| Author | Elena Moore (Department of Sociology, University of Cape Town) |
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| Overview | Long-Term Care is Family Care Long-term care (LTC) provision in South Africa is grounded almost entirely in unpaid family support. The Older Persons Act (2006) sets out the regulatory framework for services and assistance to older people, prioritising family- and community-based care. Although policy rhetoric affirms the principle of “ageing in place,” public investment in community-oriented care has remained limited and has declined (1). With insufficient government support for care services and policies that implicitly rely on families, the South African system reflects a “familialism by default” model, where the state assumes that households will carry the responsibility for care. The state’s main intervention for older persons has been income support: approximately 98% of LTC-related public spending goes toward pensions (2). The means-tested Older Persons Grant offers people aged 60+ a reliable income stream. Because community-based services are scarce and market options remain unaffordable for most people, older South Africans typically depend on relatives in the household. Many older persons reside in large multigenerational households, often with five or more members, and these are frequently female dominated. Studies consistently show that older women in particular use their pensions and unpaid labour to support adult children and grandchildren (3). This pattern is shaped by the lack of permanent state assistance for unemployed adults, persistent poverty, high joblessness, shifts in marital and fertility patterns, entrenched gender norms, and the impact of HIV/AIDS. Despite carrying significant care roles themselves, older persons also often require care, yet far less is known about how their care needs are being met. South Africa’s demographic profile is changing rapidly: six million people (one in ten citizens) are now aged 60+, and the prevalence of non-communicable diseases is high. On average, older persons spend 5–6 years in poor health, implying high demand for both health and social care. Demographic, health, and socio-economic pressures are pushing the country toward the need for a more coherent LTC system. While the post-apartheid government removed racial barriers to institutional care, it concluded that expanding residential facilities was “inappropriate on both ideological factors as well as fiscal constraints” (4). Instead, it desegregated existing institutions without significantly increasing resources in historically underserved communities (5). Although families remain central to care and many older persons prefer home-based arrangements, family care alone is increasingly inadequate in the face of growing and more complex care needs. Rising Elder Care Needs Older people in South Africa face a high risk of poverty. Historical racial discrimination continues to influence care needs. Roughly 62% of those aged 60 or more are black African and experienced severe disadvantages under apartheid, particularly in education and employment access (6). Over half of older persons live in households with no employed adult. Although the expansion of the pension has alleviated poverty, high unemployment rates mean older people often shoulder financial responsibilities for extended family members (7). In South Africa, life expectancy after age 60 is considerable, about 17 additional years for men and 20 for women (8). Yet non-communicable diseases now account for 76% of all Disability-Adjusted Life Years nationally. Among older adults, diabetes (affecting 23%) and hypertension (68%) significantly increase needs for ongoing health and social care (9). Where these conditions are poorly managed, the risk of disability, such as stroke-related impairment or diabetic amputations, rises. Families and communities largely absorb the responsibility for managing these chronic conditions. Population ageing therefore places enormous pressure on families but also on health system, which struggles to deliver accessible and high-quality care for older persons (10). Estimates of functional impairment among older South Africans vary. In one rural setting, a sizeable share required assistance with at least one basic activity of daily living (11). WHO data indicate that 38–49% of people aged 65–74 and 75+ require BADL assistance (12). Although exact figures remain uncertain, care needs rise sharply with age, and the number of people aged 70+ is expanding rapidly, expected to double by 2040 to reach 3.5 million. Lifetime disadvantage and HIV exposure further contribute to higher dependency rates among older black South Africans (13). |
| Governance and system organisation | The Older Persons Act (2006) governs the delivery of services to older adults and emphasises family and community care. Section 2(c) specifically states that a key objective is to “shift the emphasis from institutional care to community-based care” so that older persons can remain at home for as long as possible. The Department of Social Development (DSD) administers the Act, oversees and regulates community-based services, and registers and subsidises Non-Profit Organisations (NPOs) delivering care. The DSD directly provides only a handful of LTC services, most are delivered through NPOs, which must comply with norms and standards. The Department of Health (DoH) plays a complementary but critical role, offering healthcare support, limited residential care services, and they are in the process of building a strategic framework for gerontological health via the Age Well Forum. DoH also supplies medical products (such as incontinence items) to clinics and facilities, although distribution is often inconsistent. Because budgeting and implementation occur at the provincial level, there is significant variation in service availability. Most importantly, coordination between DSD, DoH, and other relevant departments, such as Transport and Housing, is inconsistent, leading to gaps between planning, regulation, and implementation, especially when linking access to health and social care. |
| Financing and coverage | Whilst there is both public and private healthcare in South Africa, only 23% of older persons, and just 5.4% of black older South Africans, have private health coverage. Most older persons rely on public health facilities and whilst helpful for accessing healthcare, they are ill-suited for accessing long term care. As stated above, the state is the main funder of the LTC system and funds primarily state pensions. In South Africa, the state provides income support through the Older Persons Grant (OPG) and, to a lesser extent, the Grant-in-Aid (GIA). The OPG is means-tested, and 73.1% of those aged 60+ (3.8 million people) received a social grant in 2022. The grant value reached R2 080 per month in 2023, with women receiving about two-thirds of all OPG payments. The GIA is intended for older persons who need full-time care. Applicants must undergo a medical assessment confirming that they are “in need of regular attendance.” In 2022, 252 161 people received the GIA, valued at R505 but this has risen to more than 500 000 recipients by 2025. Around 11% of OPG beneficiaries receive the GIA, though evidence suggests that as many as 1.5 million older persons may be eligible. Evidence suggests that the institutional practices built into accessing the GIA puts up impediments to older people accessing the grant (14). |
| Service Delivery | |
| Service Delivery Overview | Formal LTC services are limited. South Africa has approximately 400 subsidised residential facilities providing only 18,011 beds, with nearly one-third located in the Western Cape (in 2022). Service centres, primarily run by underfunded NPOs, reach approximately 80,000 older persons. They generally serve active older adults and may offer meals, social activities, and basic health services. Importantly, South Africa has no dedicated cadre of community-based or home-based geriatric care workers. Existing community care workers focus on HIV/TB compliance, maternal and neonatal care, and other priorities, leaving little room for elder care. Many care workers involved in geriatric care have minimal training. Some community services exist, limited residential care, small-scale home-based care (reaching only around 100,000 older persons), and the Grant-in-Aid. However, the GIA’s design and bureaucratic processes significantly hinder access (15). Although GIA uptake has improved in recent years, the broader policy orientation still reflects “familialism by default”: policies recognise family care but do not provide the financial or service support required to make it viable. Without sufficient funding for service centres, home-based care, or residential facilities, government effectively delegates responsibility for elder care to families. |
| Enabling environments | Many studies show that the built environment and institutional practices often fail to accommodate older persons, especially in under-resourced townships, rural areas, and informal settlements. Supportive environments are essential for ageing in place, but disabling environments make everyday care extremely time and resource intensive. Older persons require more assistance with routine activities, such as washing, toileting, meal preparation, yet one-third of older-person households do not have water inside the dwelling. More than 32% rely on communal taps, and 8% depend on water tankers or streams. Poor water access greatly increases caregiving time and reduces capacity for direct care (18). Over half of older-person households use outdoor pit latrines toilets; nearly one-fifth rely on firewood for fuel, rising to 30% in rural areas. Navigating outdoor toilets, collecting wood, or preparing meals without electricity often requires help from family members. The evidence shows that 64% of older-person households lack adequate street lighting, and 61% live in areas where refuse removal is irregular (18). Poor roads, unsafe neighbourhoods, and limited transport make accessing clinics or social welfare offices extremely difficult. Long-term care policies have been largely silent on equity of access, despite the deeply unequal infrastructure patterns inherited from apartheid. Disabling environments not only constrain older people but intensify strain on caregivers through additional financial costs, environmental barriers, and bureaucratic demands. |
| Workforce | Most care for older persons is provided by unpaid family members, predominantly adult daughters and granddaughters. Given that roughly three-quarters of older people live in multigenerational households, caregiving is mostly co-residential. Yet caregivers frequently juggle elder care with childcare responsibilities, personal health challenges, and constrained employment opportunities (16). Many leave work or stop job-seeking because few elder-care supports or family-friendly labour policies exist. Although qualitative research documents these experiences well (17), nationally representative data on family caregivers is scarce. Information on the formal LTC workforce is also limited, owing to the absence of a comprehensive registry, an issue the Department of Social Development is now attempting to address. Care work has been covered by the national minimum wage since 2019. Although the wage has grown faster than inflation, many care workers remain underpaid due to weak enforcement, short hours, misclassification as “volunteers,” and a low initial wage base. Little is known about the size of the care workforce, working conditions, or levels of training. |
| New models of care and innovations | Despite the lack of adequate state funding for community based care, there are good examples of low-cost, high impact community based care services operating across the country. South Africa, like many other low and middle income countries do not always have the formal structures to support older persons, especially in rural areas or poorly serviced informal settlements. Two examples can be highlighted here: in Cape Town informal settlement in Khayelitsha there are peer support programmes run by Grandmothers Against Poverty and Aids (GAPA) which operate a peer-to-peer support programme focused on reaching older persons living in informal settlements and reducing loneliness and improving overall well-being. In Durban, The Association for the Aged (TAFTA) adopt a neighbour based care model that draws on multiple service providers at the community level to support older persons. These models, designed in context, have a better reach, and lower cost and rely on a community-based approach. Whilst several community based care models are in operation in South Africa, few have been part of external evaluations to examine their wider impact or scalability in improving (19). |
| Performance | |
| New reforms and policies | The recent months have brought some progress, including amendments to the Older Persons Act, potential expansion of family responsibility leave to include elder care, and innovative programmes aimed at increasing GIA access. However, without sustained public funding and stronger community-based services, South Africa’s LTC system continues to rely heavily on families who have limited capacity to meet escalating care needs. |
| Suggested Citation | Moore E. (2025) Long-Term Care System Profile: South-Africa. Global Observatory of Long-Term Care, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/south-africa/ |
| References |
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KEYWORDS / CATEGORIES | |
| Countries | South Africa |
