration as to how current carework builds on past child fostering and elder care practices, and how these vary by gender, urban-rural residence, region, etc. This paper reviews evidence of the current care deficit, and the benefits and disadvantages of carework in the region, with attention to the ways that age and gender come together to shape the experience of care, the value it is given, and the importance of care as a relationship between individuals.

We then propose a conceptual framework that focuses on gendered identities and the role of social exchange to enhance future carework research in East and Southern Africa.

Central to this lens are the importance of interdependence between generations, and the ways that masculinity and femininity shape notions of carework and self. After setting out this conceptual framework, we conclude by using it to suggest directions for future research. A profound care deficit exists in East and Southern Africa because state, family and private markets of care are poorly coordinated Upton, ; Zimmerman et al. Formal care, where paid providers or governmental agencies provide assistance, include health services, daycare, residential and care facilities FCA, ; outside of urban centres, residential care facilities for older persons are rare, and where present they are generally financially accessible only to elites UNFPA, While some care may be bought through market services e.

Thus, families provide most of the care for the children, sick and elderly as they age. However, in many countries HIV has hollowed the middle generation, reducing ificantly the care providers for both the old and young Deininger et al. HIV-related care needs include: 1 young children, including those whose parents are sick and those orphaned by the epidemic; 2 sick adults; and 3 older persons whose caregivers have died of HIV.

In countries with high HIV prevalence, older adults are more likely to be living alone and without someone to provide them with care in their old age, compared to their peers in countries with lower HIV-prevalence Kautz et al. This means there may be fewer sick individuals, fewer deaths of middle-aged caregivers, and fewer new orphans. Thus, the HIV care deficit is far from stemmed; among high prevalence countries the differential pace and coverage of ART rollout will continue to shape this deficit.

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These include unconditional and conditional cash transfer programmes, as well as government-funded social grants, intended for caregivers of orphans and vulnerable children OVC Ardington et al. The expense and staffing needed to implement such programmes at a national level has meant that they often are not scaled-up despite their promise.

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In addition, these programmes are often imperfect in their ability to find and service the most vulnerable populations, and the focus on orphans ignores the fact that they are often not worse off than other poor children in the region Richter et al.

Thus, programmes are needed that cast a broader net and are more systematic in their reach. While much of the focus is on older persons caring for the generations below them because of HIV, HIV and increasingly the presence of non-communicable diseases may lead older persons to care for a spouse or to become the person that needs care.

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Some illnesses e. In either case, the extent of necessary care can be considerable, and these diseases are increasingly prevalent in this region Mayosi et al. East and Southern Africa have a long history of fragmented families. Rural to urban migration has meant that older persons and children are overrepresented in rural areas Okojie, Historically, as men migrated to cities for jobs, mothers and grandmothers were left behind in rural areas to care for children Madhavan,with few adults under 50 around.

Although some labour streams have recently dried up and slowed migration Harrison et al. Migration of adult female children permanently to urban areas to pursue education, work, or life in general, also in older persons losing their carers.

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In many East and Southern African settings, children born outside of marriage are raised by grandparents Harrison et al. Household-level analyses, like these, provide important insights into carework, but not all carework will take place within households; carework studies must expand to examine inter-household dynamics. Literature from around the world has evaluated the emotional, financial, physical and psychological impacts of caregiving on both caregivers and care recipients. Potential benefits of carework may include reciprocity, a sense of purpose, and fulfilling obligations or perceived traditional roles.

Disadvantages of carework may include worry, depression, lack of control, financial hardship, and negative impacts on health. Experiences as a care recipient can also be uneven. Carework may enrich or strain relationships, and in cases where care occurs under duress or not at all, the result may be abandonment and abuse Oppong, ; Sijuwade, Although research is nascent in East and Southern Africa on the multifaceted aspects of carework, the extant research shows both these positive and negative impacts.

The time burdens of caregiving increase poverty among poor caregivers Hansen et al. In households already struggling financially, the costs of caregiving can create further financial hardship and social disruption Seeley, ; Seeley, Wolff, et al. Time-use and income data are limited in these settings, so the full extent of these burdens, whether extensive or modest, remains undocumented.

Despite these potential limitations, there is a fairly large literature documenting the negative impacts of caregiving on health and well-being, particularly for older female caregivers; however, the differ by country, level of HIV prevalence, and types of measures captured. Other studies have found little physical impact of caregiving, but poor mental health outcomes; the loss of possible support in old age led to a pervasive sadness Ice et al.

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Little is known, however, about the effect of losing a future caregiver on older persons overall health and well-being Oppong, HIV caregiving in particular has been found to saddle caregivers with stigma, discrimination, isolation, lack of support, and the breakdown of social networks Howard et al. Importantly, the experience of carework is not static.

The study also showed that carework burdens vary over time in the ways they are experienced and talked about among family members. Consistently capturing mental health measures, longitudinally when possible, in older populations across contexts would further strengthen our knowledge in this area. Many caregivers gain satisfaction from carework; caregiving can also provide respect, and emotional and spiritual strength Abel, Mugisha et al.

Yet, these data cannot tell us if the caregivers were in better health to begin with, or caregiving itself had psychological benefits. Through carework, caregivers have agency and remain resourceful despite hardships.

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Indeed, this reciprocity of care, stemming from social exchange, is an under-researched but potentially important way caregivers receive benefits from their carework. A Ugandan study showed that those with larger caregiving responsibilities more frequently received support Mugisha et al. The older persons provide childcare, while the children contribute physical labour, e. The reciprocity of care may improve emotional well-being.

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Some caregivers feel that there is joy from having in the family Howard et al. In return the children for whom they care receive emotional support. Given the prevalence of multi-generational families, this bi-directional carework is probably more extensive than currently documented.

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In East and Southern Africa, both men and women live with the impacts of the care deficit. Importantly, gender helps determine not only who gives or receives care, but also the classification of carework both by researchers and by those answering survey and interview questions Oppong, Likewise, caring for the young or sick may not be reported as carework, as it fulfils routine family expectations and obligations Makoni, ; Schatz, Thus, adding other data sources, like time-use data, may provide more accurate documentation of gender differences in time spent on carework.

Most articles on caregiving in HIV-endemic contexts focus either on caregiving for orphans or caregiving for HIV-positive individuals, and are not sensitive to the possibility of a double care burden. We need new data and fresh analyses of existing data to understand the magnitude of this double burden.

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Documenting the types, extent, expense, duties, and impacts of carework is an important first step to understanding carework in East and Southern Africa. Expectations about care and the complexity of relationships involved are gendered and affected by the age and life stage of both the carer and cared for Oppong, ; Razavi, The social, cultural, and political environment shapes both the individual i.

Thus, it is possible that, as Makoni argues, independence in old age is valued in the Global North, but interdependence with kin is a more valued and potentially successful ageing strategy in East and Southern Africa. Gender plays an important role in older age careers and kin relationships Calasanti, Gender identity, built over a lifetime and shaped by local norms and values, affects how older persons understand themselves and what roles they believe they can and should play as they age.

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