In South Africa, most long-term care for older people happens at home through the efforts of family members, largely female kin, not through government services.
With South Africa’s population growing older, combined with reduced funding for community care, higher levels of disability in old age, and widespread poverty and unemployment, family care has become more important than ever and more challenging. But government and policy makers don’t know how it happens, and we can’t just assume it happens.
The Family Caregiving Programme is the first major programme dedicated to understanding family care of older persons in southern Africa. As part of the research team for this programme we are looking at how family care works and how it can be better supported. The five-year programme aims to improve our understanding of how family care is experienced in South Africa, Malawi, Namibia and Botswana.
For the latest research report, we worked with 103 caregivers and 96 older persons in 100 family units across seven locations in three South African provinces: the Western Cape, Eastern Cape, and KwaZulu-Natal. We worked in two rural areas, one peri-urban area and four urban areas including two townships.
Three quarters of the sample of older persons required constant care or supervision.
We found that all the care needs were being met – but at a significant cost for caregivers, older persons and society.
Care needs go beyond physiological and cognitive issues and are shaped by the physical and social environment. The environment can make care more challenging and create more dependency. Lack of access to water, sanitation and electricity adds to care work.
For care needs to be met, older persons need supported caregivers, access to care services and basic services.
The gaps
South Africa’s long term care policy encourages “ageing in place”, meaning older people should live in their homes, supported by community-based services. But the reality is that support is limited.
Of the 5.5 million older people in South Africa, around 4 million receive the Older Person’s Grant, and at least 1.5 million need help with daily activities. Very few receive home-based care or subsidised meals. Even fewer receive assistive devices and materials such as wheelchairs or incontinence products.
It’s a common assumption that if an older person lives with family, they’re being cared for. But this isn’t always true. Sometimes the available family member isn’t able – physically, emotionally, or financially – to provide proper care. Mental health support is also largely missing. Many older people experience loneliness and depression, but help is hard to find. In our study, one in five older persons experienced feelings of loneliness, anxiety and despair.
Many older people don’t have running water, proper toilets, wheelchairs, or incontinence products. If basic services are missing, the older person needs more help. Older black people in rural areas and in under-resourced townships are most affected.
Older people also need help accessing healthcare. High levels of diabetes, hypertension and arthritis in many cases lead to disability in later life. But getting help to access care isn’t always available.
Mary Mwebu (we have used pseudonyms), who lives in the rural Eastern Cape and has TB of the spine and mobility challenges, has no running water in her home. She also has no accessible and affordable transport, so she hasn’t been to the clinic in 10 years and struggles to manage her pain.
Care needs of older persons include basic provision of food. Our findings show that older persons and their households spend way below what is needed for a healthy diet.
The older person’s grant, at R2,315 (US$130) a month in 2025 and similar to the cost of incontinence products for the month, is often the main income in the household and is used to cover the costs for everyone, especially in a context where 64% of people living with an older person are unemployed.
Food is the biggest cost, often up to two thirds of income. It is the first thing to cut when there’s not enough money.
Money is particularly tight in black low-income households. In many cases expenditure exceeds income, and older people are left vulnerable. If any unexpected costs like medical needs or hygiene products arise, the older person will often have to sacrifice food.
Others will obtain loans and so many fall into debt. Borrowing from loan sharks is a way to buy food but high interest rates put people in a worse position the following month.
Limiting spending, eating less, and limited help from family members are the only other ways to meet their needs.
Why care is depleting
The average older person household has five people in it. Large households have many care needs, not just elder care. We found that women – especially daughters and female relatives – are the main caregivers.
But the findings show that due to HIV/Aids and migration, older people can’t always rely on their children. In such instances care is also provided by nieces, neighbours, and adult granddaughters.
Looking after an older person often requires caregivers to relocate. Our findings showed that one in five caregivers had to move, often with young children or leaving spouses behind.
Sometimes older persons need to move to get care. This happened in one in 10 older persons in our sample. Many are reluctant to move from their homes and the process can take years.
The findings show that family caregiving is not an endless supply of “free” labour. It is physically, emotionally and financially costly, especially for black low-income women.
Some answers
The report proposes three key recommendations.
Firstly, family caregivers and careworkers should be adequately compensated for their work.
Secondly, we call for expanding home-based care services to ease the load and give caregivers breaks and mental health support.
And thirdly, care-related items, such as wheelchairs, incontinence products and healthy food, should be made more easily available.
Supporting family caregivers means supporting the wellbeing of millions of older South Africans. It’s time the country took elder and family care seriously and backed it with real investment and action.
Elena Moore receives funding from Wellcome Trust and IDRC-CRDI for the work on elder care in Southern Africa.
Vayda Megannon and Zeenat Samodien do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
