Keywords

1 Introduction

The number of older citizens has been growing dramatically across the world, not only in absolute terms, but also in relation to the working-age population that can potentially provide care (OECD 2020, 16). At the same time, women—the traditional providers of care within the family—have been entering the paid labour force in larger numbers than before. Thus, they have much less time and drive to care. Due to the combination of these demographic and societal factors, the need for additional long-term care (hereafter LTC) is intensifying across Europe.

At the same time, recruiting enough workers in LTC remains a challenge in most OECD countries (OECD 2020, 3). Across the world, the demand for LTC workers is increasingly fulfilled by hiring workers “with a migratory background”, including migrantsFootnote 1 (Da Roit and Weicht 2013; Lightman 2020; Williams 2012). Care is thus increasingly becoming a “migrantised” occupation, not only in the West, but all across the world. MigrantisationFootnote 2 is here defined as the process of incorporating migrant workers into the formal and informal care workforces of a country. Formal care is provided within residential settings or in the receiver’s home by native and migrant workers with regular contracts. Informal care encompasses care provided not only by relatives and friends, but also by migrant workers employed with or without a regular contract and often residing in the receiver’s home (this type of care is thus often referred to as “live-in”). A sector is undergoing migrantisation when the share of migrant workers therein has been increasing over time.

Despite similar trends in terms of overall LTC migrantisation, countries differ in the ways in which migrant workers are involved in national care regimes (Da Roit and Weicht 2013). Previous research identified several modes (real types) of migrantisation, including the “migrant in the family” and “migrant in formal care” outcomes, which we define in the next section. The emergence of each mode is explained by referring to a country-specific intersection of regimesFootnote 3 of care, migration and employment (Williams 2012). However, analyses of the concrete mechanisms through which such intersections produce differential modes of migrantisation are still missing. This chapter aims to address this gap. It does so by uncovering causal mechanisms driving migrantisation processes in the elder care domain.

As the second country in the world to do so after the Netherlands, Germany introduced social insurance against the “new” social risk of LTC dependency (hereafter long-term care insurance, LTCI) in 1995–1996. Current political and societal dynamics are shaped by earlier policy choices (Streeck and Thelen 2005), and this also applies to migrantisation. In this chapter, we identify the elements of the German LTC regime, regulated chiefly by the LTCI, which shaped migrantisation in Germany.

We demonstrate that the co-existence of two parallel “circuits” of family and formal care generates two relatively distinct migrantisation processes, which result in two distinct outcomes (“migrant in the family” on the one hand and “migrant in formal care” on the other). Second, we go beyond existing studies of migrantisation by identifying five complex causal mechanisms that drive the process.

  1. 1.

    We show that a lack of major reforms in a policy field in which citizens experience growing needs generates bottom-up “remediation” processes through a turn to the market mechanism.

  2. 2.

    The lack of a substantial reform of the LTC policy field resulted in a mechanism of market-driven formalisation of previously informal processes initiated by households on the one hand and care providing organisations on the other.

  3. 3.

    The state then either ignored (laissez-faire mechanism) or

  4. 4.

    acknowledged and actively supported migrantisation (state-supported migrantisation mechanism).

  5. 5.

    The ensuing policy feedbacks resulted, at least partly, from a stakeholder pressure mechanism.

In order to identify the causal mechanisms behind the emergence of the “migrant in the family” and “migrant in formal care” parallel outcomes in Germany, we use process tracing (Beach and Pedersen 2019). We follow an actor-centred approach of causal mechanisms (Chap. 1). This means that we collected information on the causally productive activities of a variety of actors, both individual (migrants and households) and collective (state institutions, federal policymakers, stakeholder organisations, for-profit companies, etc.). As sources, we used seventeen original expert interviews with specialists, stakeholders and policymakers; academic and grey literature; and own calculations based on official statistics.

We start with a brief review of the literature on migrantisation in LTC, before describing the dual outcome that will be explained, namely, the migrantisation processes in formal and family care in Germany. We then reconstruct two causal chains and identify the mechanisms driving their progression from a trigger to the outcome, and subsequent policy feedback(s). The article ends with conclusions discussing the wider implications of our findings.

2 Migrantisation in the Literature

Most studies notice substantial differences in the way migrants are involved in care work in host countries. Previous research identified two main modes (real types) of “migrant workers” incorporation into national LTC systems (“migrant in the family” and “migrant in formal care”). These modes are shaped not only by LTC-specific policies, but also by the host country’s care, migration, employment and gender regimes (van Hooren 2012, 135; Williams 2012, 363).

The “migrant in the family” model has been identified in familialistic care regimes, including Southern European countries and Austria. It refers to the private employment of migrant care workers by individual households, with or without a legal employment contract (Bettio et al. 2006). The “migrant in formal care” model refers to the presence of migrants with regular employment status within both for-profit companies and non-profit organisations providing residential or home-based care. There are two distinct varieties of the “migrant in formal care” model: the first variety developed in countries with a high incidence of for-profit care providers (such as the UK), while the second evolved in countries with high LTC expenditures, low levels of undocumented migration and the segregation of migrants in low-skilled jobs (such as France, the Netherlands, Norway or Sweden) (Da Roit and Weicht 2013, 477). Countries with an overall bigger (for-profit and/or non-profit) formal care sector register a higher demand for migrant workers than those with limited formal provision (Da Roit and Weicht 2013, 471). Additionally, larger for-profit provision is “expected to increase opportunities for migrant care workers to enter formal care and to crowd out (informal) employment in the domestic sector” (Da Roit and Weicht 2013, 471).

The closest that the care literature comes to outlining the concrete mechanism through which growing for-profit provision leads to migrantisation comes from labour market economics. In the absence of public policies guaranteeing and financially supporting wage levels and quality standards in the care sector (or in the case of insufficient wages and labour standards), care provision through the market involves decreases in wages and employment standards. The sector thus becomes less attractive to a “native” workforce, which results in its migrantisation (Ranci et al. 2019, 4). However, labour market regulation in coordinated capitalist societies (such as Germany) limits the effects of care marketisation on migrantisation (Ranci et al. 2019, 4).

“Migrant in the family” care is said to emerge in countries with limited formal care services (Bettio et al. 2006, 278), a strong ideal of family care (Böcker et al. 2017, 228), cash-for-care subsidies that users can spend freely (Ungerson 2004), and a tendency to segregate migrant workers into low-paid jobs (Da Roit and Weicht 2013, 479).Footnote 4 According to Da Roit and Weicht, it is the combination of these causes that stimulated the development of a “migrant in the family” model in Germany and in other countries, such as Italy (2013, 479). As a driver of “migrant in the family” care specific to Germany, the literature cites the fact that the LTCI covers only a part of actual elder care costs (Böcker et al. 2017, 228).

Within informal care, demand for care workers in Western European households is primarily aimed at white, Christian and female candidates, to the detriment of migrants with other ethnic, religious and gender backgrounds (Safuta 2018). These preferences combine with unfavourable socio-economic conditions in the countries of origin to encourage the employment of “peripherally white”Footnote 5 migrant carers from Central and Eastern Europe (hereafter CEE).

Among the “push factors” specific to care emigration from formerly communist CEE countries, the literature mentions the mass unemployment that followed the post-1989 political and economic transformations in that part of Europe. Unemployment affected women more intensely because of the restructuring of many female-dominated sectors, such as health (Robert 2006, 161–63). In short, the activation (or “occupational empowerment”) of women in Western Europe combined with the deactivation of their counterparts from CEE to stimulate inflows of female migrants from CEE to Western Europe, including Germany (Kniejska 2018, 479). In accordance with the neoclassical theory of migration, (perceived) income differentials between CEE countries and their Western European neighbours also play a crucial role in encouraging migration (Cyrus and Vogel 2006, 81).

3 Migrantisation of Elder Care Work in Germany

3.1 Elder Care Shortages in Light of the LTCI

The elder care system in Germany is strongly dual, due to the Bismarckian organisational principle of subsidiarity, derived from Catholic social doctrine. As with other welfare functions, subsidiarity affirms the family and non-profits (rather than the state itself) as the most appropriate providers of elder care (Gottschall and Dingeldey 2016). This principle explains why, up to the introduction of the LTCI, public support for elder care in Germany was residual and was available only if families could not provide care themselves or afford the costs of externally provided care (Götze and Rothgang 2014, 64). The LTCI created a right to services in kind and to unregulated cash benefits paid directly to beneficiaries. In practice, this means that citizens with a recognised need for care can choose between regulated benefits that can only be spent on formal care (home-based care services or residential care) and unregulated cash payments. A combination of in-kind and cash benefits is also possible (Götze and Rothgang 2014, 82).

The crucial argument behind the introduction of cash benefits was the idea that such payments would be an effective way to acknowledge, support and activate family-based care, which was to remain the main modality of elder care provision in Germany. Together with “pension credit points”, cash benefits were described as an incentive “particularly for women with low qualifications, to take over care responsibilities” (Theobald and Hampel 2013, 15). For their part, civil society organisations (such as pensioners and disability groups) supported cash benefits as a way to increase beneficiaries’ autonomy in choosing their preferred mode of care provision (Theobald and Hampel 2013, 10). The overarching argument behind direct cash payments was however that they are a less costly way of supporting family care than benefits in kind (Theobald and Hampel 2013, 10).

The capacity/willingness of families to provide elder care has however been eroding since the 1960s, due to a combination of demographic and social factors, including population ageing and women’s increased labour market participation (Götze and Rothgang 2014, 70; Sopp and Wagner 2013, 2016). Furthermore, formal home-based care in Germany is designed as selective relief for family carers, focusing mainly on medical and nursing tasks (e.g. administering medication or wound treatment) (Böcker et al. 2017, 237).

Beyond supporting family care, the LTCI also aimed to increase the efficiency and supply of formal care (Theobald and Hampel 2013, 13). In line with this objective, LTCI legislation introduced regulated competition between non-profit, for-profit and (the rare) public providers. Before the introduction of LTCI, non-profit charity organisations had priority over for-profit providers: local governments had to contract charity organisations first and were allowed to “hire” for-profit providers only if charities were unable to fulfil municipalities’ demands (Götze and Rothgang 2014, 70). Regulated competition was thus perceived as a way to offer beneficiaries more choice between care providers (Theobald and Hampel 2013, 17). Another declared aim of provider competition was to create job opportunities for the female labour force. However, the LTCI scheme did not improve the attractiveness of the sector in terms of wages, working conditions and professional status (Ostner 1998, 128).

Increasing numbers of care-dependent people, unfavourable working conditions and comparatively low salaries make it difficult for elder care providers to recruit and retain workers. Besides the ageing of care personnel, residential care facilities are also affected by the fifty per cent quota of highly skilled personnel (Fachkraftquote). The measure was introduced in 1993 to safeguard the quality of care, as part of the staffing regulation of residential care facilities (Heimpersonalverordnung).Footnote 6 Strongly contested by (for-profit) care providers, but supported by trade unions, this controversial measure forces care facilities that do not fulfil the quota to close certain wards. Formal care providers are thus confronted with severe staff shortages and the care sector is marked by a high share of part-time work and high turnover rates (DGB and ver.di 2018). It currently takes an average of 205 days to fill a geriatric nurse vacancy (Bundesagentur für Arbeit 2020), and the need for skilled elder care workers is projected to further increase in the future (Flake et al. 2018, 34).

3.2 The Migrantisation of Family Care

Since the 1990s, care for dependent elders within high- and middle-income German households has been increasingly provided by migrants (Lutz and Palenga-Möllenbeck 2010; Kniejska 2016). Research refers to this type of care provision as the “migrant in the family” model, because employing households perceive migrants’ services as a replacement for family-provided care (Kniejska 2016, 84–85). This type of care is mostly provided on a live-in basis: migrants live with the care receiver and are available to them almost 24/7.

Most recent estimates suggest that there are 500,000 live-in migrant care workers (“live-ins”) in Germany (Benazha and Lutz 2019). Estimating the actual numbers of live-ins is difficult because of the mostly irregular character of this type of employment. The biggest association representing brokering agencies in Germany, VHBP, estimates that ninety per cent of all migrant care workers in German households work irregularly (Petermann et al. 2017, 4).

In a comparative perspective, Germany ranks in-between countries such as Italy or Spain, where four to six people out of every hundred aged sixty-five or over are cared for at home by a migrant worker, and France, the Netherlands, Sweden or the UK, where the phenomenon has a very low incidence or is nearly absent (Da Roit and Weicht 2013, 473–74). Böcker et al. (2017, 228) are much less moderate when they conclude that “the employment of migrant care workers in private households has become a mass phenomenon [in Germany]”. Lutz and Palenga-Möllenbeck even conclude that the German care regime would collapse without live-in carers from abroad (Lutz and Palenga-Möllenbeck 2011, 349).

Most live-in care workers are women over fifty who come from CEE (Karakayali 2010, 291–93) without formal elder care qualifications (Böcker et al. 2017, 230). Live-ins used to be recruited through informal migratory networks, which are now increasingly superseded by private brokering agencies (Leiber et al. 2019, 366). Estimates of the number of such agencies active in Germany and recruiting across CEE have substantially increased: from 50 in 2014 (Krawietz 2014) to 274 in 2018 (Leiber et al. 2019, 375). They target almost exclusively households in Western Germany, probably due to higher average incomes in this part of the country (Krawietz 2014).

Most live-ins in Germany come from Poland, although the share of workers from Bulgaria, Romania and Ukraine is increasing (Emunds 2016, 190). In the 1990s, Poles were at an advantage compared with other non-EU nationals, as they were exempted from the German visa obligation. However, possibilities for employment in Germany were mostly limited to irregular employment, which meant that female migrants from CEE were segregated into domestic and care work within private households. The 2004 enlargement of the EU to eight CEE countriesFootnote 7 did not immediately grant citizens of those countries access to regular employment in Germany. Until May 2011, they could only work as self-employed service providers or as workers posted by a company based outside of Germany. This meant that they could not work within formal care settings without obtaining a work permit and hence concentrated in informal live-in care. Similarly, after their countries joined the EU in 2007, citizens of Bulgaria and Romania had to wait until January 2014 to access the German labour market without restrictions. Non-EU citizens are less likely to work on a live-in basis because of residence and work permits, although Ukrainians often work in Germany as posted workers, on the basis of a contract with a Polish employing agency.Footnote 8

3.3 The Migrantisation of Formal Care

Formal care in Germany consists of home care, day care and residential care provision. Formal care has a comparatively well-qualified workforce thanks to high-standard occupational training programmes. Formal care workers are mostly employees of registered non-profit and for-profit organisations providing care, although within home-based care they can also work on a self-employed basis (Auth 2017, 338).

In line with the literature on migrantisation, in this chapter we are primarily interested in migrants in the sense of individuals who migrated (temporarily or permanently) to another country as adults. However, it is difficult to obtain numbers on people who migrated to Germany as adults, as most official statistics in the country refer either to people with foreign citizenship or to “persons with a migratory background” (see footnote 1). Statistics showing the percentage of elder care workers with foreign citizenship (including those born in Germany) or “with a migratory background” are, therefore, only an approximation of the extent to which the elder care workforce in Germany is migrantised.

On average, foreign-born workers make up over twenty per cent of the LTC workforce in the OECD (OECD 2020, 44). In a comparative perspective, migrant care workers are less predominant in the formal care workforce in Germany than in other European countries, but the numbers show a clear tendency towards migrantisation. According to official statistics from the Federal Employment Agency, the number of formal elder care workers with foreign citizenshipFootnote 9 doubled from 6.8 per cent in 2013 to 13.6 per cent in 2019.Footnote 10 The share of workers with foreign citizenship in elder care is slightly higher than their average share in the labour market overall (12.5 per cent in 2019).Footnote 11 Statistics on care workers with foreign citizenship show that the number of those employed as low-skilled care assistants was twice as high as of those employed as skilled care workers.Footnote 12 Based on self-identification, the Socio-Economic Panel (SOEP) shows an even higher proportion of foreign-born workers: in 2018, 26.3 per cent of all employees in elder care stated that they were born abroad compared to 17.7 per cent in the overall labour market (Khalil et al. 2020, 5).

Most foreign care workers are women aged between twenty-five and fifty-five. In 2019, the top countries of origin of foreign care workers employed in Germany were Poland, Bosnia-Herzegovina, Turkey and Romania.Footnote 13 The formal care sector in Germany draws from a migrant workforce with permanent work and residence rights, including “ethnic Germans”Footnote 14 from Kazakhstan, Russia and Ukraine, who have the possibility to obtain German citizenship (Theobald 2017, 222). Besides spontaneous labour migration, German authorities have also concluded specific recruitment agreements with several non-EU countries.Footnote 15 With high-skilled care migration on the rise in recent years, placement agencies have proliferated to broker between migrants and organisations providing care (Mosuela 2020).

4 Actor-Centred Approach to Migrantisation Processes

The previous section introduced the care shortages faced by households (as providers of family care) and by organisations providing formal care. Migrantisation is, to a large extent, the result of households and formal care providers meeting their care needs by hiring workers from abroad. Recruitment abroad is now facilitated by the emergence of a new type of actor—brokering agencies. These agencies profit from and further enable care migrantisation by matching demand in Germany with labour supply from CEE and other regions with substantial wage differentials compared to Germany.

This section shows that the type of migrantisation (“migrant in the family” or “migrant in formal care”) is, to a large extent, structured by three principles governing the country’s elder care regime: cash benefits, provider competition and the skilled worker quota. Adopting an actor-centred approach to migrantisation allows us to show the way households and employers “make use of” migrant workers as a solution to the care shortages they encounter. While remedying these care shortages, households and care providers trigger causal chains involving other social and political actors, such as brokering agencies, decision-makers, trade unions and employers’ associations. Those causal chains are examined here along with the mechanisms that drive them (see Figs. 10.1 and 10.2).

Fig. 10.1
A block diagram for the migrant of the family model with parts 1 to 3, outcome, and feedback blocks. The outcome is in a different shade. The blocks are linked to form a chain.

Causal chain behind the entrenchment of the “Migrant in the Family Model”. (Source: Own representation)

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Fig. 10.2
A block diagram for the migrant of the formal care model with parts 1 to 5, outcome, and policy feedback blocks. The outcome is in a different shade. The blocks are linked to form a chain.

Causal chain illustrating the rise of the “Migrant in Formal Care” model. (Source: Own representation)

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4.1 The “Migrant in the Family” Causal Chain with Its Mechanisms

Part one. Individuals and households in Germany are confronted with care needs they are unable or unwilling to fulfil themselves. At the same time, female migrants from CEE were searching for employment in Germany, following the economic and political transformation of that part of Europe after 1989, due to rising unemployment, early retirement, bankruptcy, debt or low wages (Dietz 2007, 32).

Part two. The inflows of migrants from CEE (especially Poland) to Germany created the opportunity structure for German households to fulfil their care needs by privately hiring migrant live-in carers. They were encouraged to do so by the unregulated cash benefits offered by the LTCI: the employment of live-in migrant carers increased rapidly after the introduction of the LTCI, with its cash benefits (Böcker et al. 2017, 229). Furthermore, families can cover only parts of necessary home care services from LTCI benefits—additional services must be paid entirely out of pocket. Private co-payments in residential care are increasing constantly, as nominally fixed benefit caps are not adjusted, while fees are ever increasing (Rothgang and Müller 2018, 86–87). In consequence, increases in the price of formal care might encourage relatives to provide care informally (themselves and/or by hiring a migrant care worker) and opt for cash payments instead of benefits in kind (Götze and Rothgang 2014, 84). This mechanism could be described as a turn to the market: when relatives cannot or do not want to carry out social functions (in this case elder care) traditionally fulfilled by the family, and if they do not perceive state or non-profit alternatives as sufficiently accessible/affordable/good-quality, relatives make use of market solutions. The likelihood of a turn to the market is increased by the combination of unregulated cash benefits with the availability of a cheap migrant labour force (Ungerson 2004). The spread of “migrant in the family” employment creates a transnational market for live-in care between Germany and CEE countries.

Part three. The spread of “migrant in the family” care encourages a new type of actor to profit from the transnational care market. Brokering and employing agencies took over previously informal networks in facilitating movement across borders and matching labour supply with demand. They make use of the posted workers directive (Directive 96/71/EC concerning the posting of workers) to hire care workers under more advantageous country of origin terms, which in practice often means circumventing German working hours and wage regulations (Leiber et al. 2019). Some agencies located in Germany however aspire to be recognised as legitimate care providers under the LTCI scheme (Leiber et al. 2019, 383). This mechanism could be described as market-driven formalisation: when the market takes over a social function previously carried out by the family, supply and demand initially connect through informal actors and networks. With time however, the matching of supply and demand is taken over by formal commercial intermediaries, some even developing a preference for regularising their activities and the market they participate in. Non-profit care providers Caritas and Diakonie for their part introduced alternatives to irregular “migrant in the family” employment (CariFair and FairCare). These initiatives are not significant in terms of numbers of hired migrant care workers, but they mark a move towards the formalisation of “migrant in the family” employment (Emunds and Habel 2020, 114).

German authorities tolerate irregular live-in care work, but do not regulate it. The country did not follow the example of its smaller neighbour Austria, which introduced a legal framework regularising the grey market of migrant live-in care in 2007 (Österle and Bauer 2012). Until 2002, migrant workers could not even obtain a work permit in Germany on the basis of care work in private households. In 2002, German authorities introduced limited work permits for “household helpers”, later extended to migrants providing home-based basic nursing care. Permits were granted only to workers with a valid work contract, which are still a minority among all migrant domestic workers. The take-up of this scheme remained very low, as related administrative procedures were very complex (Karakayali 2010, 118).

Even though Germany ratified the ILO’s Convention No. 189 safeguarding basic labour rights for domestic workers, the government allows exceptions for agencies and households that apply to live-in employment, irrespective of the Convention’s working time regulations. Experts, opposition parties and NGOs strongly criticise this course of action (Jaehrling and Weinkopf 2020). The spread of “migrant in the family” care can be explained by a laissez-faire mechanism, combined with limited and superficial formalisation: authorities neither regulate nor outlaw this type of care. This type of care sustains family care, which was entrenched by the LTCI legislation as a central pillar of the German elder care system. Authorities’ reluctance to regulate “migrant in the family care” is often explained by the constitutional right to the inviolability of the home (Auth 2017, 345). At the same time, fragmented and superficial formalisation might protect decision-makers against accusations of complicity in migrant care workers’ exploitation/rights violations and of neglect towards care receivers’ and their families’ needs.

Outcome. Supported by positive media representation, “migrant in the family” care provision is now a cheap and socially acceptable option for households to individually solve their care needs (Storath 2019). The entrenchment of this model further maintains the centrality of informal care in the German elder care system. The migrantisation of family care is mainly driven by the market, as the state does not really support families and agencies in solving care shortages. Reforms of the LTCI framework do not address this development and focus instead on expanding the range of beneficiaries, introducing new types of benefits (some targeted at family care givers) and increasing the value of monthly benefits (Nadash et al. 2018, 592).

Benefits remain too low to cover all the costs of formal home or residential care, which contributes to the comparative attractiveness of “migrant in the family” care: too low to cover the total costs of formal care, LTCI benefits are however sufficient to finance the salary of an irregularly employed migrant care worker (Kniejska 2018, 479). Reforms expanding the range of LTCI beneficiaries result in less time per care-dependent person within formal care. Some households thus perceive live-in migrant care not only as a cheaper alternative to formal care, but also as a better-quality solution (Kniejska 2018, 479). Formal care is ill-adapted to provide support with tasks which cannot be scheduled and when there is a need for nearly constant supervision (in cases of dementia for example or when there is a high risk of falls). “Migrant in the family” care does not have such limitations and is often supplemented by formal home-based care (Böcker et al. 2017, 235).

Policy feedback. From trade unions (Böning and Steffen 2014) to care providers (bpa 2020), stakeholders criticise the undeclared character of “migrant in the family” care provision and the fact that it does not adhere to labour law, especially with regard to working time, resting periods and so on.Footnote 16 Care providers do not however agree regarding the regularisation of such arrangements: while Caritas advocates for it, the Federal Association of Private Social Service Providers (bpa) was in the past reluctant towards formalisation (Scheiwe and Krawietz 2010, 145). Stakeholders acknowledging “migrant in the family” care and positioning themselves triggered a stakeholder pressure mechanism, resulting in this mode of care provision finally arriving on the policy agenda.

After fifteen to twenty years of “semi-compliance”, the Federal Ministry of Health and the Ministry of Labour are now discussing a possible regularisation of live-in care provision, together with ways to enforce labour law compliance in the sector.Footnote 17 The Health Ministry proposed a reform of the LTCI, which would allow (under certain conditions) recipients to spend up to forty per cent of their benefits for home care on live-in (migrant) care.

4.2 The “Migrant in Formal Care” Causal Chain with Its Mechanisms

Part one. The quota for skilled personnel introduced in 1993 entrenches the existing segmentation of the care labour market into skilled and unskilled jobs. It also sustains a high demand for skilled care workers. Brought about by the introduction of the LTCI, provider competition further stimulates the demand for care workers, due to the multiplication of care providers that ensued. The number of for-profit and non-profit home care providers rose from 10,820 in 1999 to 14,688 in 2019, while the number of institutions providing residential care rose from 8859 to 15,380 (Mätzke and Wiß 2017, 131–32, Statistisches Bundesamt 2020). Care provider competition did not substantially improve wages or employment and working conditions: up until today elder care workers express that they are not paid appropriately and experience extreme time pressure at work (DGB and ver.di 2018). These evolutions did not contribute to the attractiveness of the care sector; rather care providers face continuous recruitment difficulties.

Part two. Faced with recruitment difficulties, care providers recruit among vulnerable sections of the German labour market, including migrants already present in Germany (Afentakis and Maier 2013). The active recruitment of workers from abroad only starts in the 2010s.

Part three. At first, decision-makers do not directly address those workforce shortages in subsequent reforms of the LTCI. Reforms lead instead to an extension of beneficiaries by including people with low to moderate care needs and expanding services (e.g. Pflegestärkungsgesetze I-III), providing higher benefits for people with dementia (Pflegeneuausrichtungsgesetz) and modifying entitlement rules ensuring that specific needs are assessed properly (Pflegestärkungsgesetz II). Combining with the ageing of care personnel and the skilled worker quota, these measures further intensify the demand for care workers, particularly skilled ones.

In the absence of substantial policy reforms addressing recruitment difficulties in the formal care sector, a similar turn to the market mechanism occurs as in family care: in the 2010s, German care providers start actively recruiting high-skilled workers abroad. They initially establish recruitment schemes with Southern European countries that were particularly hit by the economic crisis, such as Spain and Greece (Braeseke and Bonin 2016, 252). As many care workers hired within the framework of those schemes returned home after short periods of work in Germany or moved to the better-paid hospital sector, those initiatives are considered unsuccessful (Sell 2019, 93–94). Unsuccessful attempts with EEAFootnote 18 workers prompt care providers to recruit outside of the EEA and better prepare the integration of employees hired this way into the German labour market.

Part four. Recruitment outside of the EEA is made possible by the 2005 major reform of the German migration regime,Footnote 19 which opens the German labour market to migrants with non-academic vocational credentials in shortage occupations such as care work (Braeseke and Bonin 2016). The Federal Employment Agency supports care providers’ foreign recruitment efforts from 2012 onwards. The EURES (European Employment Services) network facilitates the recruitment of skilled care workers from Southern European EU member states (Krawietz and Visel 2016, 188). Moderately successful, these recruitment schemes within the EEA were a learning experience both for care providers and for public authorities. Unlike dynamics in family care, formal care is characterised by a mechanism of state-supported migrantisation, as decision-makers and state actors facilitate (through ad hoc policy changes) and actively participate in the foreign recruitment of care workers.

Part five. Many employers “abandon their own recruitment activities in favour of outsourcing them to private sector or state-like actors (such as the German Corporation for International Cooperation, GIZ)”, while others develop their own business model, combining the role of service provider and labour market intermediary (Kordes et al. 2020, 9). Similar to dynamics in family care, a mechanism of market-driven formalisation also occurs in formal care: commercial or state-like agencies act as intermediaries between workers and employers, reducing transaction costs and easing cultural brokerage after arrival (Pütz et al. 2019, 28).

Outcome. The “migrant in formal care” model of care provision is not as entrenched in terms of prevalence and normalisation as its “migrant in the family” counterpart. Although formal elder care provision is not yet as dependent on migration as family care, a recent representative survey found that every third care provider hires personnel abroad (Evangelische Heimstiftung GmbH, COGITARIS GmbH et al. 2020). The migrantisation process that we observe in the case of formal care is hybrid: market-driven and, more recently, also supported by the state.

Policy feedback. German authorities conclude several bilateral agreements with non-EEA countries targeted both at skilled care workers and at candidates seeking a care apprenticeship in Germany (Krawietz and Visel 2016). The German Agency for Health and Nursing Professions (DeFa) dedicated to the transnational recruitment of skilled health and care workers is established in 2020. Those evolutions result, at least in part, from a stakeholder pressure mechanism, as some private care providers advocated with federal authorities to support their efforts to recruit abroad.Footnote 20

Policymakers generally assume that increasing the attractiveness of care work for native workers will decrease the sector’s dependence on a migrant labour force (van Hooren 2012, 144). The 2018 reform of the training system for nurses and care professionals (Pflegeberufereformgesetz) stems, at least in part, from such a concern with improving the sector’s attractiveness (Bundesregierung 2018). This reform makes the training of care workers similar to the system that already exists in Germany for (male-dominated) industrial professions. While previous school-based training programmes for nurses required an unpaid internship, candidates will now be paid while in training. According to a representative of the Federal Health Ministry, a positive side effect of this reform is that foreign credentials are now more easily recognised,Footnote 21 which is likely to stimulate further foreign inflows.

5 Conclusions

This chapter explains the migrantisation of elder care in Germany. Migrantisation is a dual process, in line with the strong dualism of the German elder care system. On the one hand, “migrant in the family” care has been an entrenched pillar of the German care system since the 1990s. On the other hand, formal care providers and public authorities have been exploring active recruitment abroad for less than a decade. “Migrant in formal care” is thus an emerging solution to care workforce shortages, although not yet as entrenched as “migrant in the family” provision. The duality of the German care system creates a bifurcation of recruitment profiles in the family and formal care settings. Most households currently recruit CEE live-in migrants without corresponding qualifications (more rarely, with unrecognised care qualifications from their country of origin), while formal care providers actively recruit mostly skilled non-EEA migrants.

Both migrantisation outcomes stem from the bottom-up efforts of individual actors (households and care providers) to solve the care shortages they are confronted with. As “migrant in the family” and “migrant in formal care” spread, brokering agencies emerge, formalising recruitment processes. Those agencies are a new type of actor in the care domain, appearing precisely due to migrantisation. Public authorities get involved only at later stages—once “migrant in the family” is a widespread and socially accepted mode of care provision (to potentially regulate it), and once foreign recruitment becomes a generalised practice in formal care (to further facilitate and support it).

By adopting an actor-centred approach to migrantisation, the article identified a new dimension of migrantisation, so far unexplored in the literature: which actors drive migrantisation? We show that migrantisation is originally driven by households themselves and the market. However, once (and if) the state acknowledges care shortages and opts to support recruitment abroad, migrantisation is then driven both by the market and by the state. We show that the mechanisms driving elder care migrantisation are also the mechanisms that maintained the basic structures of the LTCI programme in a relatively unchanged form over the last twenty-five years.

The migrantisation of elder care in Germany contradicts the previously held idea that “migrant in the family” provision develops in countries with low levels of state support for elder care. While Germany has comparatively high levels of social support for elder care provision, its elder care system focuses first on upholding care by relatives, particularly through unregulated cash benefits. This resulted in the development of “migrant in the family” care, so far characterising less generous care regimes, but in this context manifesting in a system with substantial care benefits and supply of in-kind care.

The development of “migrant in the family” care in Germany also disproves the expectation that larger for-profit provision crowds out informal care provision by migrant workers (Da Roit and Weicht 2013, 471). Indeed, the multiplication of for-profit care providers in Germany following the introduction of provider competition did not reduce the growth of informal live-in care. This is due to a strong ideal of home-based family care and capped formal care benefits.

The German variety of formal care migrantisation also complicates the two types of “migrant in formal care” provision identified in the literature. The recruitment of care workers from abroad is still less pronounced in Germany than in liberal welfare regimes with more deregulated care markets, characterised by a high incidence of for-profit providers (such as the UK). Regulatory measures such as the skilled workers’ quota steer recruitment efforts towards skilled migrants. Nor does the German model fit in with the channelling of migrants into low-skilled care jobs identified in countries with high public care expenditure, low levels of undocumented migration and a strong overall segregation of migrants into low-skilled jobs (such as France or Sweden). On the contrary, the German skilled workers’ quota incentivises the recruitment of skilled foreign care workers.

Foreign recruitment in Germany is still less pronounced than in the more deregulated labour markets of liberal care regimes. However, labour regulation measures (such as the skilled workers’ quota) and professionalisation efforts (such as the training reforms) do not necessarily slow down migrantisation through improving the sector’s overall attractiveness. On the contrary, the German case shows that regulatory policies can intensify shortages of skilled care workers, encouraging care providers and public authorities to recruit abroad.

As wage levels between Western and CEE countries are likely to gradually equalise, the importance of CEE as a source region for the German elder care system should decrease, to the benefit of countries further East and South. Such a shift is already ongoing, as the share of live-ins from Bulgaria, Romania and Ukraine increases (to the detriment of Poland), while formal care recruitment targets non-EEA countries. It is however unlikely that the reliance of the German elder care system on migrant workers will end any time soon, as care needs will most probably intensify due to demographic and societal dynamics. Thus, migrantisation in Germany contributes to existing or emerging care gaps in migrants’ countries of origin. These gaps in turn stimulate the formation of transnational care chains, such as the one already linking Ukraine and Poland (Safuta et al. 2016).