Migrant Home Attendants: Regulation and Practice in 7 Countries

Abstract

We compared regulation and working and living conditions of foreign home attendants in 7 countries (Canada, Germany, Israel, Singapore, Spain, United Kingdom, United States). We conducted a literature search in the PSYCinfo, MEDLINE, and Google Scholar databases for 2002 to 2012.

We found substantial between-country differences in the legal status of migrant caregivers and regulations regarding working and living conditions and drew 3 conclusions.

Improving regulations will likely improve not only the well-being of foreign home attendants but also the care they provide. Countries in which many foreign home attendants work without specific legal entry programs should rethink their policies. Finally, requiring an employer’s recommendation to obtain permanent residency may constrain foreign workers from registering complaints or leaving suboptimal employment situations.

THE USE OF MIGRANT workers as home attendants has broadened significantly among the more affluent countries during the past decade or so.^1,2 However, treatment of these workers differs substantially across countries, in both official regulation and the practical conditions under which they live and work.

Several international studies have examined aspects of regulations concerning migrant workers in general and their actual living and working conditions.^1,3,4 Nonetheless, research into the practical conditions and official regulations concerning migrant home attendants is sparse. Particularly lacking are meaningful international comparisons of methods of legalization for these foreign workers, official regulations concerning their working and living conditions, and the resulting actual conditions of their lives.

The increasing number of older persons in affluent countries, coupled with higher rates of chronic illnesses associated with older ages (e.g., Alzheimer’s disease, Parkinson’s disease), results in the need for rising numbers of professional home attendants to provide around-the-clock care. Unlike in the past, women in most Western countries are active in the labor market; their traditional role as caretakers for young and old family members has diminished. In addition, demographic development has altered the relationship between the “productive” population and retirees. Hence, the pool of potential home attendants, both informal and professional, is declining as the number of people who need care is growing. In some European countries and the United States a shortage of professional home attendants and health workers is already evident,^5,6 and a state of emergency is approaching.⁷ Both the overall higher standard of living and low salaries for home attendants⁸ make caregiving for older persons an economically undesirable job for most native citizens in highly industrialized, wealthy countries. As a result, migrants make up a high proportion of home attendants in several affluent countries.

Apart from such pull factors,⁹ several push factors also influence the migration of health workers and home attendants. In their home countries, a significant proportion of these workers are paid at or below the minimum wage and often below subsistence levels.⁹ Other factors motivating migration are unstable political situations, unemployment, and workplace hazards, such as violence, injuries, and inadequate occupational protection, in the country of origin.

Legislation and regulations that foster decent practical conditions for migrant caregivers are important for several reasons. Foreigners employed in private homes are vulnerable to abuse, as are frail older persons receiving care. Indeed, studies of the performance of highly trained caregivers have shown that overwork and poor environment and working conditions are associated with fatigue, stress, and, eventually, poorer work performance.^10,11 Working conditions and environment are also correlated with workers’ attitudes toward the older persons they attend to and the quality of care that is provided.^12–14

We analyzed regulations regarding working and living conditions and the actual experiences of foreign home attendants in 7 countries: Canada, Germany, Israel, Singapore, Spain, the United Kingdom, and the United States. We conducted a literature search and found mostly studies and surveys focusing on single countries.

We drew review material from the PSYCinfo, MEDLINE, and Google Scholar databases for 2002 to 2012. We used various combinations of the core search terms “home caregivers,” “work conditions,” “labor laws,” “caregiver,” “caregiving,” “migrant workers,” “foreign workers,” “regulations,” “legal status,” “visa,” and “naturalization.” We located additional studies through articles’ citation lists. We also searched the following German sources: http://www.dimdi.de, http://www.CareLit.de, http://www.GeroLit.de, http://www.WISE.de, the Federal Statistical Office (http://www.destatis.de), the Federal Ministry on Health (http://www.bmg.bund.de), and the federal labor agency (http://www.arbeitsagentur.de).

LEGAL STATUS OF MIGRANT CAREGIVERS

Among the 7 countries in our review, we found substantial differences in 4 aspects of the legal status of migrant caregivers: (1) the availability of and conditions for a temporary work visa program, whether a special visa designed for this category of worker or a visa offered to foreign workers or to domestic workers in general (e.g., nannies); (2) legal alternatives allowing specific categories of migrants to work without a visa; (3) the existence and extent of regularization programs for illegal–undocumented workers; and (4) access to permanent residency status and naturalization in the host country. Aspects of legal status in the 7 countries are summarized in Table 1.

TABLE 1—

Legal Status of Foreign Domestic Caregivers in 7 Countries

Legal Provision	Canada	Germany	Israel	Singapore	Spain	United Kingdom	United States
Temporary visa program available for domestic caregivers	Yes	For citizens of non-EU states (EU citizens are free to settle and work in country)	Yes	Yes	No	No	No
Length of temporary visa and renewal conditions	2 y	3 y (renewable after spending the same time span out of country)	Caregivers can work in country for a maximum of 63 mo; visa may be extended over this period if the caregiver worked with the same employer for ≥ 1 y and the employer is dependent on this care	2 y, renewable up to 8 y, conditional on health and pregnancy tests	NA	NA	NA
Possibility of permanent residency	Yes (conditional on health, English proficiency, education, training/experience, 6 mo continuous employment for same employer)	Legally employed domestic workers with 3-y permit can apply for a nonrestricted permit	No	No	Yes, with conditions depending on country of origin	NA	NA
Permanent residency/naturalization term of application	All legal migrant domestic workers can apply after 2 y; naturalization possible after obtaining permanent residency	Only EU citizens can stay permanently	No	No	Eligibility varies by citizenship; EU citizens gain permanent residency after 4 y	No	No
Alternatives to special visa	No	EU citizens are free to settle and work in country; self-employed domestic workers and those brought by Eastern European companies may stay ≤ 24 moa	No	No	EU citizens are free to settle and work in country	EU citizens are free to settle and work in country	NA

Note. EU = European Union; NA = not applicable.

^aSelf-employed must register as tradespersons in their country of origin and prove that they pay taxes and social duties required there. If their working stay lasts > 3 months, they must inform the German trading supervision office. Companies are responsible for covering workers’ social insurance and fulfilling other duties in country of origin.

Temporary Work Visa Programs

Canada's Live-in Caregiver Program offers a 2-year temporary work visa, with a possibility of applying for permanent residency when the visa expires. This program is available to migrants with a direct job offer from a Canadian permanent resident or citizen and is contingent on medical examination, proof of English proficiency, completion of high school, and 6 months of classroom training or 1 year of full-time paid employment in the required field during the past 3 years, including continuous employment of at least 6 months with the same employer. This program has no quotas.^15–17

Israel has a temporary work permit designed for foreign home attendants, renewable for up to 5 years and 3 months, but without a possibility to apply for permanent residency or naturalization. Official eligibility for this visa requires paying up to US $1000 to mediating agencies that serve as official sponsors of these workers, passing a personal interview that tests candidates' people skills, and undergoing a physical examination.¹⁸ In addition, if the care recipient passes away before the expiration date of the foreign employee’s temporary work permit and the mediating agency does not find the worker an alternative employer within a limited time, the work permit is revoked and the foreign domestic worker must leave the country or stay illegally.¹⁸

Singapore has a general visa that is applicable to domestic workers and consists of a 2-year work permit that is renewable for up to 8 years. Qualifying for this visa requires initial health and pregnancy tests and checkups every 6 months. Eligibility is withdrawn for women who become pregnant or who are diagnosed with HIV or a venereal disease in the mandatory semiannual medical screenings. Singapore does not offer the possibility of acquiring permanent residency status nor an option for naturalization.^19,20

Germany offers foreigners who do not come from European Union (EU) countries a residency permit for full-time work as a home attendant for a maximum of 3 years with the consent of the German federal employment bureau.²¹ Such permits can be issued only if an agreement between labor authorities in Germany and a migrant's country are in place; currently these exist with Bulgaria and Romania.²² However, after 2013, Bulgarians and Romanians will enjoy the same freedom of movement as other EU citizens. During the 3 years of their stay, foreign employees can change their employer. After 3 years, they cannot receive a new residency permit before spending at least 3 years outside of Germany.

Spain, the United Kingdom, and the United States do not offer visas for foreign home attendants on entry. The United States has no official visa option for foreign home attendants, regularization program, or any other legal option for obtaining a work permit. The United Kingdom and (to a lesser extent) Spain have had limited programs suitable for foreign home attendants, subject to quotas.

Legal Alternatives to Special Visas

The United Kingdom, Spain, and Germany admit home attendants from other EU countries (including the 8 Eastern European member states that joined in 2004). Hence, foreign workers from other EU member states can automatically obtain a work permit after arrival in the United Kingdom or Spain.^23,24 EU nationals are not automatically entitled to a work permit in all EU countries; regulations are at the discretion of each member state.

One option for legal work in Germany is through an Eastern European company that offers the same services in workers' country of origin. The company is responsible for covering workers’ social insurance and fulfilling other duties in the country in which workers hold citizenship. This type of contract permits a working stay of 24 months. Self-employment is another option. Workers must register as tradespersons in their country of origin and prove that they pay taxes and social duties required there. If their working stay lasts more than 3 months, they are obliged to inform the German trading supervision office. The overall working stay is also limited to 24 months.²⁵

All these options are only available for the citizens of EU member states. Thus, home attendants from non-EU countries can only work illegally, entering the country as tourists, mostly on 3-month visas. Non-EU home attendants who wish to work leave the country before the tourist visa expires and return to Germany after a few weeks.²⁶ Home attendants from EU member states sometimes also work illegally for financial reasons (e.g., to avoid payment of social insurance and taxes by employees or employers).

Regularization Programs

Among the 7 countries in our review, only Spain and Germany offer regularization programs aimed at existing illegally employed immigrants. Spain, coping with increasing numbers of illegal immigrants and limited legal processes available for foreign workers with little education, has implemented 5 regularization programs in less than a decade. The largest of these began in 2005 and covered 300 000 foreign home attendants already living in Spain. This program offers a renewable 1-year work permit. Eligibility for the program requires proof of residency from August 2004, no criminal record, and a contract for future employment for at least 6 months.²⁷

Germany has introduced some incentives for legalization of the employment of foreign home attendants. For example, households employing them legally can get an annual tax reduction of up to €4000. In addition, employers can use benefits from long-term care insurance to pay legal home attendants. By contrast, substantial penalties are imposed for illegal employment of home attendants. For example, an employer can be charged with retroactive taxes for the entire employment period of an illegal caregiver. However, Germany has made no serious attempts to create additional opportunities for work for foreigners in households with care-dependent older people. The main reason is Germany’s ambivalence toward immigration (often summarized thus: Germany is not a country of immigration), as well as other reasons such as a concern for quality of care and local home attendants’ fear of competition.²⁶

Permanent Residency and Naturalization

Of the 7 countries in our review, only Canada and Spain offer a realistic prospect for obtaining permanent residency that leads to an option for naturalization. In Canada, any migrant domestic worker can apply for permanent residency at the end of the 2-year visa, and once the new status is granted, the worker can initiate an application for naturalization.^15,16 In Spain, most home attendants are immigrants from Latin America and the Philippines.³ Permanent residency is granted for any EU national after 4 consecutive years of residency in Spain. Citizens of the Philippines, Portugal, and certain South American countries may apply for citizenship after 2 years of residence in Spain; citizens of other countries are subject to a 10-year waiting period.²⁸

Singapore, Germany, Israel, the United States, and the United Kingdom do not offer naturalization or permanent residency to migrant domestic workers.^{2,19,20,29,30,31} Their visa programs are designed to limit the stay of foreign workers. The majority of home attendants working in Germany do not need a visa because they come from EU member states or live in countries without a visa obligation for Germany (e.g., successors of former Yugoslavia), and therefore it is relatively easy for them to enter Germany. Difficulties arise for people from successor states of the former Soviet Union (e.g., Ukraine and Belarus), who need a visa to visit Germany (e.g., as tourists) and cannot get permission to legally work in Germany.

REGULATION OF WORKING AND LIVING CONDITIONS

We found significant between-country differences in the living and working regulations for foreign home attendants; 6 countries fall into 2 main categories. Singapore and Spain have very few regulations concerning the working and living conditions of migrant home attendants, unlike Canada, Germany, the United Kingdom, and Israel, which have enacted much more comprehensive regulations. These regulations are designed to protect foreign workers from unfair working and living conditions. The United States alone has no official policies concerning the working and living conditions of migrant home attendants. Regulations concerning working conditions of foreign domestic caregivers in the 7 countries are presented in Table 2.

TABLE 2—

Regulations Concerning Working Conditions of Foreign Domestic Caregivers in 7 Countries

Regulations	Canada	Germany	Israel31,32	Singapore20	Spain	United Kingdom33	United States
Working and living conditions of foreign domestic caregivers are regulated	Yes	Yes	Yes	Very little	Very little	Yes	No
Minimum wages	Yes	Recommendation only (wage must not be immoral)	Yes	No	Yes	Yes	NA
Room, board, and accommodation	Yes	Not obligatory but commonly accepted, high standard	Yes, but only low standard of accommodation required	Own room if possible; otherwise sufficient space, protection from environmental elements, safety, ventilation, and adequate food required		No	NA
Right to free time (holiday, days off, limits on work time)	Yes	Yes	Yes, a weekly rest period of ≥ 36 h on Friday, Saturday or Sunday, according to religion of worker	Yes, a weekly rest day		Yes, but is often ignored	NA
Workplace safety insurance	Yes	Yes	Yes	Yes		No insurance regulations; employer must ensure workplace is safe	NA
Social insurance	Yes	Yes	Yes		No	Yes	NA
Medical care/health insurance	Yes	Yes	Yes	Yes	No	Statutory sick pay	NA
Written contract	Yes	Yes	Yes	No	Yes	Yes	NA
Contact with family and place of origin	Employer pays travel expenses for home visits	Reimbursement is not obligatory; only Internet and phone are commonly accepted					NA

Note. NA = not applicable.

Limited Regulations

Singapore’s visa program for foreign home attendants offers very limited protection. These workers, whether foreign or local, are not covered by the Employment Act. Consequently, no specific regulations address minimum wage, hours of work, rest days, or public holidays.^19,20,30 The regulations concerning living conditions are hazy to nonexistent. For instance, guidelines to employers of foreign domestic workers (FDWs) offered by the Singaporean Ministry of Manpower state,

Where possible, your FDW should be given a separate room of her own. If that is not possible, you should ensure that sufficient space and privacy are provided for your FDW.³⁰

Hence, providing the home attendant with a separate room is not an obligation, and even the stipulation regarding a sufficient space is neither quantified nor defined in detail. Although the regulations stipulate that employers should provide food, a bed with a mattress, a blanket, towels, and toiletries, they do not require respect for privacy (e.g., private room, private storage space, private bath, or at least an available facility within a reasonable distance). Employers are encouraged, but not required, to sign a written contract with a home attendant.³⁰

Singapore's limited requirements for employers of home attendants mainly involve buying health and work safety insurance against injuries on the job. Violence against employees (e.g., willfully causing hurt, wrongful confinement, assault, or rape) is prohibited and can be penalized by law, if such acts are reported.³⁰

Spain has enacted regulations regarding basic conditions, such as minimum wage (set at €641 per month for 2012), maximum 40-hour workweek, and the obligation of employers to draft and sign a mutually agreed-upon contract with their employees. Employers are not required to provide medical insurance or unemployment benefits for home attendants or to pay a share of their social insurance.^33a

More Comprehensive Regulations

Among the 4 countries with more extensive regulations designed to protect migrant home attendants, Canada's is the most comprehensive. All home attendants (hired within the framework of the 2-year Live-in Caregiver Program) are entitled to the legal minimum wage as well as to room and board. Employers are required to provide home attendants with a furnished and lockable private room (including private bath and toilet), which should be properly heated and ventilated. The residence structure should have no visible or needed repairs, and it should (at least) comply with the standards of community residential buildings.³⁴

Employers of foreign home attendants are obligated to pay medical and workplace safety insurance in full (i.e., they are forbidden to deduct any part from employees’ salary). Employers also have to pay the travel expenses of foreign home attendants from their home country to Canada, as well as reimburse them for any mediation fees they had to pay. Finally, employers are required to provide a clear written contract specifying the work conditions (e.g., holidays, days off, wages, overtime wages).^16,34

Israel has detailed but less generous requirements for the minimum accommodations provided for foreign home attendants. Home attendants are not guaranteed a private room, but employers are required to provide a proper bed, a lockable private cabinet, a heated and ventilated room (private or shared), access to a bathroom at a reasonable distance, and access to a refrigerator and washer.¹⁸ Israel's official regulations state that foreign home attendants are entitled to 9 holidays per year, in accordance with the religion they practice, and 36 hours’ leave from work per week.³¹ They are also entitled to receive the standard minimum wage (23.14 NIS/hour, equivalent to ∼US $6).³¹ Employers of home attendants are expected to pay their workers a higher hourly rate for overtime (i.e., work of > 8 hours/day or > 45 hours/week).³¹

In Germany, the care recipient or recipient's family can take on the role of employer for a foreign caregiver. An employment contract regulates tasks and amount of work. Minimum wage must not be “immoral”: the recommended hourly rates are €8.75 in West German states and €7.75 in East German states. Workers who come to Germany from Bulgaria and Romania receive €1341 per month in East Germany and €1587 per month in West Germany. Younger employees (< 30 years) are entitled to 26 days of vacation per year; employees aged 30 years and older are entitled to 30 days of vacation per year. Home attendants from other EU countries are entitled to at least 24 vacation days per year and a working day of 8 hours. Further regulations deal with protection against dismissal, probation time, accommodations (the asset value is calculated at €180/month), and the provision of meals (calculated value is €219/month). Employers and employees share the costs of social contributions including health insurance. Employers must contribute to the health care fund, the long-term care fund, retirement insurance, and statutory casualty insurance for the worker.³⁵

The situation is different for home attendants sent to Germany by an organization or company that offers the same service in their home country.²⁵ In this case, the caregiver’s stay is limited to 24 months. If the care recipient requires further care, the company can send a replacement caregiver. The organization takes on the role of employer, fulfilling all social and governmental obligations in the home country of employees. Immorally low wages are forbidden. Since January 2012, Germany has mandated minimum wage salary for all employees in nursing and long-term care positions, even if they are not classified as professional caregivers. The regulation of working time corresponds to German law. Usually, the care recipient is obliged to make room and board available.³⁵ Commonly, reimbursement for travel expenses, phone, Internet, satellite TV, and, on occasion, a brokering fee (at present ≤ €1000) must be paid by care recipients or their families.

Still other regulations are in place for self-employed home attendants, also known as sole traders, who are responsible for all duties imposed by the trade law in their country of origin. Frequently, German authorities suspect that their entrepreneurship is only a pretense to avoid social security contributions.³⁵ Self-employed domestic helpers and caregivers sign a contract with their client and freely negotiate the price for the service. At present, prices vary between €1300 and €2000 per month, in addition to room and board.³⁵ Accommodation is not required; it is in fact illegal for self-employed home attendants to live in the home of the person for whom they are caring.³⁶ Regional differences affect wages, as do special capabilities, such as proficiency in German or qualification as a nurse.

The United Kingdom has no separate legal programs designed specifically for home attendants and therefore no regulations concerning their living conditions. Indeed, even the Web site of Kalayaan, a key nongovernmental organization advocating for the rights of immigrant home attendants, has no reference to minimal living conditions.³⁷ However, home attendants share a few basic rights with other workers in the country. These include 24 hours' leave from work every week, 28 paid holidays each year (for full-time workers), and statutory sick pay of £79.15 per week for workers who are sick for 4 or more days and provided they earn £82 or more per week. Workers are entitled and mandated to contribute to national insurance (covering such expenses as pensions and unemployment pay but not health care); this is deducted from their salary. Working conditions and wages are stated in a work contract, which is to be signed within 2 months of employment. Kalayaan advises home attendants not to work more than 48 hours a week, but employers have no legal obligation to observe this cap.^33,37

ACTUAL LIVING CONDITIONS

Among 6 countries in our review (excluding the United States, which offers no targeted legal residency options for foreign home attendants), we observed gaps between official regulations and the actual conditions in which migrant home attendants live and work. The nature and the extent of these gaps vary between countries.

Canada's protection of the basic rights and well-being of migrant home attendants is the most comprehensive. Yet even there we found evidence of violations of the protective regulations. The most obvious violations involve monthly wages and working hours. According to an estimate in 2011, the salary per month for these workers ranged between Can $1280 and Can $1760, varying by province.³⁸ Another study revealed hourly wages of $4.53 to $4.73 per hour for 48 to 50 hours per week. Such rates are significantly lower than the $5.40 to $6.85 legal minimum hourly wage at the time the study was conducted.¹⁵ These estimates depict an hourly rate as low as 70% of the minimum wage.^15,38

Other studies conducted in Canada revealed mistreatment and hardships borne by home attendants that technically might not have violated the regulations. Studies reported home attendants being forced to carry out countless domestic chores unrelated to health care, such as cooking, ironing, housecleaning, snow shoveling, laundry, and mopping floors.³⁹ Scholars have pointed out that home attendants neither have, nor can insist on, a clear boundary between being on and off duty. Hence, their continued physical presence at the workplace makes them on call virtually 24 hours a day,⁴⁰ causing them to feel that they are under constant surveillance and to be socially isolated.⁴¹ Another study showed that many home attendants felt as though they were living other people’s lives, giving rise to feelings of hate, fear, and stress.⁴²

In the United Kingdom, a survey conducted by Kalayaan and Oxfam found that among more than 500 home attendants, only 8% received a salary equivalent to the 2008 United Kingdom national hourly minimum wage of £5.52.³³ In fact, disclosed wages earned by migrants (not necessarily home attendants) are reported to range from £100 to £199 per week, or 20% to 30% less than the earnings of their United Kingdom–born counterparts.⁴³ In addition, Kalayaan and Oxfam found that 68% of female home attendants were allowed no time off and were expected to be on call 24 hours a day.³³ Other reported unlawful conditions included lack of a working contract, no compensation or any payment for sick days or holidays, and unlawful dismissal.⁴³ Kalayan and Oxfam also found that as many as 61% of migrant home attendants were not allowed to leave their employer’s house without permission and that more than half had no room or private space of their own. Among the respondents in this study, 72% reported psychological abuse, 24% reported physical abuse, 9% reported sexual abuse, and 41% reported insufficient food.³³

Reports from Singapore have described work days of 12 hours or longer, 1 weekend day off once a month (if at all), and wages ranging between US $125 and US $400 for Filipina home attendants.⁴⁴ However, a new regulation took effect in January 2013, obligating employers to grant 1 day off per week for a domestic worker, unless the parties have a written agreement stipulating compensation for working on a rest day. This compensation must be at least 1 day’s salary or a replacement rest day taken within the same calendar month.²⁰ Numerous reports of unpaid wages have been collected by the Philippine Embassy, accounting for about 15% of complaints filed by employees. The embassy has also received many reports of employer sexual abuse and harassment, including 200 official complaints in 1997 alone. Complaints decreased between 1997 and 2001 because of severe penalties provided for by Singaporean law, but application of the law faces inherent limitations.⁴⁴

In Israel, divergence between the official regulations and the actual conditions of foreign home attendants pertain to work hours and wages, substantial overpayments for mediation funds, medical insurance, adequate food, and private space. For example, a survey conducted by Kav L’oved (workers' hotline), a nongovernmental organization, showed that among 100 home attendants, 95% were working an average of 12.7 hours per day, 6 days a week, amounting to 326 hours per month, while being paid for only 186 hours per month.⁴⁵ Most of the respondents said they were given 24 hours' leave per week, instead of the 36 hours required by Israeli law, and only 6% of these foreign workers believed this law was applicable to them. In fact, 16% claimed they were not given any time off. In the same survey, 31% of the caregivers reported they were sharing the same room with the person for whom they provided care and lacked any sense of privacy, and 12% did not have proper medical insurance. Around a third of the respondents reported verbal violence by their employers or their employers’ families, 12% reported physical abuse, and 4% (all of whom were women) reported sexual abuse. In addition, 27% complained about food: either amounts were inadequate, or home caregivers were not allowed to cook because their employer kept a kosher kitchen. Estimates of overpayments to mediating agencies and individuals are often as high as 9 times the permitted amount (i.e., US $8000 instead of ∼US $900).⁴⁶

In Germany, treatment of many foreign home attendants violates the regulations in place to guarantee their protection. These laws disregard the market and the financial realities of potential employers. Labor protection is expensive and is frequently accompanied by an increase in care costs. For example, if the regulation working day is 8 hours, the recipient who needs around-the-clock care must employ 3 caregivers, easily costing €5000 or more. Neuhaus et al. estimated in 2009 that only about 10% of families employing foreign home attendants were in a position to pay more than €2000 for services of this kind; they also found that only about 10% of foreign home attendants were registered.²⁶ Normally, self-employed home attendants have no protection.⁴⁷ The activities of employment agencies that bring in home attendants are generally not fully transparent,⁴⁸ and neglect of labor rights is often tolerated by German authorities.

Experts describe a shadow economy of care in Germany,⁴⁹ where foreign home attendants labor with no dismissal protection, no guarantee of wage continuation in the case of illness, and only rarely a paid vacation.⁴⁷ The working day is long, and frequently foreign home attendants have only 3 or 4 hours a day of free time.²⁶ One day off per week is considered to be a good working condition.⁴⁷ However, Neuhaus et al. found that 54% of foreign home attendants had regulated breaks and nonworking days.²⁶ A survey conducted in Stuttgart and its vicinity revealed that 20% of foreign home attendants were not insured and that 30% had to travel back to their home country for medical care.⁴⁸ The home attendant industry in Germany involves frequent household rotations, which enables attendants to see their families during breaks between 2 service engagements.²⁶ On the other hand, many complain about working in isolation. Women in particular complain that the only person with whom they are in contact all day is the person for whom they care, who in many cases is suffering from dementia, depression, or inability to communicate. Most participants in the Stuttgart survey wanted dignified interaction with their care recipients and their relatives or with the employment agency; some expressed a wish for a consulting center and professional mediation of conflicts.⁴⁸

One qualitative study conducted with Filipina workers in Spain (n = 50) indicated that they were content with their wages, work conditions, and employers’ treatment. The monthly wages ranged from US $550 to US $1000 (by contrast with US $125–US $400 in Singapore and Hong Kong).⁵⁰ However, Calavita paints quite a different picture. She reports on a study stating that Moroccan women performing domestic work in Spain earn as little as US $275 per month. Calavita also cites a study carried out by the Catalan government that showed that remuneration per hour paid to immigrant workers was 21% less than that paid to indigenous workers for similar work in agriculture, 18% less in construction, 40% less in industry, and 50% less in the service sector, where most immigrants are concentrated.⁵¹

CONCLUSIONS

We found an association between the extent and method of legalization options for home attendants in a particular country and the official regulations regarding their working and living conditions. At one end of the spectrum stands Canada, which has the program most tailored for foreign home attendants, with a clear path to permanent residence. Canada also has the most detailed regulations governing the working and living conditions of home attendants, as well as a special visa program designed for them. At the other end of the spectrum is the United States, with neither an official visa option upon entry to the country nor regularization programs for illegal home attendants; it also has no regulations to protect the rights of foreign home attendants.

Spain, which offers a legal option for entry, primarily for EU citizens, and regularization programs that have covered a large number of illegal home attendants already in the country, is an exception to our observed correlation between legalization and protection.²⁷ Spain's regulation of the living and working conditions of domestic workers is quite limited.

The existence of methods of legalization of foreign home attendants and of official regulations concerning their living and working conditions may not in themselves be sufficient to improve these workers' situation, because regulations may be ignored. Even in countries in which strict regulations exist, there is substantial evidence of violation of these regulations. The German case shows that the formal protection of foreign caregivers is of little use if the needs and the means of care recipients are disregarded. Thus, the problem of illegal home care is not solely a consequence of unavailability of visas and restrictive immigration laws. Illegal employment is also driven by recipients’ need for affordable care and by foreign workers’ desire to keep the greater part of their modest earnings. At present, a very small part of the cost of care required is covered by long-term care insurance. Reform in this area could improve the situation of both older persons in need of care and the workers—foreign and domestic—who provide that care.

The literature suggests that although mistreatment of foreign home attendants occurs even in countries with optimal policies, such as Canada and Spain, fewer violations are are reported there than in other countries. However, even in Canada and Spain, the reported violations do not necessarily depict an accurate picture of the actual conditions. For example, an official prerequisite to applying for permanent residency in Canada is a recommendation from the home attendant’s employer. Foreign home attendants thus have an obvious incentive not to antagonize their employers. Although Spain has no such requirement, Filipino workers can request permanent residence status after 2 years of residence in Spain, which may serve as a similar disincentive to complain about employment conditions.

The limitations of the data in our review include fear of repercussions from reporting complaints against employers, which may have constrained some foreign home attendants from airing their true concerns, and the difficulty of obtaining representative samples, especially of illegal workers. Neither did the data explore the perspective of the employer and its effect on the condition of the foreign home attendant. We did not examine what other caregiver options (e.g., nursing homes, native home attendants) are available in each country and how these fit the financial means of care recipients. Also missing were data on the living conditions of people in each country and whether most citizens are likely to have an extra room to provide for a foreign home attendant. Exploring these issues may shed much-needed light on the treatment of foreign home attendants.

Future research should examine not only the de facto state of regulations but also the intentions of the regulators. In certain countries, the focus may be on protecting local workers and curtailing competition from foreigners, leading to limits on immigration and to the demand for equal treatment of foreign and local workers. Other countries may focus instead on protecting the human rights of foreign workers.

Our review led us to draw 3 main conclusions:

• Regulations regarding working and living conditions of home attendants should be as detailed and as generous as possible to ensure that these workers enjoy decent conditions in practice.

• Such regulations are more likely to be enacted in countries that provide legal options for foreign home attendants to enter the country, rather than only regularization programs for existing illegal foreign workers.

• Requiring an employer’s recommendation to obtain permanent residency may constrain foreign workers from registering complaints or leaving suboptimal employment situations. Alternative protocols may be needed, such as an assessment of quality of care by a neutral social worker.

Appropriate employment conditions for foreign home attendants are crucial to ensure proper care for the disabled older persons and to guarantee basic human rights and respect for all members of society. Our review delineates some of the complex factors underlying these conditions as well as the wide array of approaches taken by different countries to address them. We hope that our analysis of those approaches can provide a first step toward improvement of the lives of migrant home health workers.