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The Provision of Home Care as a Policy
Problem
Joyce Outshoorn
a
a
Leiden University, The Netherlands
Published online: 14 Feb 2008.
To cite this article: Joyce Outshoorn (2008) The Provision of Home Care as a Policy
Problem, Journal of Comparative Policy Analysis: Research and Practice, 10:1, 7-27, DOI:
10.1080/13876980701833649
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The Provision of Home Care as a
Policy Problem
JOYCE OUTSHOORN
Leiden University, The Netherlands
ABSTRACT The problem of home care for the growing number of elderly people no longer able
to take of themselves has long been overshadowed by the debates on pensions and rising medical
costs. Taking the feminist critique of the welfare state as point of departure, this article examines
in how far the breadwinner-caretaker model still informs ageing policies in the Netherlands (a
prime example of this model) and takes women as carers for granted, despite changes in the
family and women’s growing labour market participation. Overall, policies since the 1990s have
shown remarkable continuity, defining informal care, mainly done by women, as the cornerstone
of home care policy, with state-provided care seen as strictly supplementary and rationed to cut
costs. This is consistent with the welfare mix of the conservative welfare state, but contradictory
to a more individualized welfare state in which women’s labour market participation is becoming
essential to maintain welfare state benefits in the face of the ageing issue.
Introduction
The increasing costs of maintaining collective provision of pensions and health care
dominate the policy debates on ageing. In the majority of these debates health care is
typically reduced to the costs of medical care (‘‘cure’’), while provision of long term
care necessary for the increasing number of elderly people who are no longer fully
able to take care of themselves tends to be marginalized. Welfare states differ as to
who provides this care: in conservative welfare states most of this has always been
supplied by informal carers1
within the family (mainly women), the state only
stepping in when it was insufficient, while in social democratic ones the state has
taken on the provision of care. ‘‘Home care’’ is the term that covers both the
informal care given by family members and the professional care delivered to clients
and patients in the home. This professional care can be state-run or funded; in some
countries there is also a commercial market for care.
Home care is currently at risk because of a number of trends. In an era where most
welfare states are intent on controlling state expenditure, decreasing the national
Joyce Outshoorn is Professor of Women’s Studies and Director of the Joke Smit Institute for Research in
Women’s Studies at Leiden University, The Netherlands, where she is also a member of the Department of
Political Science. She is the editor of The Politics of Prostitution. Women’s Movements, Democratic States
and the Globalisation of Sex Work, Cambridge University Press, 2004; and (with Johanna Kantola)
Changing State Feminism, Palgrave, 2007. She has published extensively on abortion politics, women’s
movements and women’s public policy.
Correspondence Address: Joyce Outshoorn, Department of Political Science/Joke Smit Institute for
Research in Women’s Studies, Leiden University, PO Box 9555, 2300RB Leiden, The Netherlands.
Email: outshoorn@fsw.leidenuniv.nl
Journal of Comparative Policy Analysis,
Vol. 10, No. 1, 7 – 27, March 2008
ISSN 1387-6988 Print/1572-5448 Online/08/010007-21
ª 2008 The Editor, Journal of Comparative Policy Analysis: Research and Practice
DOI: 10.1080/13876980701833649
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debt and meeting the criteria of the EMU, there is reservation about taking
responsibility for the care of the growing numbers of the elderly. In the conservative
welfare states, relying on informal care, there are additional problems. Family size
has decreased over recent decades, leaving fewer children to take care of their elderly
relatives. Increased geographical mobility created distance between relatives, making
care on a day-to-day basis impossible. Women are increasingly in paid employment,
leaving them with less time to perform their ‘‘traditional obligations’’ of caring.
Furthermore, substituting informal care with formal care runs into obstacles of
recruiting the necessary personnel, as the decline in the birth rate means there are
fewer younger people to take on the work in the formal care sector. Labour market
shortages in some countries in recent years have aggravated the problem.
The aim of this article is to uncover to what extent the ‘‘breadwinner-caretaker
model’’ (Bussemaker and Van Kersbergen 1994: 20) of the family still informs policy
debates on ageing and to show how welfare states, despite restructuring, are slow in
responding to changes in the family and women’s labour market participation. More
specifically it will focus on the policies of home care in the Netherlands, in which
adjustment seems to be lacking. The Netherlands features in the literature as one of
the examples of the strong breadwinner state (Lewis and Ostner 1991, Lewis 1992),
with women mainly cast in the role of housewife, and thus is a prime case to study the
consequences of ageing for the provision of home care. The Netherlands was also
something of an anomaly in the debates about the typology of welfare states of
Esping-Andersen (1990), as Bussemaker and Van Kersbergen have contended (1994:
21–24). Moreover, the Netherlands have always stood out in cross-national European
comparison. Having nearly the lowest number of married women in the labour force
in the 1950s and early 1960s, it now ranks among the nations with the highest
percentage of women in the labour market, a percentage made possible by the fact
that most work part-time. Although the breadwinner/caretaker model was originally
developed to unearth the implications of welfare state arrangements for the social
entitlements for women and focused mainly on women as mothers or workers, it is
also a useful point of departure for the analysis of the issue of care for the elderly.
Underlying the model is the same gendered division of labour which also structures
other types of care than care for children in terms of responsibilities, obligations and
opportunities for giving and receiving care, including free-riding and opting out.
The choice for the policy area of home care lies in its neglect by the dominant
debates on ageing. Although in public debate the issue crops up regularly, the
financial and economic aspects of ageing dominate the debates of the political elites.
This also goes for much public policy research on ageing, in which pensions and
medical care predominate. I shall be addressing three questions: What proposals and
remedies on home care and ageing have been put forward over the past decade? How
far do these still assume a gender order in which women are informal carers and men
breadwinners, and to what contradictions does this lead when taken in combination
with other policies on ageing? What conclusions can be drawn for the theorizing on
welfare states and the issue of ageing?
In order to address these questions I shall first discuss the feminist critique of
welfare state theory on its neglect of the family and unpaid work. I then trace the
development of the ageing issue in the Netherlands, showing how home care is
organized and how it featured on the political agenda prior to the 1990s. I shall then
8 J. Outshoorn
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analyze the policies on home care since the 1990s in more detail. In particular I shall
focus on the four main policy papers on home care and ageing of the national
Ministry of Health and Welfare2
which structure current policy (Thuiszorg 1991,
Thuiszorg en zorg thuis 1997, Zorgnota 2001, Zorg Nabij 2001). These policy papers
are official government statements, determining both the direction of the policy and
the allocation of funding. They have been debated and sometimes amended by
Parliament but on the whole the measures have been implemented very much
according to policy intentions. The effects have been deeply felt by the organizations
providing homecare (e.g. Meloen 2000), the care givers and care receivers (Vulto and
More´ e 1996, Van der Lijke 2000, Potting 2001, Timmermans 2003). The policy
papers will be analysed by tracing the problem definition, the policy goals, proposed
remedies and the core values espoused by the policy makers, followed by a gender
analysis of the texts.3
They will then be compared on these points, as well as on the
underlying gender order and the possible changes in policy over time. I then discuss
the findings in the context of other policies on ageing in the Netherlands over the last
decade and return to my questions, reflecting on the importance of including home
care in the analysis of policies of ageing.
Caring and the Welfare State
In the literature on welfare states care provision is often taken for granted. In the
1990s the new feminist scholarship took the original Esping-Andersen model (1990)
to task for its blind spots about gender (e.g. Lewis 1992, O’Connor 1993, 1996,
Orloff 1993, Sainsbury 1994, 1996, Ostner and Lewis 1995, Daly 2000a). It argued
that the typology, by focusing on state/market relations, marginalized the family and
other non-market relations within society.
This not only neglects unpaid labour both inside and outside the family, but it also
hides the fact that unpaid labour is essential for maintaining many welfare
arrangements. Much public welfare, such as caring, is secured by a combination of,
largely female, paid and unpaid work (Daly 2000a: 5). Welfare states depend on
different mixes between state, market, civil society and the family in their provision of
care; they structure what is being paid and unpaid, and they determine where the work
is done and by whom (Daly 2000a: 39). In this process, welfare states buttress the
gender order, a division of labour between the sexes governed by ‘‘norms, principles
and policies informing the allocation of tasks, rights and life chances to both sexes’’
(Ostner and Lewis 1995: 161). The allocation of care is structured by the welfare state
mix and this allocation co-determines the gender order. It follows that the gender order
also structures the field of home care, as is the case for most other welfare provisions.
A central part of the feminist critique focused on the concept of decommodification,
‘‘the degree to which individuals, or families, can uphold a socially acceptable
standard of living independently of market participation’’ (Esping-Andersen 1990:
37). It ‘‘occurs when a person can maintain a livelihood without reliance on the
market’’ (ibid.: 21–22). In other words, it is emancipation from dependence on the
market. But feminist scholars demonstrated that this was hardly applicable to
women who do the unpaid labour in the family and to their emancipation. As
Sainsbury (1996: 36) remarks, for women it is vital whether benefits are tied to the
individual or to the family. When it is the family, benefits usually go to the ‘‘head’’ of
Provision of Home Care as a Policy Problem 9
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the household: the husband. For women it is important, however, that they can live
independently of family relationships at a socially acceptable level, either by paid
work or social security provision, for which Ruth Lister has coined the concept of
‘‘defamilialization’’ (Lister 1997: 173). Caring in the family, even if many women find
it a rewarding and pleasurable activity, and the lack of individual (entitlement to)
benefits, stands in the way of this process: provision of care by the state (or market)
can enable further defamilialization.
Recent feminist scholarship has taken care as a crucial point of access for analyzing
welfare states (e.g. Jenson 1997, Knijn and Kremer 1997, Lewis 1998, Sevenhuijsen
1998, Daly and Lewis 2000). On the whole, this work pays much more attention to the
issue of child care for mothers; the issue of care for the elderly and the chronically ill is
relatively neglected (but see Kremer 2000, Daly 2000a, b, Daly and Rake 2003). All
point to the moral obligation for women to care, even if this is detrimental to their
financial security or runs counter to their own needs. Welfare states presuppose this
disposition and the feminine identities which embody it, but differ in the way they build
their caring arrangements. Crucial for women is how far these allow for defamilialization:
an independent life and a positive choice whether to provide care or not.
As mentioned, there has been considerable debate about the position of the
Netherlands in the typologies of welfare states inspired by Esping-Andersen, who
originally placed the country in the social democratic type of welfare state.
Bussemaker and Van Kersbergen (1994: 21–24) have argued that it was precisely his
neglect of gender and unpaid work that caused the wrong casting: the Netherlands do
have a high degree of decommodification, but also a high level of social stratification
between men and women, as in conservative welfare states. Social security benefits
are generous, but were designed to provide a family income, not because of solidarity or
social justice, but to enable the male breadwinner to live a decent life for himself with
his family, ‘‘under the assumption that women would not engage in wage labour’’
(ibid.: 23). When it comes to the provision of care the Netherlands should be classified
as a conservative corporatist state, operating on subsidiarity. The state only steps in
when ‘‘the family’’ cannot provide the necessary care (Kremer 2000). In comparative
research on the provision of home care in Western European welfare states, it occupies
a modest position in the rankings of how many people receive state-provided home care
and for how many hours a week (Rostgaard and Fridberg 1998: 52; see also Anttonen
and Sipila¨ 1996; Rostgaard 2004).
The consequences of the Dutch arrangements for the labour market have been farreaching;
the Netherlands has had notoriously low rates of married women working
in paid employment deep into the 1980s. Increases over the last two decades are to a
large part due to the explosion of women in part-time work: of all women working,
70 per cent are working part-time. Fourteen per cent of men also work part-time,
making the Netherlands world champion in part-time work (SCP 2004a: 293). As
women carry the responsibility for care, they cannot work full-time, and in turn the
Netherlands can still rely on women to supply informal care. Women form 60 per
cent of all informal carers (SCP 2003: 36); most of them are between 45 and 65 years
old; and they put in three times as many hours than men, although figures vary,
partly due to definitional problems. It is further estimated that informal carers
provide 80 per cent of the required home care (SCP 2003: 119). Formal care is
provided by local authorities and seen as strictly supplementary, meted out after a
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strict assessment of ‘‘need’’ determined by the amount of informal care that can be
extracted from the family. The informal carer does not receive a tax credit or
allowance for her work; in most cases she is dependent on her husband’s income,
or on social insurance for her maintenance if she is single. Less than 15 per cent of
women between 55 and 65 years hold a (part-time) job. The preference of
consecutive governments for informal care as displayed in the policy papers is driven
by a powerful financial incentive: it is very much cheaper than state-provided
professional care.
Ageing as a Political Issue
The Netherlands is relatively well off in comparison to other European states when it
comes to the consequences of the ‘‘second demographic transition’’ – the decline of
the birth rate coupled to a large increase of the number of the elderly, as it has a lower
elderly dependency ratio.4
This relatively favourable position is due to the fact that
the baby boom after the Second World War lasted for a much longer period of time,
giving present-day policy makers some extra time to prepare adequate measures for
the inexorable fact of a greying population. The birth rate declined sharply since the
mid-1960s – when it was still around 3.2 children per woman – to 1.6 per woman in
the 1990s, a figure well below the replacement level of 2.1. The current figure is 1.75
(CBS 2005a: 9), an increase ascribed to higher fertility rates among migrant women.
Life expectancy has increased from 60 years (men) and 62 years (women) in 1900 to,
respectively, 76.87 and 81.44 in 2005 (CBS 2005b). Currently there are 2.2 million
people aged above 65 in the Netherlands; 93 per cent of these are living at home and
are the (potential) clients of home care. Even of the 85þ generation, 70 per cent are
still living independently (SCP 2004b). Despite two decades of policy to reduce the
number of elderly in residential care, the Netherlands still has the highest percentage
in residential care among EU states (Kremer 2000: 31).5
Old age has been a regular issue on the political agenda since the construction of
the Dutch welfare state after the Second World War. In 1956 the state guaranteed a
basic pension (Algemene Ouderdoms Wet – AOW, General Old Age Law) to all
citizens over the age of 65. Until 2006 there was a national health care insurance
covering all persons below a certain wage level,6
and state-funded homes for the
elderly. Old age policy has always led to debate about costs; by the mid-1990s
‘‘greying’’ and the burden for future generations were well entrenched as the
dominant policy definition. Within this overriding concern there have been shifts in
the problem definition of what makes the elderly problematic. Bijsterveld (1996: 67–
68) has noted that in the 1940s it was the ‘‘urgent needs’’ of the elderly; in the 1950s
their proneness to psychiatric disorders; in the 1960s their loneliness and isolation; in
the 1970s their marginalization in society. These definitions had in common that they
put the needs of the elderly centre stage, but financial considerations were never far
away. Concern among policy makers about the costs of the facilities for care
provision was already in evidence during the 1960s, which led to reductions in
residential care and the promotion of home care in the late 1970s. With the new
demographic discourse about ‘‘greying’’ and the costs for future generations, the
needs of old people were no longer the problem, but the number of old people were
(Bijsterveld 1996: 68–69, emphasis added).
Provision of Home Care as a Policy Problem 11
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The demographic shift and the issue of ageing started to figure in policy circles in
the mid-1980s, when demographers and state agencies such as the Central Bureau for
Statistics (Centraal Bureau voor de Statistiek – CBS) and the Social and Cultural
Planbureau (Sociaal en Cultureel Planbureau – SCP) raised the alarm about the
consequences of the shift. The Netherlands Scientific Council for Government Policy
(Wetenschappelijk Raad voor het Regeringsbeleid – WRR) published no fewer than
four reports on the issue in the 1990s (Outshoorn 2002). The warnings were soon
followed by major policy papers from most of the pertinent government
departments. The corporatist network around health care also proved highly prolific
on the issue, producing no less than six reports between 1992 and 1997.
The new focus emerged in the policy papers of the Ministry of Health and Welfare
on restructuring health care and on the elderly at the end of the 1980s. In 1987 the
report Bereidheid tot verandering (Readiness for Change) by the Commission Dekker
was published. It recommended the introduction of market principles to improve the
health care system in the expectation it would provide a better match between supply
and demand. Although the incumbent government embraced its principles, the
report failed to make much headway. With greying in mind, one of its
recommendations was to substitute intra-mural7
care with extra-mural care, and
this extra-mural care was not to be supplied by the state, but by zelfzorg, self-care, by
people themselves (Meloen 2000: 36). Another attempt to restructure the health care
system was made by the Commission Dunning (1991). Its report Keuzen in de Zorg
(Choices in Care) directly linked the problems of the health care system to the issue
of ageing; the elderly – already the major users of the services of care – would
increasingly need more care, not just more retirement benefits and the AOW. To
maintain the quality of care, the Commission recommended cutting the costs of care
and creating more efficiency in the care system. Due to lack of consensus within the
incumbent government its recommendations were not followed.
The 1990 policy paper of the Ministry of Health and Welfare on the elderly,
Ouderen in Tel (1990) (the title denoting both the ‘‘numbers’’ aspect and the idea that
the elderly should matter), attempted to redefine the problem of ageing as the need of
the elderly to be able to participate more fully in all walks of life. A careful analysis,
however, shows that this policy goal was also informed by anxieties about the costs
and the organization of care provision, including the matter of the supply of carers
(Mossink and Nederland 1994: 46). Under the label of ‘‘participation in society’’,
middle-aged women were encouraged to take on more informal care work, although
they were already providing the lion’s share. By the early 1990s greying and its
consequences had lodged itself firmly on the political agenda of the Ministry.
The Structure of Home Care
In the Netherlands home care is financed by the taxpayer under the 1974 AWBZ
(Algemene Wet Bijzondere Ziektekosten – General Law Costs Special Medical
Needs) which was designed to cover health risks considered to be ‘‘not-insurable’’ for
individual persons. Employees pay a certain premium and by principle everybody is
entitled to its benefits. Family members were insured for no extra costs through the
breadwinner. Its introduction was part of an overall restructuring of the healthcare
system in which the state became the central player in planning health care (Maessen
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1989). The health care system was envisaged as a two-tier system; the first tier
consists of GPs, paramedics (physiotherapists and such) and professional care
workers (e.g. district and school nurses); the second tier consists of the medical
consultants, hospitals and residential care. Underlying the whole system is informal
care and self-care. Home care encompasses both the first tier care workers and
informal carers; as an overall term to denote the area, it only came into general usage
at the end of the 1970s (Meloen 2000: 15).
This restructuring was a departure from the way care had been provided before.
Home care evolved from two earlier traditions of care in the Netherlands: family
care and the community nursing system (kruiswerk). Family care originated in
Christian charity which helped families in crisis, for instance when the mother of a
family fell ill. Some municipalities took on this responsibility at the turn of the
twentieth century. Since the Poor Law of 1854 local authorities have also provided
care for the poor elderly and some medical services such as midwifery. The
community nursing system originated from private initiatives in the latter part of the
nineteenth century and was later institutionalized along the lines of the Verzuiling in
a wide array of local and regional associations (Maessen 1989; Thuiszorg en zorg
thuis 1997: 32). People joined the associations by paying a small contribution and the
associations provided public health services for the members. Later the associations
obtained additional funding through state subsidies.
Home care became increasingly important when the state started to reverse its old
age policy in the mid-1970s. After the Second World War this policy had set up
residential care for the older generations on an extensive scale. Underlying this policy
were severe housing shortages: the reasoning was that when the elderly moved into
residential homes, younger people could move into the houses they vacated (Kremer
2000: 34). The Den Uyl government (1973–1977) was the first to reverse this policy,
aiming to keep the elderly in their own homes as long as possible in order to control
expenses more directly. Residential care became strictly rationed by the establishment
of a system of ‘‘indications’’ to determine eligibility. Moreover, health care
policy aimed at an overall shift towards extra-mural care; hospitals started to send
patients home sooner after treatment, and many treatments formerly performed
during a hospital stay were now performed on an out-patient basis.
Home care was to provide the services to help to achieve this goal, but home care
was neither expanded nor modernized. The most important ‘‘innovation’’ was the
introduction of a new care worker, the so-called ‘‘alpha-helpers’’ (alpha hulp) in
1977. These carers had a contract (with their clients, not with a home-care
organization) for no more than 12 hours a week, so that they could be excluded from
social security benefits (Maessen 1989). The idea was to recruit married women, who,
in the policy reasoning, did not need benefits as they had a breadwinner who was
entitled to family benefits. One of its effects was to make the work less attractive to
women; even in the 1980s with its high unemployment, shortages in labour supply
remained.
As this measure was not very successful, successive governments in the 1980s
started to promote informal care; formal care became defined as strictly
supplementary to what ‘‘the family’’ could provide in the way of care. The move
was ideologically legitimated in terms of the preferences of the elderly themselves;
they preferred to stay at home and remain independent as long as possible (Van der
Provision of Home Care as a Policy Problem 13
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Lyke 2000: 25–26, 49). Informal care also was portrayed as more humane, of better
quality and more effective in reducing loneliness than professional care. Policy
documents of the early 1980s emphasized informal carers’ strength and argued for
raising their status in the care system. With awareness of the demographic shift
dawning in the early 1990s, policy makers began to worry about the supply of care
workers and whether informal carers would be able to take on more care. The focus
shifted to the person of the informal carer, which raised the awareness of the genderspecific
nature of the work (Van der Lyke 2000: 53–55).
The 1991 Policy Paper
The Lubbers III government (1989–1994) (a coalition of Christian and Social
Democrats) took the issue of the rising costs of care seriously and proposed a series
of measures to curb the growth. The most important paper about home care, Home
care in the 1990s (Thuiszorg 1991), set out to provide a future vision for home care.
The rising demand for home care was defined as the policy problem. This was caused
by the ageing of the population and the processes of individualization and the
emancipation of the ‘‘citizen’’, which led to a preference for people to stay in their
own home as long as possible (ibid.: 6). At the same time the average size of
households was declining and the number of single old people, especially older
women, was on the increase. According to the paper, the current supply of home care
would not be able to meet demand in the future. Surprisingly, budgetary
considerations were hardly mentioned.
The present structure of the health care system, along with its system of financing
which obstructs flexibility and co-ordination of services, was constructed as the
second problem definition in the document. More attention to home care was
essential, but in the view of the government, this would not entail more state
responsibility. The state was to step back and limit its obligations to encouraging
and supporting other actors in the care sector, such as insurers, care suppliers and
consumers/patients in ‘‘taking their responsibility’’ (ibid.: 3). Informal care, defined
as care provided by family, neighbours and friends on a non-professional basis, was
to be primary; professional care was to be supplementary (ibid.: 5).
The paper noted that home care would be an extra burden to women, as they are
the main providers of care at home (ibid.: 10). It also noted that ‘‘the growing labour
market participation of women has consequences for the availability of informal
care. Women will increasingly have paid work and will no longer take it for granted
that they should shoulder the work of caring’’ (ibid.: 11). Along with improved coordination
and integration of professional services, the policy goal formulated was
‘‘maintaining the existing level of this unpaid care provision’’ (ibid.: 11). Many of the
proposed policy measures targeted better organization of the home care sector. The
major proposal was the revision of the health care insurance system to include all
Dutch citizens, but as the government failed to achieve consensus on this
fundamental reform all that remained of the measures were a number of statesupported
experiments for linking different types of care provision. All aimed at
reducing intra-mural care.
To maintain the supply of carers, the paper proposed several remedies. First, the
integration between district nursing and family care was to save money as it would
14 J. Outshoorn
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enable residential care to be substituted by home care. Second, the care sector was to
concentrate on eliminating labour market shortages. The work itself was to be
professionalized by differentiation in functions and wages and by additional training.
The workload was to be reduced (a small budget was provided) and the sector was to
improve its image to attract more women workers. Women returners to the labour
market were targeted as sources of labour, for whom the paper recommended more
childcare (even 24-hour childcare ‘‘might’’ be considered) (ibid.: 28). No concrete
proposals to finance this were suggested. Third, to maintain supply of informal care
the paper wished to promote voluntary work, which was to be made more attractive
by setting up volunteer organizations and providing compensation for volunteers’
expenses.
The 1991 policy paper was well aware of the gendered nature of home care, both in
regard of the care providers and the clients. It made the necessary distinctions
between men and women as a social category, noting the difference in longevity
between women and men and that older single women are the ones requiring more
professional care, the more so as they receive less informal care. It also had eye for
the gendered division of labour, showing that it is women providing the bulk of
informal care (ibid.: 10–11). The policy makers did worry that women’s traditional
gender identity, in which care takes a central place, would erode with their
participation on the labour market. Men’s traditional gender identity is taken for
granted as a role for them in caring is not envisaged for the future.8
The core value of the paper was the preference of people for staying at home as
long as possible, although this was not backed by any empirical research. With this
observation the policy makers side with the clients; whether staying at home is
always the preference of the informal carer is never questioned. Care at home was a
second core value, portrayed as important and indispensable and, by connotation,
also as a haven of warmth, security, intimacy and personal service. In this way a
dichotomy is created to professional care, linking it to remote, cold impersonal
service.9
The proposal, by retaining informal care as the cornerstone of home care
policy, in no way called the traditional gender order into question, and in fact
reinforced it.
The policy intentions were accepted by the major actors in the debate such as the
political parties and the top echelons of the formal care sector. A rising feminist
opposition, uniting a feminist older women’s organization, feminist scholars and two
new small trade unions of care workers, protested against the lack of formal home
care, but were ignored by the government, the major trade unions and the main
parties in parliament (Oldersma and Outshoorn 2007). Throughout all the debates a
stronger coalition was impeded by differing interests between groups of women;
doing away with the alpha workers and professionalization of home care was in the
interest of women workers, but against the interest of most women clients who
would not be able to afford the subsequent higher costs of hiring home care.
In line with the policy aims, the formal care sector became subject to a series of
reorganizations that aimed to increase efficiency so that it would be able to cope with
the increased demand for its services.10
Different types of home care were centralized
into large organizations covering a neighbourhood, a town or even a region. Under
the influence of the new management ideology, these new organizations became
quite hierarchical, with financial-economic experts moving in to fill the top positions
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(mainly men); the female directors of the old system became the middle management.
They were the ones who had the shop-floor knowledge and the contacts with the care
workers (Meloen 2000). The actual work in the home was being done by the lowpaid
alpha workers (women), whose work was increasingly standardized by strict
guidelines. This turned their work into mainly housework with little time left to pay
attention to the social and psychological needs of their clients (Vulto and More´ e
1996). The emphasis on informal care can also be traced in other policy papers of the
Ministry of Health and Welfare, such as the yearly reports to parliament and various
official reports on the chronically ill.
The Ministry further focused on funding research on informal care and supported
several experiments in informal care, such as the persoonsgebonden budget, a personal
budget for a client who could then buy services for care. Researchers and policy
makers began to worry about the heavy burden of the informal carer and the risk of
stress and burn-out. In order to relieve informal carers, they became the object of
policy intervention. They were to undergo training and courses in ‘‘coping’’ and were
to co-operate with the professional care workers, a co-operation portrayed as an
alliance (Van der Lyke 2000: 63–64). Here a process of hierarchization can be
discerned, obscured by the metaphor of the ‘‘allies’’; informal carers were gradually
placed under the tutelage of the professionals to enable them to keep up their useful
work. Ironically, the professionals are also mainly women, creating a new conflict of
interests in the debate.
The problems were exacerbated by the abortive attempt in the mid-1990s to allow
commercial organizations to enter the field of the provision of home care, an attempt
to introduce competition and in this way enhance productivity. Some 25 commercial
bureaus entered the market, who could select their clients while the state-subsidized
organizations had the obligation to take on all clients. Some of the commercials
started to ignore the collective bargaining contract (CAO) and refused to pay their
workers the union rate, which raised the fury of the traditional home care
organizations, the unions and the left wing political parties. Waiting lists for services,
high turnover of personnel, high absenteeism, problems in recruiting new workers,
bureaucratic red tape and remoteness of top management from the ‘‘shopfloor’’
made for newspaper headlines. The successor to Lubbers III, the ‘‘Purple’’ Kok I
government (1994–1998), a coalition of Social Democrats, Social Liberals and the
Liberals, had to face regular parliamentary questions on the hot issue of home care,
and to renege on promises made in election campaigns and party programmes about
improving the services (Oldersma and Outshoorn 2007).
The 1997 Policy Paper
In 1997 the first Kok I Purple coalition government published a new policy paper on
home care, Home care and care at home (Thuiszorg en zorg thuis 1997). Its most
important measure was to freeze the experiment on introducing competition by
privatizing home care. The problem definition of the new paper was the increasing
number of elderly, often with chronic diseases, requiring care in the (near) future.
Demand was also expected to rise because of the renewed goal of shifting from
residential types of care to extra-mural care. The policy was again legitimated in
terms of preferences: terminally ill people prefer to die at home which will require
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additional home care.11
Moreover, demand would be qualitatively different;
requiring more specialized care as well as more luxurious care demanded by the
growing number of affluent elderly. The government did state that the large group of
people with only the state old age pension would still require care provided by the
state.
The paper noted that most care provided is informal care (only 16% of care is
provided by professionals), but that this was under pressure by the decreasing birth
rate, the growing number of women in the labour market (the paper noted that, next
to partners, it is mainly daughters providing informal care), increased geographical
mobility and the rising divorce rate, with children having to look after two parents in
different parts of the country (ibid.: 13). Formal care was under pressure as fewer
people were attracted to work in the care sector. The number of younger people in
the population is declining and fewer of them are choosing to work in the care sector.
As in the 1991 paper, there was a second problem definition; the organization of
the care sector which made for fragmented and badly co-ordinated care provision.
The Minister admitted that efficiency measures taken in the early 1990s had become
counterproductive and that it was not possible to reduce the number of hours per
client any further (ibid.: 11). Management had grown disproportionately, causing
imbalances between its costs and those spent on the actual work (ibid.: 16); high
turnover and absenteeism among the workers were rife. Despite a very strict system
of the allocation of care to those who ‘‘deserve’’ care, long waiting lists were
endemic.12
Still, the policy goal was to follow the route of the 1980s, ‘‘to enable people to stay
at home as long as possible, or let them return to their home as soon as possible after
a hospital stay’’ (ibid.: 4). The paper praised the worth of the informal care sector
and acknowledged that its volume exceeds the professional (formal) care supply. The
basic goal of home care policy remained intact however, regarding formal care only
as a supplement to informal care. It cannot be that ‘‘with the arrival of the
professional carer, the informal carer gradually withdraws’’ (ibid.: 23). Formal carers
and informal carers are an ‘‘alliance’’ that needs to co-operate within the home to
look after the patient/client (ibid.: 14, 23). The emphasis on informal care ties in
neatly with the professed policy goal of bringing care ‘‘close to the people – to their
homes and neighbourhoods’’ (ibid.: 5, 18).
For the source of labour supply the paper looked at the growing group of vital
young pensioners and early retirers who have the time available to take on informal
care and volunteer work. The elderly themselves are living longer and the declining
difference in life expectations between men and women would mean that, instead of
six years of widowhood, women will only be faced by three years of widowhood on
average by 2050. It is ‘‘partners’’ who are to provide the bulk of informal care. The
paper noted (with some satisfaction) that men also enjoy this work more than
women (ibid.: 13). Resident migrants were seen as potential suppliers of care; they
are also favoured to meet the emerging needs of ageing migrants (ibid.: 12). Even the
long term unemployed were suggested as possible sources of labour (ibid., 22).
The policy measures were divided into short and long term measures. The most
important one, already mentioned in the previous paragraph, was to freeze the
introduction of competition in the care sector: no new firms were to be admitted.13
The short term measures aimed at a more effective implementation of policy, such as
Provision of Home Care as a Policy Problem 17
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the integration of family care and district nursing (on the agenda since the 1970s!);
strict indications for formal care; uniformity in financing care institutions, tariffs and
clients’ financial contributions for formal home care. The state increased the budget
for home care from 2 per cent to 3 per cent per annum to deal with the increase in
demand. As to labour market policy, the government left it to the care sector itself,
only recommending a more active policy in fighting absenteeism by improving
working conditions and training of the low-skilled employees. It did not mention
higher pay – this was left to the social partners.
The government also provided a budget for experiments exploring new directions
in care provision and for redesigning the first tier of the care system, as well as better
co-ordination of types of care to counter the current fragmentation. Care leave was
to be promoted so that people can provide informal care for their families. Allowing
people on social security to work as informal carer or volunteer in care work without
losing their benefits was to be explored. The paper did not take a definite position on
the two hottest topics in health care: the structure of health care insurance and the
introduction of competition in the overall health care sector. The reason was the lack
of consensus on these issues among the three parties making up the government.
As for gender, on the one hand the government was aware of sex differences
among the elderly and among the caregivers, 95 per cent of whom were women.
Among all employees of the total health sector, 85 per cent were women (Thuiszorg
en zorg thuis 1997: 15). On the other hand, however, most of the paper was written
in a gender-neutral style, talking about ‘‘people’’, ‘‘the elderly’’, ‘‘management’’, the
‘‘well-off seniors’’, ‘‘informal carers’’, the ‘‘early retirers’’, ‘‘partners’’, ‘‘personnel’’,
‘‘part-timers’’, ‘‘allies’’ in home care. It assumed that ‘‘partners’’ would take care of
each other, ignoring the existence of the growing number of single people. This
gender-neutral terminology hides much of the hierarchical gender relations and the
gendered division of labour. It also veils the gendered structure of the labour market,
with its very high degree of sex segregation when it addressed labour market
shortages and recruiting new workers. The paper also reveals traditional cultural
gender values. Ignoring pay when talking about making formal care work more
attractive assumes that women do not care about money, either because they have a
breadwinner, or that they work for social or altruistic reasons. It banked on vital
early retirers taking on informal care or volunteer work in the care sector, not
mentioning that in the current generation these are mainly men with traditional
masculine identities, for whom caring is still seen as feminine. It also banks on
traditional feminine identities in assuming that women will continue to take on the
lion’s share of informal care despite their increasing integration in the labour market.
The core values of the report were solidarity, efficiency, and the central importance
of self-care and informal care. Informal care should be the fundament of the care
system as people give preference to staying at home in familiar surroundings: if they
leave hospital early it speeds up their recovery. It is more humane and comforting
and partners want to take care of each other. In this way the paper builds on values
traditionally associated with the feminine in Western culture; stressing interconnectedness
and altruism. Implicitly informal care is framed in a dichotomy to formal
care, where professionalism and efficiency are the central values. Both latter terms
have a masculine connotation; despite the fact that informal care is preached as
fundamental, a hierarchy is established between the two in which formal care has the
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higher status. Informal carers are portrayed as allies of the professionals, and are to
co-operate with them. On close reading, it emerges that the formal carers ought to
take the lead and train the informal carers, as they have superior knowledge (ibid.:
23). And the informal carers should not try to shirk their obligations – which they
might if more formal care is available. One can conclude that this policy paper in no
way calls into question the traditional gender order, but instead builds heavily on
traditional gendered cultural values and identities.
The debate on the 1997 paper was less consensual than that on the 1991 one; the
government had to back down on the privatization issue and the budget cuts on
home care. The parliamentary debate focused on the unsuccessful introduction of
market principles in the home care sector and the costs of the national health
insurance. No party, however, attacked the basic philosophy of regarding formal
care as supplementary to informal care, and the debate was carried on in genderneutral
terms (Oldersma and Outshoorn 2007). This was in spite of the fact that the
government members in charge of health care and many of the parliamentary
parties’ spokesmen were women. The lobby by the Emancipatieraad (Emancipation
Council), the official advisory body to the government on women’s status, which had
come out against the alpha workers and called for more professional formal care,
also failed to change the terms of the debate. In general women’s movement
organizations gave the issue low priority and only a few feminist scholars joined the
opposition against the 1997 measures.
The most important policy outcome of the discussions and protests about waiting
lists in home care at the end of the 1990s was indeed the increase in the budget.
Attempts to oust home care from state funded social security arrangements were not
successful and further attempts to introduce market principles were forestalled, with
the exception of personal budgets for clients, which were such a success that the
funds reserved for this type of care had to be frozen. The mergers of home care
organizations were over by the beginning of the new century.
The 2001 Policy Papers
However, the problems had not disappeared. Waiting lists for home care prevailed
and stories about overworked informal carers made it to the press regularly. With
national elections due in 2002, several budgetary restrictions on health care were
lifted. To meet the continual pressure, the second Purple coalition (Kok II) (1998–
2002) produced a Zorgnota 2001 (Policy paper on Care) (2000) covering the whole
health care sector, both ‘‘cure’’ and ‘‘care’’. Its problem definition was the shortfall
in the supply of care caused by shortages on the labour market, and the workload
of employees in health care. Its goal was to decrease the waiting list and increase
the volume of services. This was deemed necessary to meet the increasing demands
of the critical consumer for higher quality care. The magical phrase for care was
‘‘zorg op maat’’ – customized care. The government proposed a range of measures
to make work in the health sector more attractive, but again left most of this to the
social partners. In addition, the usual efficiency measures were proposed to
improve productivity, including a redistribution of the costs of residential care
between the Ministries of Health and Welfare and of Public Housing. Extra
budgets were made available to decrease the workload at the level of health
Provision of Home Care as a Policy Problem 19
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institutions and further training aimed at increasing professionalism among health
workers.
It was striking that the government stuck to a gender-neutral frame and analysis.
The only reference to gender was that the policy paper notes that 78 per cent of
workers in the health care sector are women, and that 73 per cent of all its jobs
are part-time – as compared to 44 per cent of all jobs in the Netherlands (Zorgnota
2001 2000: 175). Even those returning to the labour market were not gendered, but
if one looks at the measures for recruiting them, a woman/mother is obviously in
mind: jobs should be close to home, with suitable hours and a limit on the number
of hours (ibid.: 187).
As to home care, the basic philosophy about the mix of formal and informal
care remained untouched. The government noted that elderly people were staying
at home much longer out of choice, but also because there were waiting lists for
residential care. This led to higher work pressure for both home and residential
carers. The government now offered alpha workers in home care the choice to
become employees of care work organizations or retain their old status. The most
striking aspect of the paper is that informal care was not discussed. The
conclusion must be that the policy makers assume its presence as natural fact of
life. But its neglect also reveals the very low value awarded to it, not surprising in
a paper where the approach is mainly economic, emphasizing efficiency, quantity
and cure.
The policy paper had its first parliamentary reading in November 2000. During the
debate no party challenged the basic philosophy on the mix of home care. The
Minister did not mention informal care at all, but now there was strong opposition
from several women Liberal and Social Democrat MPs. Feminist scholars on the
issue had been able to lobby, influencing both the MPs and the women’s policy
agency, which finally took up the issue in the late 1990s. Formerly it had interpreted
care as child care and hence focused on the combination of work and family life for
mothers (Oldersma and Outshoorn 2007).
The government responded by drafting the 2001 paper Zorg Nabij (Care close to
home). This paper tried to redress the insult of the previous policy paper by praising
the informal carer for contributing to social solidarity and acknowledging that long
term carers are threatened by social isolation and overload. The government stated
that an informal carer should be able to participate normally in social life and that
the professional home care institutions should not use the maximum hours an
informal carer can deliver as the gauge for providing for professional care (Zorg
Nabij 2001: 9, 22). The informal care worker, however, was portrayed as a male,
since the paper used Dutch masculine nouns and pronouns to denote the carer. The
paper did note that twice as many women than men provide informal care, and do so
for many more hours (the paper did not specify the exact amount, ibid.: 10). The
paper still assumed the traditional gender division of labour, along with women’s
traditional obligation to take care and women’s identities that predispose them to
take on the responsibility of providing care. All proposed measures: more volunteers,
advice centres for informal carers, weekend takeover when things become a bit too
much and ‘‘respite’’ leave are all aimed at preventing the informal carer from calling
in the professionals. At the same time the government noted that women’s
participation in labour market still needs to increase. It supposed that a more
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generous future system of paid care leave will enable ‘‘working people to take on
informal care, and informal carers to work’’ (ibid.: 17). In no way is the gender order
called into question; its impact is more likely to reproduce traditional arrangements
and values.
The Purple coalition government lost power in 2002, after the populist revolt led
by Pim Fortuyn and the subsequent electoral swing to the right. However, the two
ensuing right-wing coalition governments did not alter home care policy, despite the
fact that Pim Fortuyn had targeted the waiting lists in health care as one of the major
failings of the earlier Purple coalitions. Budgetary constraints are strictly maintained
by the Balkenende II government (2003–2007) (a Christian Democrat/Liberal/Social
Liberal coalition). The basic philosophy is that people should take their own
‘‘responsibility’’ and not depend on the state for help. The major change enacted in
the area of health care is the 2005 Zorgverzekeringswet (Health Insurance Law; see
note 6) which does not impinge on the home care issue. However, pending is a bill to
decentralize a large part of the AWBZ funds to the municipal level, including home
care (Wet op de Maatschappelijke Ondersteuning – Law on Social Support). It does
not alter the basic philosophy underpinning home care but there is much debate on
how local councils will implement the law in this area. Many fear that if the funds for
the elderly, handicapped and chronically ill are not earmarked, councils will use the
money for other purposes.
Discussion
Overall, when we compare the policy papers, there is great continuity in the policy on
home care. The problem definition has not changed, neither have the basic policy
solutions. Informal care remains the cornerstone of home care policy; state-funded
services only step in when informal care fails, and extra-muralization is to be
continued on all fronts. In all government policy the policy is legitimated by pointing
to the preference of older people for remaining at home as long as possible. The
causes of the problem are defined in very similar ways: ageing and the poor
organization of services. One must conclude that after 15 years of debates, money
and measures there is still a lack of integration, a great deal of inflexibility, and poor
co-ordination standing in the way of more and better service delivery. All papers aim
at maintaining informal care and limiting formal care, which is to remain
supplementary to informal care. The core values of the papers also show great
continuity such as the preference of the elderly to remain at home as long as possible,
solidarity between carers and care receivers. This goes for the subtext of the
documents, that is about costs and efficiency.
Solutions to the problem have proved more varied. In 1991 the government hoped
to restructure the sector by a new system of basic health care insurance and the
introduction of competition. With the failure of the insurance reform, all hope was
then pinned on the maintenance of informal care; in 1997 privatization was stopped.
In 1991 informal care was to be provided by volunteers; in 1997 ‘‘partners’’ were the
solution; in 2001 the usual suspects as well as migrant women returners to the labour
market. In all papers shortages in personnel were to be decreased by making
professional care work more attractive (without mentioning higher wages) and by
combating staff turnover and absenteeism. While the 1991 paper showed high gender
Provision of Home Care as a Policy Problem 21
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awareness, the subsequent papers reverted to gender-neutral language, hiding the
gendered division of labour. Not obscured is the lasting attachment of policy makers
to traditional gender values and gender identities; all policy papers assume they are
there to stay and use them as a point of departure.
An important point in the 1997 paper is the very strict rationing of care by a
system assessing the amount of informal care for the indication for professional care.
This paper is also notable for the relatively generous admission of policy failure by
freezing the experiments in privatized home care. Moreover, in contrast to the 1991
paper, the ‘‘necessity’’ of reducing state expenditure is no longer hidden in the
subtext of the document. The 2001 papers reaffirm the need for strict criteria for the
allocation of professional home care.
It is when we contrast the aims of home care policy to other major government
goals in the Netherlands that contradictions in ageing policy emerge. The most
striking one is in the area of labour market policy. Because of the large number of
married women not participating in the labour force, the Netherlands had a very
high economic dependency ratio. While OECD reports already pointed out this
weakness in the Dutch economy in the late 1970s, increasing married women’s
labour market participation was not official government policy until 1994. As long as
the Christian Democrats, with their strong familial ideology, had the pivotal position
in any coalition government, they could effectively prevent any steps in this
direction. Measures such as subsidizing child care, reforming the tax system, or
abolishing the advantages of the male breadwinner family in social insurance and
social security were out of the question.
With the advent of the Kok I government in 1994 (in which the Christian
Democrats were excluded from power for the first time since 1918), work became the
paramount concern in fighting unemployment and combating the number of people
dependent on social benefits. A series of measures to promote (married) women’s
work, including those with very young children, was implemented to reduce
dependency of women on social benefits. In this way the financial base of the welfare
state (draagvlak verbreding) is to be maintained. Reducing the economic dependency
rate also became more urgent when policy makers realized the consequences of the
greying of the population. It is this employment policy that contradicts home care
policy with its emphasis on informal care to meet the needs of the elderly. Given the
fact that it is mainly women providing informal care, it clashes with the proclaimed
necessity of increasing women’s labour market participation. Policy makers agree
that formal care work should be made more attractive to maintain labour supply,
but given the goal of reducing public spending and the costs of labour, raising wages
in the health care sector is never the preferred policy option.
In the 1980s the Netherlands finally started to restructure its gender order, moving
away from the strong breadwinner model to individualization of entitlements to
benefits and obligations. This was the result of pressure to comply with the equal
rights legislation of the European Union and of the challenges posed by the new
women’s movement, one of the strongest in Western Europe. In her study of four
European welfare states, which included the Netherlands, Diane Sainsbury has
provided the necessary empirical evidence to show that the inequalities between
men’s and women’s social benefits and tax allowances diminished; the reform of the
old age pension (AOW), a universal scheme, was particularly successful from the
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point of view of equal entitlement (Sainsbury 1996: 187). Wife and husband now
each receive 50 per cent of the pension, while formerly the pension was paid to the
husband when he reached the age of 65. The old breadwinner’s advantage is not
totally eradicated: a housewife does not pay contributions for the state pension,
while a wife who has worked for wages does pay the required premium. With the tax
reform of 2000, the remaining advantages for the breadwinner in taxation have also
been removed: previously the generous tax rebate for men with non-working wives
proved to be an obstacle for their entry into the labour market.
The process of individualizing social benefits has decreased women’s financial
dependence on their husbands, but at the same time it has worsened the position of
those women who cannot earn enough to be economically independent. This is
where the obligation of informal care comes in; it is one of the main reasons why
women are not acquiring economic independence, and, from the point of view of the
state, still present a risk for the volume of social security benefits. Part-time work
may seem a solution for procuring informal care (although this is never said in
official papers), but it does not contribute much to reducing the economic
dependency rate. When it comes to informal care the Netherlands still depends on
the traditional gender order, and at the intersection of the contradictions between
policies it is women who have to straddle the divide.
Conclusions
Overall, the policy mix on home care in the Netherlands shows little change over the
years. Informal care remains the cornerstone of policy, with professional care only
issued on a strict system of allocation. The underlying argument of policy makers is
that the state should ration the supply of care, as any extra costs will lead to higher
insurance premiums for employers and employees, which lead to demands for higher
pay, which in turn are detrimental to labour costs and thus to Dutch competitiveness
in an increasingly competitive globalizing market. For similar reasons, but also to
meet the EMU criteria, the national debt has to be decreased, setting limits on state
spending. The legacy is a continual situation of shortages in care, erratic service
provision and overloaded workers in both the formal and informal sector, which will
continue to plague care givers and care receivers as well as public administrators and
politicians.
This case study has also shown that the policy of long term care for the elderly
is still predicated on a breadwinner/caretaker gender order and that the provision
of care is to be secured by a strict division of labour between unpaid and paid
care worker. The Netherlands locates care primarily in the family. The bulk of
caring is to be performed as unpaid work, in the home, and by ‘‘partners’’.
People have to take on the obligation of caring for their kin, and, given the
prevailing gender order, this is most likely to be met by women. It must therefore
be concluded that the policy will not lead to defamilization, but to greater
dependency of women on the family. The solution is consistent with the welfare
mix of the conservative welfare state, but not consistent with the move towards
an individualized welfare state where the structure of benefits does not impede
women in determining their life course and tie them to unpaid work within the
family. Home care is constructed as a family obligation, with minor public
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responsibility. Given the rationing of care, the market is already providing some
care services for those able to pay. Government policies ignore the fact that
increasing female labour market participation will clash with the necessary supply
of informal carers. They also tend to ignore that women’s traditional identities, in
which care takes an important place, and the ideology of moral obligation to care
are both in decline.
In policy debates about ageing, home care tends to be ignored as its provision by
women is usually taken for granted by policy makers. The outcome of the analysis of
the Dutch case, which has uncovered serious contradictions in policies for taking
care of the elderly, is highly relevant for the ageing policies of other conservative
welfare states predicated on the same gender contract. All of these are faced with the
same dilemma as the Netherlands; the case shows that building on informal care to
solve the problem of care for the elderly will hardly suffice. Moreover, it is not
compatible with states’ major policy goals of reducing the costs of the welfare state
and boosting women’s employment.
The analysis also shows the importance of studying the welfare state from the
point of view of care. The demographic shift, with its growing number of elderly
people, brings the issue of care to the forefront. As Mary Daly has observed, ‘‘the
risk of requiring care or having to take care are two major life contingencies for
individuals’’ (Daly 2000a: 68). Welfare states, by changing the welfare mix,
determine who has to take the responsibility for care and whether the person who
does the actual work will get paid for their services or revert to dependency on their
family. Rethinking the welfare state to encompass the need for care of the old and
the frail is unavoidable.
Acknowledgements
The author wishes to thank the participants of the Workshop: The Politics of
Ageing, Joint Sessions of Workshops of the European Consortium for Political
Research at Turin in April 2002 for their comments on a previous version of this
paper, and of the meetings of the Research Network on Gender Politics and the
State (RNGS). She also thanks the (ex-)colleagues of the Joke Smit Centre for
Research in Women’s Studies, in particular Jantine Oldersma, for triggering my
interest in home care.
Notes
1. Informal care can be defined as ‘‘care that directly ensues from a social relation’’ (Van der Lyke, 2000:
19). It is care delivered by partners, friends, family and neighbours and originates in commitment
(ibid.). The Dutch term used in policy debates is ‘‘mantelzorg’’ (lit. cloak care, suggesting the warmth
of a cloak or overcoat).
2. The names and tasks of this ministry have changed several times over the last decades. From 1983 it
was the Ministry of Welfare, Health and Culture (WVC); from 1994 the Ministry of Health, Welfare
and Sports (VWS). For practical purposes I will call it the Ministry of Health and Welfare in this
paper.
3. For this analysis I will follow Outshoorn (2002: 18–187). Four layers of gender are distinguished: (1)
Gender as a social category distinguishes between men and women: what differences are there and are
these taken into account in the text? (2) Gender as a principle of social order looks at the underlying
24 J. Outshoorn
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gender order: what are the explicit/implicit assumptions about the division of labour between the sexes
in the text? What does it say about it, and what assumptions are made about behaviour of women and
men? (3) Gender as a cultural principle giving meaning at the symbolic level looks at notions of
femininity and masculinity, the values can be derived from the problem definition of the policy text
and what normative assumptions and how these are gendered? Is it done in a hierarchical way? (4)
Gender as identity looks at what identities are ascribed to women and men in the text and what is
assumed about these identities.
4. See Van Ewijk et al. (2000: 16–17) The elderly dependency rate is defined by the number of people over
age 65 as a percentage of 20–64-year-olds.
5. She bases this on figures of 1996, which are likely to report on the situation in the early 1990s.
6. On 1 January 2006 a new law covering all persons for basic health care (Zorgverzekeringswet) became
effective. The national health system was privatized, but all insured had to be accepted by insurance
companies, who cannot select for the basic health coverage (Basispakket). Its costs vary little per
company in 2006, but are expected to rise after this year. One can also take out extra coverage beyond
the basic insurance.
7. Intra-mural is care/cure within a hospital, clinic or specialized institution; extra-mural is care outside
of these institutions, usually meaning the home.
8. Van der Lyke (2000: 57–58) maintains that policy started to target men to fill in the deficit. In n.50
(p.166) she refers to a short version of the 1991 policy paper in which men are targeted: this is,
however, not to be found in the final 1991 paper. Her other references (n.51, n.52) refer to the policy
papers of the women’s policy agency, which after much pressure from the women’s movement finally
started to include men in its papers on the status of women. No traces of this can be discerned in the
two policy papers of the Ministry of Public Health analysed here, where home care resides.
9. A similar outcome is described in More´ e and Oldersma (1991) who analyzed early policy reports on
family care of the 1980s.
10. It started with: Ministerie van WVC/Heroverwegingsgroep, Van samenwerken naar samengaan;
gezinszorg en kruiswerk; naar een geintegreerd aanbod in de thuiszorg, Rijswijk: WVC, 1990. It expected
to save Hfl. 25 million. Subsequent policy papers of WVC also set integration as a high priority.
11. In 1970 19 per cent of people went to a hospital to die; this number rose to 35 per cent in 1995, leading
to criticism about the medicalization of the last stage of life (Thuiszorg en zorg thuis 1997: 17).
12. To establish eligibility, during the intake interview the following questions are asked: what can the
person still do her/himself, in the household and in personal care? Is informal care available? This is
then supplemented by formal home care (Thuiszorg en zorg thuis 1997: 10). The Minister also
published new guidelines in 1997 in the so-called Indicatiebesluit. The rules for allotting care are
followed strictly.
13. The policy paper notes that between 1994 and 1996 no fewer than 25 commercial enterprises entered
the market.
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