In the words of Maria-Angeles Duran: "Creating a new care system requires a prior intellectual decision: to recognize that care is not a private residue of the economy, but one of its foundations"
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The following text is adapted from the keynote remarks delivered by María Ángeles Durán during the Europe and Central Asia Care Forum, which took place from 11–12 May 2026 in Istanbul, Türkiye. The views and opinions expressed in this article are those of the speaker and do not necessarily reflect the official policy or position of UN Women, the United Nations, or any of its affiliated organizations.
I have been researching care for more than six decades. But I want to underline the value of the knowledge held by those who, outside academia, confront every day both the generous and the painful face of care, even when they do not turn that knowledge into a report, a statistic or a theory.
Because of my age, I have already travelled through almost the whole life cycle. Like most people of my generation, I received care in childhood and adolescence; I became a caregiver when I formed my own family and had children; I fought for work-life balance and learned how difficult that balance can be. I have seen the previous generation become ill and die, and I have witnessed their need for care over years, sometimes decades. I have also seen at close range the enormous wealth that older people contribute as unpaid caregivers. Now I am more aware than ever of the importance of self-care, and I know that the time is approaching when I will need intensive care from those who love me and from the institutions able to provide it.
What we mean by care: the emergence of the careariat
In its political dimension, care is a relatively young term. The civil codes that in many countries referred to the 'duty of maintenance among relatives' have had to be explicitly reformed in order to broaden that concept to include the provision of care2.
Two different ideas converge in the meaning of care. One is precaution and attentiveness in order to prevent harm: an activity that is above all mental, psychological and moral. The other is the physical action of helping people who cannot manage them alone to carry out the tasks of daily life: moving, eating, washing, receiving therapies or maintaining social ties. Some languages have different words for these facets, which is why the term is difficult to translate precisely and why international statistics are difficult to compare. The same word is interpreted differently depending on whether the context is health, education, social services or even leisure. If I am not mistaken, in Turkish the care of a sick person is expressed with bakmak, while özen göstermek is closer to the idea of paying attention or showing diligence.
The purpose of this Forum is to encourage the creation and improvement of care systems: coordination and integration among services, wider coverage of types of care, broader coverage of population groups, greater continuity over time and better quality for those who receive and provide care. It is therefore essential to define what care is, how the need for care is assessed and to whom the responsibility for meeting that need is assigned: to an individual, a family, the market, the community or a public institution.
You have probably never heard the term 'careariat3', although you will be familiar with related terms such as 'peasantry' or 'proletariat'. The careariat is an emerging social class, made up of those whose main function in the economic structure is to produce care. It is characteristic of twenty-first-century societies and consists mainly of women who provide unpaid care, although it also includes paid care workers. Their work receives less recognition and is rewarded with fewer rights than the work of other workers. Yet they are the invisible base of the iceberg; without them, the rest of productive activity would not be possible. For now, care producers have little awareness of their own importance. The caretariat has an enormous capacity for social transformation, for becoming a historical actor. But in order to achieve that leading role, it will need to find better ways to organize, create leaders, theorists, alliances and channels for expression and negotiation.
The modes of production of care
In the twenty-first century, the economies of all countries are complex structures that integrate, not without friction, several subsystems or modes of production. Each has its own institutions, values, affected population, experts and theories. These subsystems are communicating vessels: any change in one immediately affects the others. In order to measure the transfers among them more accurately, it is advisable to use time flows in addition to monetary flows.
Families are the main institution of the domestic mode of production, although for methodological reasons it is households that are usually studied. They produce human beings who later act within the other subsystems. Their main rule of internal interaction is donation and non-monetized exchange.
Firms and markets are the main institutions of the capitalist mode of production. Their objective is profit, and their main mode of interaction, both internal and external, is monetized exchange. In general, they are more agile and more receptive to technological innovation than other institutions.
The State and its agents are mediators and regulators in relation to the rest of the institutions; together, they form the state mode of production. In democracies, the State has the prerogative of the legitimate use of force and can impose criteria on the population and on other institutions: for example, it can decide the tax burden, set minimum wages or regulate the length of the working day. It collects revenue through taxes, redistributes resources and provides subsidized services. It also consumes goods and services through the market.
The cooperative or philanthropic mode of production is less powerful than the previous three, although it is enormously important in relation to care. Its most common institutions are NGOs and non-profit organizations. Its main mode of interaction is donation, but unlike the family, it is directed toward people outside the kinship network.
Care is produced through all these institutions. However, throughout the world today, households remain the main producers and consumers of care. And within households, most care is produced by women.
The invisible economy of care
The role of the market, firms, the State and its institutions has received a great deal of attention from economists. Although in its Greek origin the word economy referred precisely to the rules for administering households, the economic role of unpaid work received little theoretical or normative attention until the late twentieth century. It was mainly at the insistence of women's associations and feminist thinkers that it began to be studied in greater depth.
In 1995, the Platform for Action adopted at the United Nations Conference on Women pointed to the biases introduced into macroeconomic analysis and into indicators as widely used as Gross Domestic Product or National Income when the production of goods and services for household self-consumption, especially by women, is not taken into account. A large part of that production could be defined as care.
The annual volume of unpaid work on which care largely depends may be greater than all the work produced for the labour market.
That may sound strange, but it is not so strange. Market workers usually enter the labour market later than those who produce care services at home, especially girls. Moreover, retirement at 65 has only been an achievement for paid workers. As countries reach higher levels of economic development, workers enter the labour market later because they extend their education and live more years after retirement, producing a large amount of services for their own consumption and for others. Domestic care don’t stop in holidays or weekends . In countries where life expectancy is close to 90 years, time spent in the labour market represents only about half of total lifetime.
As a significant anecdote, the 'extra' time that women in Spain devote to unpaid work over the course of their lives, compared with men, is equivalent to the time required to earn five university degrees at the Complutense University of Madrid.
According to time-use surveys promoted since 1995, if unpaid work were converted into money, it would be equivalent to between 20% and 70% of Gross Domestic Product. The estimates vary widely, not only because they refer to different productive structures but also because of the criteria of definition, the methodology used in each source and the value assigned to an hour of unpaid work4. Care for sick people and people with disabilities is only one fraction of total care: it does not include children, frail older people who are not ill, people at social risk, self-care or care provided to healthy people who have been 'freed' from producing care. Other sources offer somewhat different results, but in any case care is an activity that may consume as many hours of work each year as all productive sectors combined.
The demand for care and its iron law
Although we often use them as equivalents for the sake of simplicity, the need for care does not automatically become demand or consumption. This is the so-called iron law of care. Often, those who need care most have little possibility of expressing that need, and even less of demanding that it be met. The demand for care is extremely elastic, and in every country there is hidden and unmet demand. This is why researchers, opinion-makers, activists, professionals and political leaders are so important: they make visible a need that, by itself, does not always manage to become a right or a service.
Within the aggregate demand for care, several large groups of consumers stand out: children; people who are ill or have disabilities; and vulnerable older people. There is a fourth group that is harder to name, a heterogeneous group of 'people at social risk': refugees, victims of violence, people harassed for reasons related to sexuality, ideology or any other cause, and those going through situations of severe lack of protection.
To these groups we must add a fifth, one that is not usually mentioned in forums such as this one: people who consider themselves freed from the obligation to care for others and, at the same time, entitled to consume large amounts of care. Sometimes this freedom is the result of a freely agreed division of labour. But in many cases it responds to social pressure that distributes the burdens of care very unequally: for example, between women and men, young and old, rich and poor, nationals and immigrants. Every care system must look directly at this distribution of power.
Care planning requires some kind of common unit of account. Since much care is provided outside the market, monetary estimates are not enough. It is useful to create another unit of account that serves as a benchmark or standard, even though it may have different equivalences at each time and place. This unit of account is what we have called the "care demand unit" and is equivalent to the amount of care time demanded or consumed by each person (per capita) among the average population aged fifteen to sixty-four at a given time and place.
Aggregate demand is made up of the demand from children, people who are ill or disabled, older people, people at social risk, and the population aged fifteen to sixty-four without special care needs. Supply is made up of household supply (which can in turn be broken down into women and other household members), state services, market services (including self-employed workers), nonprofit organizations, and other possible care providers5.
Equilibrium occurs when aggregate demand is equal to aggregate supply, although equilibrium for the system as a whole does not guarantee the absence of partial imbalances.
Both supply and demand are elastic; they respond quickly to both internal and external stimuli. For example, when expectations or aspirations related to the labor market, migration laws, or the epidemiological situation change.
In more refined studies, all components of supply and demand can be broken down into their constituent parts, specifying more detail, applying them to a single type of care need, or referring to different time and territorial horizons.
For planning care in a care system, it is very useful to keep in mind the overall view provided by this equation and the effort involved in operationalizing each concept, converting it into an estimate of the number of care units to which it is equivalent. Converting a concept into a figure is not easy; it depends on sound practical knowledge and the availability of statistical information, but simply setting it out already serves as an incentive to obtain and improve demographic, time-use, and any other kind of data.
Measuring the demand for care: Demographic projections and weighted scales
The most systematic, comparable and high-quality data on which to base care policies are demographic data, both for the current situation and for medium- and long-term forecasts. The excellent United Nations report Demographic Change in Europe and Central Asia: A Call for Labour Force Inclusion (2025), prepared with the participation of the ILO, UNECE, UNFPA and other organizations, clearly identifies the trends in Eastern Europe and Central Asia. The region reflects different stages of demographic transition, with ageing in some areas and strong demand for child care in others.
As an alternative to the so-called Oxford scale of material consumption, which is widely used to measure household poverty, I have constructed weighted scales that take the population aged 15 to 64 as the reference group or standard, assigning one unit of care consumption to each person in that group. My scale assigns three care units to each person aged zero to four and to each person over 80; two units to those aged five to fourteen and those aged 65 to 79. There are adaptations that adjust these weights according to local demographic or epidemiological data. Unlike clinical scales such as the Zarit test, which measures the subjective burden of a specific caregiver, the scales I propose are macrosociological tools. They make it possible to estimate aggregate demand according to the age composition of the population, relate that demand to potential caregivers inside and outside the labour market, and facilitate the development of ideal models for distributing the overall burden of care.
On economic realism: Technology, productivity, multipliers and limits
In care, quantity and quality require a delicate balance. Care policies bring together two different ideas of progress: progress as an increase in material goods measured by GDP, and progress as an improvement in the population's quality of life.
How much can technology help care? Without doubt, a great deal. In industry, productivity growth is mainly due to technological improvements; but for now, care remains a predominantly artisanal activity, and serial production risks undermining quality. In terminal illnesses, the abusive use of technology can turn patients into hostages, into dehumanized cyborgs.
Productivity and multiplier coefficients are key issues for care. In the monetized economy, especially in firms, productivity is measured by the capacity to improve output with the same resources; it has an immediate translation into money.
The State is more difficult to analyse because it does not make sales, and the value of its production is usually measured by its costs.
In households, much of the production and consumption of care coincide. When care is outsourced, the cost of travel time, transport and the buildings in which the service is provided increases.
Child care can be considered an investment in human capital, with medium- and long-term returns. The productivity of care for older people is more difficult to measure. Preventive care reduces morbidity episodes and social and health-care costs, but it does not necessarily translate into days of work gained.
Paradoxically, the productivity criterion for care is insufficient because care can prolong life in conditions of intensive consumption and, therefore, make it more expensive in monetary terms.
Multiplier coefficients are one of the strongest arguments for creating comprehensive care systems. Replacing unpaid work with paid work puts money into circulation, enables workers to buy goods and services, and generates income for the State through social contributions and taxes.
Investment in care creates a great deal of direct employment because it is a labour-intensive sector. Some studies estimate that for every million dollars invested in civil construction, 12 jobs are created; in care, that figure may be exceeded, with up to 19 jobs created.
But these estimates have limits. If care jobs are placed at the lowest level of the labour market, with poor wages and working conditions, workers will be unable to save, will pay little tax and will depend heavily on subsidized public services. In addition, such jobs will not be attractive to local workers and will only be filled by migrant workers from countries with worse labour conditions. For governments, investment in care is not money fallen from the sky; it is money transferred from other sectors. For that reason, the multiplier effect must be offset by the reducing effect wherever available investment decreases.
Financing and sustainability
The COVID-19 pandemic was a major laboratory for the study of care. You know better than I do what the situation was in your own countries. The higher mortality of older people made it urgent to review the model of residential care homes, where the death rate was very high. After the pandemic, proposals were made to improve the ratio between staff and residents, increase the pay of salaried workers in order to support retention and qualifications, and allocate more private and collective space to residents.
In Europe and Central Asia, the average legal working week ranges between 38 and 41 hours. By comparison, in Spain, as of 2026, the working week in the public administration is 35 hours. A sick person who requires care 24 hours a day, 365 days a year, if cared for individually at home, in practice requires five full-time public workers, not including travel. In residential care homes, a cumulative improvement of 25% in the staff ratio, employee pay and available space can almost double the cost per place. The production cost of a place in an average, non-luxury residential care home is currently about 2,500 euros per month, more than twice the average pension of retired women. From the perspective of geriatric institutions, that improvement can only occur if the available budget is doubled or the number of places offered is cut in half. This is why sustainability is so important.
If financing is borne mainly by households, long-term care will be inaccessible for the majority, who have neither sufficient income nor sufficient capital. If it is provided through subsidized institutions, the cost is shifted to taxpayers. Public opinion is usually very favourable to the creation of care services, but hostile to increases in the tax burden. This is why the media and leaders capable of generating informed public opinion are so important.
Another path widely used by governments is debt, which in practice means transferring payment to later fiscal years or to the next generation.6 If the economic cycle is favourable, the ratio of debt to GDP falls and this becomes a sound option; but if the economy stagnates or contracts, the weight of debt and its interest becomes a significant drag on the economy as a whole.
"Creating a new care system requires a prior intellectual decision: to recognize that care is not a private residue of the economy, but one of its foundations."
What is not measured is made invisible; what is made invisible is assigned to those with the least power to refuse it. That is why measuring care, valuing time and distributing responsibility are central political tasks.
Maintaining and improving the care system requires political capacity, negotiation and agreements among all actors: families, the State, the market, social organizations and care workers.
Eastern Europe and Central Asia face profound demographic transformations, migrations, gender inequalities and new demands for social protection. No care system will be sustainable if it rests indefinitely on the silent availability of women. The challenge is to transform that invisible availability into rights, services, decent employment and shared responsibility.
That, in my view, is the horizon of this Forum: not only to speak about care, but to build the conditions in which caring and being cared for are compatible with a dignified life.
2 This was the case, for example, in Spain, where, following the democratic Constitution of 1978, the entire body of legislation had to be modernized, including the Civil Code.
3 The Spanish term used by the author is cuidatoriado, a neologism formed from cuidado (“care”) and modelled on collective class terms such as proletariado or campesinado.
4 According to the Survey on Perceptions of Equality between Women and Men and Gender Stereotypes (CIS, November 2023), 12% of women over the age of 18 and 7% of men provide unpaid daily care to sick people and people with disabilities. The average time devoted to this care each day by caregivers is 405 minutes for women and 314 minutes for men. Expressed as full-time jobs, on the basis of a 1,711-hour working year, this is equivalent to 5.367,000 salaried workers. The employed labour force as a whole is 22.5 million workers, of whom 3.5 million work across State institutions. If these caregivers were paid at the minimum wage, their cost (or value) would be equivalent to 12% of total State expenditure; if they were paid at the average wage, it would be equivalent to 21% of total State expenditure.
5 CB= Care balance. Dch = Demand from children. Dill = Demand from ill or disabled people . Dold = Demand from older people. Dsr = Demand from people at social risk. D15-64 = Demand from people aged 15-64 without special care needs. Shh = Household supply .Sst = State supply. Smk = Market supply . Snp = Nonprofit supply .Soth = Other supply.
6 The State's external debt In Spain is equivalent to one year's GDP. This amounts to approximately 30,000 euros for each resident; if it is allocated only to those who pay taxes on personal income, the figure rises to 60,000 euros. According to FMI, in comparable terms of total public debt, Western Europe averages around 70% of GDP, although some countries are close to or above 100%. In the Western Balkans, the average is around 44%, and in Central Asia around 23%. If only public external debt is measured, (owed to non-resident creditors) the Western Balkans stand at around 27% of GDP and Central Asia at around 19%.