Want an economy that works for women? Keep care services public – and fund them properly

In virtually every country around the world,  women are giving up paid work or reducing paid hours because of care responsibilities, adding to the gender gap in earnings. In at least four south-east Asian countries, women spend more than double the time men do on unpaid care and domestic work, with the largest gender gaps seen among women of peak reproductive age, as many move from paid employment to unpaid childcare. In Bangladesh, for instance, 79% of female workers who have left jobs in the apparel sector did so to care for their families.

That economic penalty paid by millions of women springs from a massive care deficit: support for care responsibilities, largely done by women, just isn’t there, with huge gaps in public provision. This includes sectors such as early years childcare, education, health, social care, as well as vital care-related infrastructure such as water, sanitation and energy. And that deficit looks set to widen as global demand for care surges driven by demographic shifts: there will be an extra 100 million older people and an additional 100 million children aged 6 to 14 years needing care by 2030.

The recent ASEAN Declaration on Strengthening the Care Economy and Fostering Resilience Towards the Post-2025 Community highlights that addressing unpaid care and domestic work will be a key priority for the ten ASEAN member states. The questions remains what pathways will be pursued to achieve these priorities.

Governments need to address the injustice of women supporting the market economy with cheap and free labour, and of supporting the state by providing care that should be financed and guaranteed by the public sector.   

However, there is an absence of real investment to tackle this injustice: in fact, governments around the world are increasingly saying they can’t afford to fund many care services and are looking to implement deep cuts to public spending, all at a time when carers and their communities face a cost of living crisis.

Alongside this is a persistent and growing narrative, championed by many UN bodies, International Financial Institutions (IFIs), and governments, that the private sector is best placed to fill the gaps in financing for, as well as delivering, care services.

We find both these trends deeply worrying and they need to be challenged in two ways. First, it is a myth that there is a scarcity of resources to finance comprehensive and decent care and other public services: rather, it is a matter of political will and addressing the huge inequalities in the global economic system that sees wealth hoarded by elites and multinationals, largely in the global North. Cutting care as a public service also implies that this is somehow optional, when it should be seen as a core and essential responsibility of the state, just like health or education.

Second, private sector service providers that prioritise profit will not necessarily deliver the safe, high-quality, universally accessible public services, infrastructure and social protection that women need. For example, reaching remote communities or the most marginalised groups of women may never deliver a profit. Instead care needs to be seen as a public good provided by the public sector as part of the state’s duty to realise gender equality and rights for all.

Governments often assert they don’t have the resources to pay for care services.  Yet solutions exist if states have the political will to embrace them.

First, we need international action to address the unsustainable and unjust debt burden for many global South countries. Today, more resources go to debt servicing than health and education services. Loan conditionalities by IFIs also promote austerity and steep cuts to cut public services. Now 85% of the global population are thought to be living under austerity.

Second, states need to end regressive taxation and budgeting that inflate the wealth of elites and multinational corporations whilst depriving states of the resources they need to invest in  rights-based, gender-responsive public care services and infrastructure. This is a political commitment that requires investment.  

We recommend dramatically increasing tax revenues that can be invested in care services by taxing corporations and individuals with top incomes and wealth: a 0.5% tax on the wealth of the richest global 1% over the next 10 years would be enough to create 117 million jobs in education, health and elderly care and other sectors – the majority of which would go to women given their predominance in these sectors  and to close the care deficit.

Where there are no public services, people must rely on private providers or unpaid care. Too often that means only the better-off can afford care services, shifting unpaid care work back onto women and leading to inequality of opportunity and care outcomes.

The way some for-profit services are run is also deeply alarming. In the health sector for example, Oxfam’s recent publication, Sick Development, uncovered huge problems withfor-profit hospitals across the Global South funded by the World Bank Group and several European governments. We uncovered evidence that these hospitals (as well as being implicated in a range of serious human rights abuses, including patient detentions) were charging fees for essential healthcare, including maternity services, that were way out of reach for average earners.

In India, the hospitals were found to be blocking patients from using their government health insurance cards  and pushing them into poverty with bills that should never have been charged. Fees charged to patients who sought care at these same hospitals ranged from between three-and-a-half months’ to 14 years’ worth of wages for an average earner in India.

Many of these hospitals, as well as healthcare and care providers internationally are increasingly being taken over by private equity funds. A review of international evidence found that this type of ownership is associated with increased costs for healthcare users (or insurers or governments on their behalf) and with mixed to harmful impacts on quality of care.

Profit-making services will also not deliver the comprehensive coverage women and their communities need. They might, for instance, prioritise profit at the expense of reaching remote or lower-income communities. Yet it is often these groups who most lack access to quality services.

Many governments, UN entities and International Financial Institutions like the World Bank are also continuing to champion ‘Public private partnerships’ (PPPs) – where governments contract a private entity to deliver a public service – to address the care crisis. These may seem to offer an opportunity to take the responsibility for service delivery off (often overstretched) public hands and ‘leverage’ additional private investment. However, the advertised ‘benefits’–  additional private financing, increased efficiency and economy – are often unfounded. This is particularly true in the long term, with states generally paying a high cost and carrying excessive risk for PPP projects, which have also been found to generally lead to decreased or less equitable access.

Such partnerships with private providers are also being promoted using development finance from donor countries. As we outlined above, Oxfam evidence from the health sector shows the dangers of funding the expansion and growing market dominance of expensive private services.

It’s time to recognise and fund public care services as a social good, intrinsic to the realisation of gender justice and the rights and wellbeing of citizens and economies. That means governments must play a leading role in defining, guaranteeing and financing access to quality services, infrastructure and social protection for all people.

Oxfam urges all governments and international financial institutions to move away from the politics of scarcity, austerity and inequality that sees a push towards private providers, to instead prioritise expanding and improving public care services to ensure equitable access for all.

We call upon governments to:

1. Increase funding for universally accessible public care services, infrastructure and social protection, allocating sufficient resources to address the care deficit.
2. Develop and implement comprehensive care policies and systems, integrating public healthcare, social care, early years childcare and education. These should be based on the “5R Framework” advocated by feminist movements and their allies: recognition, reduction, redistribution, reward and representation.
3. Ensure decent and dignified work for paid carers, including by enhancing care workforce development, providing training, living wages, and decent working conditions.
4. Foster community-led care initiatives, supporting local solutions and empowering caregivers, ensuring they have a meaningful voice in decision-making.
5. Ensure accessibility, affordability, and cultural sensitivity in care service delivery.
6. Develop new measures of economic success beyond GDP that measure, amongst other things, women’s time-use on unpaid care and domestic work, to help make this work visible and to track progress in redistributing it to the state.