/ Andrzej Lisowski Travel Gael Fostier de Moraes Shutterstock.com Nicola Duell archive Mohamed Ihsan Ajwad TVTC ... THE CARE BOOM Addressing care through Technical and Vocational Education in Saudi Arabia Gael Fostier de Moraes Nicola Duell Mohamed Ihsan Ajwad © 2024 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Web: www.worldbank.org Some rights reserved. Disclaimer This work was prepared by The World Bank at the request of the Kingdom of Saudi Arabia’s (KSA) Technical and Vocational Training Corporation. The findings, interpretations, and con- clusions expressed in this work do not necessarily reflect the views of the Executive Direc - tors of The World Bank or the governments they represent. 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Because The World Bank encourages dis- semination of its knowledge, this work may be reproduced, in whole or in part, for noncom- mercial purposes as long as full attribution to this work is given. Attribution: Fostier de Moraes, Gael, Nicola Duell, and Mohamed Ihsan Ajwad. 2024. The Care Boom: Professionalizing Care Provision Through Technical and Vocational Education in Saudi Arabia. World Bank. Washington, DC. Translations: If you create a translation of this work, please add the following disclaimer along with the attribution: “This translation was not created by the World Bank and should not be considered an official World Bank translation. The World Bank shall not be liable for any content or error in this translation.” Adaptations: If you create an adaptation of this work, please add the following disclaimer along with the attribution: “This is an adaptation of an original work by the World Bank. Views and opinions expressed in the adaptation are the sole responsibility of the author or authors of the adaptation and are not endorsed by the World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Pub- lications, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. ACKNOWLEDGEMENTS This report is the product of collaboration between the Technical and Vocational Training Corporation (TVTC) and the World Bank under the Technical Coopera- tion Program with the Saudi Arabian government. The authors of the report are Gael Fostier De Moraes (Economist and Lead Author); Nicola Duell (Senior Econ- omist), and Mohammed Ihsan Ajwad (Senior Economist and Task Team Leader). Guidance from two peer reviewers Elena Glinskaya (Lead Economist, HAWS3) and Amanda Devercelli (Senior Education Specialist, HMNED) is gratefully acknowl- edged. In addition, Johannes Koettl (Senior Economist and Task Team Leader for the GCC Social Protection and Jobs RAS Engagement), Ramy Zeid (Labor Econo- mist, World Bank), Dana Alrayess (Labor Economist, World Bank), Carole Chartouni (Senior Economist, World Bank), and Ekaterina Pankratova (Senior Social Protec- tion Specialist and Program Coordinator for the GCC Social Protection and Jobs RAS Engagement, World Bank) provided useful input. Harry David (Editor-Consul- tant, World Bank) provided editorial support. Manuel Gache (Designer-Consultant, World Bank) designed the report. Yasmine Khaled-Jaiser (Translation and Arabiza- tion Consultant, World Bank) carried out the translation of the report from English into Arabic to enhance outreach to Arabic-speaking audiences. The report benefited from strategic guidance and insights of Safaa El Kogali (Country Director, Gulf Cooperation Council Countries, World Bank) and Cristob- al Ridao-Cano (Practice Manager, Social Protection and Jobs, Middle East and North Africa, World Bank). The World Bank taskteam expresses its sincere appreciation for those involved in the World Bank’slong-standing partnership with TVTC, who provided guidance and valuableinsights—namely, His Excellency Dr. Ahmad Alfahaid (former Gov- ernor, TVTC), Dr.Adel Alzenedy (Deputy Governor for Training, TVTC Eng. Sutlan Alsunaya (General Manager forInternational Cooperation, Owner of the project, TVTC), Bandary AlFarraj(Project Management, TVTC), Taghreed Albalawi (Proj- ect Management Office,TVTC), Mr. Abdulmajeed Alrushaydan (General Admin- istration of InternationalCooperation, Project Manager, TVTC), Eng. Abdo Azibi (General Directorate ofCurricula, TVTC), Eng. Mishaal Al-Saif (Deputy Director of Strategic ManagementOffice, TVTC), Dr. Ahmed Al-Haydan (General Functional CoordinationAdministration, TVTC), Eng. Abdulaziz AlDayhan (General Admin- istration ofTrainees Affairs, TVTC), Eng. Mohammed AlAhmad (General Admin- istration ofTrainees Affairs, TVTC), Hatem Al-Rudaini (Office of the Assistant DeputyGovernor for Training, TVTC), and Taybah Mousa (Office of the Assis- tant DeputyGovernor for Training, TVTC), Eng. Fahad Alsehli (Manager of Plan- ning, TVTC),Eng. Abdulaziz Aldukhayyel (Office of Deputy Governor for Planning and BusinessDevelopment, TVTC), Eng. Saleh Alshowaier (Deputy Manager for GeneralDirectorate of Curricula, TVTC), Eng. Malik Almania (Strategic Manage- mentOffice, TVTC), Fatimah Alsalman (Strategic Management Office, TVTC), FayzahAlghamdi (Office of the Deputy Governor for Training, TVTC), Abdulrah- manAltayyar (Deputy Manager for International Cooperation, TVTC), Eng. Adel Alaood (General Manager for Trainers Affairs, TVTC). 6 ACRONYMS AND ABBREVIATIONS EAP East Asia and Pacific ECA Europe and Central Asia ECE Early childhood education ECCE Early care and childhood education EMT Emergency Medical Technician GASTAT General Authority for Statistics (Saudi Arabia) GDP Gross domestic product GER Gross Enrollment Ratio GSSWA Global Social Service Workforce Alliance HALE Healthy life expectancy ILO International Labour Organization ISIC REV International Standard Industrial Classification of All Economic Activities, Revision LFS Labor force survey LTC Long-term care MENA Middle East and North Africa OECD Organisation for Economic Co-operation and Development SAR Saudi Riyal (currency) TVET Technical and vocational education and training TVTC Technical and Vocational Training Corporation UAE United Arab Emirates UK NHS United Kingdom National Health Service UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations International Children’s Emergency Fund USD United States Dollar VET Vocational education and training WHO World Health Organization TABLE OF CONTENTS Executive Summary 12 1 Introduction: The Care Economy is Important 20 Box 1 The Technical and Vocational Training Corporation 26 2 The demand for care: it’s growing rapidly 29 Recent growth in the population of children has added pressure to Saudi Arabia’s care sector 30 The population of older persons is increasing 32 Box 2 Projected impact of aging population on noncommunicable disease burden and costs in Saudi Arabia, 2020–30. 34 The population of people with disabilities is expected to grow as the population ages 36 The shifting population composition is increasing the demand for care 38 3 The care provision landscape: too many untrained and unpaid workers and too few professionals 42 Unpaid care work: Women do much of the care work without pay 43 Paid care work: untrained providers make up almost half the care workforce 47 Care workers in childcare 47 Care workers in health and social work 50 Box 3 Saudi Arabia’s new model of healthcare 54 Untrained care providers: Domestic workers are the dominant source of paid care 57 4 Professional care services are falling short: Labor shortages and skills are to blame 61 Care service provision: the missing professionals 62 Care professions are in high demand: just look at wage growth and hiring 67 Skills development for the care economy in Saudi Arabia 73 5 Equipping the care workforce: international experience has lessons for Saudi Arabia 78 Skills development for care workers in childcare and education 80 Skills development for long-term care of older persons and people with severe illnesses 82 Skills development for care workers in the health sector for people with health issues and people with disabilities 83 Skills development for care workers in social services for fragile and vulnerable groups 85 Developing a comprehensive care strategy 86 Training 87 Migration, skills-mobility partnerships, and training of migrants 89 Working conditions 90 6 Policy reform areas: TVTC can play an important role 92 Recent reforms in the country 93 Recommendations 95 Assess current training needs and the existing training provision 96 Increase training opportunities within the care sector 97 Diversify curricula and courses to include care and care modules 99 Engage with partner organizations and stakeholders to respond to emerging skills needs 100 Implementation considerations 101 Bibliography 103 Annex 108 Annex I List of International Standard Classification of Occupations in care as defined by the ILO and OECD 108 Annex II Care workers in education 110 TABLE OF FIGURES Fig. ES 1 Population under 14 and over 65 years old, Fig. 23 Labor force participation rate in Saudi Arabia, historical and projected, Saudi Arabia 14 female, by age (%) 46 Fig. ES 2 Labor force participation rate in Saudi Arabia, Fig. 24 School enrollment, pre-primary (% gross), female, by age (%) 15 by World Bank region 49 Fig. ES 3 Care-workforce composition by country 17 Fig. 25 Distribution of employment by economic activity, Fig. ES 4 Framework for meeting demand human-health and social work activities (ISIC REV 4) for care through TVET education 18 —high-income countries by region, 2021 51 Fig. 1 Infographic: Who are the main care recipients? 21 Fig. 26 Density of health personnel (per 10,000 population), 2012–20, in OECD countries and Saudi Arabia 52 Fig. 2 The main care providers are unpaid or paid 22 Fig. 27 The new model of care 55 Fig. 3 Key challenges in Saudi Arabia’s care economy 24 Fig. 28 Mapping of social service workforce by type of ministry Fig. 4 Framework for meeting demand under which they operate (number of countries, for care through TVET education 25 by region and by type of ministry) 56 Fig. 5 TVTC training offer related to the care economy 27 Fig. 29 Care-workforce composition by country 58 Fig. 6 Population under 14 and over 65 years old, Fig. 30 Number of domestic workers in Saudi Arabia 59 historical and projected, Saudi Arabia 30 Fig. 31 Care workers as a share of total employed (%), 2012–16 59 Fig. 7 Population in Saudi Arabia by age group, children aged 0–14, 2010–20 31 Fig. 32 Size of trained care workforce x care dependency ratios 63 Fig. 8 Projected population in Saudi Arabia by age group, Fig. 33 Skills shortage by industry in 33 countries 66 children aged 0–14, 2020–50 31 Fig. 34 Shortage and surplus of skills by country and type Fig. 9 Population aged 65+ in Saudi Arabia, of skill, health, and social work activities (NACE) 67 by age group, 2010–20 32 Fig. 35 Shortage and surplus of skills by country Fig. 10 Projected population aged 65+ in Saudi Arabia, and type of skill, education industry (NACE) 67 by age group, 2020–50 32 Tab. 1 Labor-market-pressure-analysis framework 68 Fig. 11 Population composition by region, Tab. 2 Summary of observations for the market current and projected 33 -pressure analysis 68 Fig. 12 Annual healthcare costs for priority noncommunicable Fig. 36 Shortage occupations in care (or care-related) diseases among people aged ≥ 15 years, 2020–30 35 industries based on wage and job growth Fig. 13 Prevalence of disabilities among Saudis for Saudi nationals (2013–19) 70 facing some level of difficulty, by age group 36 Fig. 37 Shortage occupations in care (or care-related) Fig. 14 Prevalence of disability, by World Health industries based on wage and job growth Organization region, 2021 37 for non-Saudi nationals (2013–19) 71 Fig. 15 Change in prevalence of health conditions associated Fig. 38 Market-pressure analysis applied with moderate and severe levels of disability, to the care economy, Saudi Nationals 72 globally, 2010 and 2021 37 Fig. 39 Size of care workforce × GDP per capita (2015 USD PPP) 74 Fig. 16 Population composition in Saudi Arabia, Fig. 40 Women, % of total employed in health and social work 75 current and projected 38 Fig. 41 Women, % of total employed in education 75 Fig. 17 Age dependency ratios (% of working-age population) Fig. 42 Average monthly wage by education and nationality, in Saudi Arabia—current and projected 39 Saudi Arabia, 2022 (in SAR) 76 Fig. 18 Age dependency ratios (% of working-age population) Fig. 43 Examples from Europe in training care and care-related in Arab states—current and projected 39 occupations in TVET settings 80 Fig. 19 Population in Saudi Arabia by age and nationality, 2022 40 Fig. 44 Education-level profiles of care workers in education Fig. 20 Percentage of households with dependents, 2022 40 and in healthcare and social work 81 Fig. 21 Visual of classification of care providers 43 Tab. 3 Medical technical assistant length of training examples 85 Fig. 22 Proportion of time spent on unpaid domestic and care Fig. 45 Framework proposed for meeting demand work, female (% of 24-hour day)—latest available year 44 for care through TVET 96 Executive summary Shutterstock.com / Andrzej Lisowski Travel The Care Boom 11 Executive summary EXECUTIVE SUMMARY A well-functioning care sector has positive im- inefficient allocation of resources. Finally, poli- pacts on individuals, households, and the econ- cy makers do not fully incorporate the fact that omy.1 Better care services enhance the quality of care work tends to be resistant to automation, life of the population. Too often, household mem- an increasingly important consideration when bers, predominantly mothers and grandmothers, preparing people for employment in the future. act as default care providers. Improved care ser- Care work, broadly defined, involves activities vice provision enables these default care provid- and relations aimed at addressing the physical, ers to pursue education and careers, thereby in- psychological, and emotional needs of individ- creasing labor force participation, boosting GDP, uals. Care receivers can be anyone that needs and reducing the gender wage gap. attention and support. Typically, care receiv- Despite the benefits of a good care sector, ers are children; older persons; or individuals of policy makers often underemphasize the im- any age having disabilities, physical and mental portance of the care sector. The care sector is health issues, or a lower level of autonomy. a critical component of the economy, not only The care economy is the value of all forms of because the availability of care services en- work, whether paid or unpaid, dedicated to ables individuals with care responsibilities to taking care of people. Historically, caregivers participate in the labor market, but because it have primarily been unpaid family members, a contributes to higher GDP growth. A good care commonality in many cultures worldwide. How- sector can also improve government spending. ever, with the changing structure of families For example, in the health and education sec- and labor markets, the sole reliance on family tors, the current reliance on the most educated members for care is becoming less common. personnel to carry out tasks, some tasks that Today, care work is provided by individuals who do not require high qualifications, represents an are unpaid and paid. Unpaid service providers 1 Kramer and Kipnis, 1995; Lewis, 2006; Thévenon, 2013; Del Boca, 2015; OECD, 2016; Morrissey, 2017; OECD, 2017c; Olivetti and Petrongolo, 2017; Kunze, 2018; Cortes, 2019; Kleven et al., 2019; Girgis, 2021; Goldin et al., 2022a; Goldin et al., 2022b; Neuberger et al., 2022; and Ahmed et al., 2023.) The Care Boom 12 Executive summary include family members and members of an In Saudi Arabia, the demand for care is in- informal support network. Paid service provid- creasing sharply for two reasons: ers can be trained workers, such as those work- • Demand for care is rising because Saudi ers in healthcare, social service, and education. Arabia’s demographics are changing They can also be untrained workers, such as significantly. The demographic changes are most domestic workers. Although training is so significant that it is leading to the current measured on a continuum, and not necessarily working age population to be called the as a binary state, in this report we define trained “sandwich generation” because they must care workers as care workers who are certified simultaneously care for their own children and to carry out a particular task. their aging parents. The increasing population A well-functioning care sector of older people (people older than 65 years) is can enhance quality of life, allow likely to increase the demand for healthcare, “default” caregivers to pursue long term care, 2 and care for people with careers, increase labor force disabilities. The rising population of children participation and GDP, and has increased the demand for pediatric care, reduce the gender wage gap. childcare, day care, etc. ( Figure ES 1 ). The population of children under 14 and persons This report, written at the request of the over 65 years is projected to more than double Technical and Vocational Training Corpo- to reach over 18 million by 2050 up from under ration (TVTC) in Saudi Arabia, explores the 8 million people in 2010. Although not all importance of addressing care challenges individuals at those ages need care, it is often in Saudi Arabia. The report examines the size the case that many younger and older people and composition of the care workforce, identi- need some type of assistance and care. fies the population of care recipients, and esti- mates labor shortages across care occupations. The report benchmarks Saudi Arabia with oth- er comparator countries, mostly Organisation for Economic Co-operation and Development (OECD) countries, and reviews international ex- periences in training the care workforce, partic- ularly through TVET. Finally, recommendations are provided to address current and projected care challenges in Saudi Arabia and to serve as a roadmap for strengthening the care sector, with a focus on the role of TVTC in professionalizing the care workforce. 2 Defined by the OECD (2020a) as “range of medical, personal care and assistance services that are provided with the primary goal of alleviating pain and reducing or managing the deterioration in health status for people with a degree of long-term dependency, assisting them with their personal care (through help for activities of daily living, such as eating, washing and dressing) and assisting them to live independently (through help for instrumental activities of daily living, such as cooking, shopping and managing finances).” The Care Boom 13 Executive summary Figure ES 1 Population under 14 and over 65 years old, historical and projected, Saudi Arabia 20,000,000 18,000,000 16,000,000 Historical Projected population numbers 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 2010 2015 2020 2035 2050 0-4 5-9 10-14 65-69 70-74 75-79 80 or more Source: authors’ calculations using data from the Population Estimates and Projections database, World Bank. • Demand for care is rising also because Saudi In Saudi Arabia, the demand for women, who have traditionally been the main care services is rising sharply caregivers, are entering the labor force at due to significant demographic a record pace. Labor force participation changes and increased labor increases in Saudi Arabia are particularly steep force participation by women. among women in childbearing age (Figure ES 2). As they join the labor market, the need for alternative sources of care rises. Additionally, the need for care workers increases with national income3 and economic development 4 because of factors including women joining the workforce, higher life expectancy, and higher demand for childcare, healthcare, and education. All these trends are observed in Saudi Arabia. 3 For instance, Moore and Newman (1992) find that “income is the most important determinant of health care spending, explaining well over 90 percent of the variance in expenditures across countries.” More recently, Özkaya et al. (2021) reach similar findings at the individual level, which is also supported by a literature review. 4 As discussed, for example, by Razavi, 2011. The Care Boom 14 Executive summary Figure ES 2 Labor force participation rate in Saudi Arabia, female, by age (%) 50 45 40 35 30 25 20 15 10 5 0 2017 2018 2019 2020 2021 2022 2023 Total (15+) 15-24 25-54 55-64 65+ Source: authors calculations using GASTAT LFS data. Saudi Arabia’s care provision landscape has decisions, and it affects their educational four main characteristics. Care provision falls choices. Globally, it is estimated that 647 million on women, low-skilled domestic workers, a very people of working age were out of the labor small share of trained professionals, and a large market in 2018 because of care duties. 6 The share of migrant workers. obvious impact of engaging in unpaid care • Characteristic 1: Care work is predominantly work is having less time or no time to join the unpaid and carried out by women and labor force, which leads to foregone income girls.5 Unpaid caregivers exist in all countries, from employment, but also lower wages and regardless of the size or generosity of the worse career prospects.7 In instances where welfare state, with women generally being women engage in paid work, they often face the main service providers. When women, the double burden of having to work at their especially working-age women, dedicate place of employment and carrying out most of time to unpaid care, it affects their availability the care work in the home. This leads to worse to obtain and maintain paid employment, it mental and physical health outcomes. affects their work performance and their career 5 UN Women, 2018; Alonso et. Al, 2019 ; and Redaelli et. Al, 2023. 6 ILO, 2018. 7 UN Women, 2018; ILO, 2018. The Care Boom 15 Executive summary • Characteristic 2: Almost half of paid care work have no specific training for their caring is carried out by a pool of (low-skilled) domestic duties. In advanced economies like Australia, workers. 8 While domestic workers ease the Canada, France, and Germany trained care double burden on women, the use of domestic workers make up 20 to 30 percent of the total workers raises concerns about the quality workforce, and in Norway and Sweden even and affordability of care services. Domestic more than 30 percent.12 Moreover, evidence workers represent about 24.5 percent of total points to a lack of accessible childcare facilities employment in Saudi Arabia9 and an estimated in Saudi Arabia, with private childcare services 42.5 percent of the total care workforce in the having substantial costs, rendering affordability country (Figure ES 2). However, while domestic a challenge for many families. workers fill a significant gap, they often do not • Characteristic 4: The care economy is highly have the skills or training to effectively carry reliant on migrant labor. In Saudi Arabia, all out their care duties. In addition, families most domestic workers, who form a substantial in need of help are the least able to afford paid segment of the care workforce, are migrants. domestic workers. Almost half, 49.6 percent, of all workers employed in health and social activities within Saudi Arabia’s care provision the private sector are non-Saudis. While this landscape is characterized by: dependence on migrant labor is not inherently unpaid people, mainly women; a low- problematic, the fact that the skills verification skilled domestic workers; a small system for non-Saudis is nascent raises share of trained professionals; and concerns about the quality of care. significant reliance on migrant labor. • Characteristic 3: The share of trained professionals engaged in care work is low. In Saudi Arabia, there are about 6 percent of workers in health and social work, which is one of the lowest among high-income countries. That is consistent with the country’s low density of professional health workers.10 Overall, employment within the care economy represents around 30 percent of the country’s employment. However, trained workers in the care economy11 make up only 16.8 percent of the total workforce. The remaining care workers are domestic workers who often 8 Defined by the GASTAT methodology as “individuals who provide a household with services for a salary and live with it, such as the female domestic worker, driver, gardener, and building guard who lives with in the household.” 9 GASTAT Administrative data. Q4, 2022. 10 See Chapter 2 for a detailed discussion and evidence on those numbers. 11 Although training can be considered as a continuum, and not necessarily as something that was either been completed or not, for assessing and quantifying the workforce, we define Trained care workers here as care workers in education, care workers in health and social work, care workers in noncare sectors, and non-care workers in care sectors, excluding domestic workers. All component terms for care workers are as defined by ILO, 2018—also available in Annex I. 12 ILO, 2018. The Care Boom 16 Executive summary Figure ES 3 Care-workforce composition by country 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Qatar UAE Kuwait Saudi Arabia Uruguay Cyprus Spain Italy Portugal Greece Luxembourg Romania France Switzerland Canada Germany United States Korea Finland Ireland Poland Austria Malta United Kingdom Hungary Croatia Latvia Australia Belgium Netherlands Sweden Iceland Czechia Norway Denmark Lithuania Slovenia Estonia Slovakia Russia Japan Domestic Careworkers Careworkers in health Non-careworkers Careworkers in workers in education and social work in care sectors non-care sectors Note: We use as a proxy for trained care workers the sum of care workers in education, care work- ers in health and social work, care workers in noncare sectors, and noncare workers in care sec- tors as percentages of the total employed population. We exclude domestic workers. Source: authors calculations using data from ILO, 2018. Professional care services are in high demand respond to the increasing demand over time and demand will likely increase over time. To- because of demographic factors and because day, many professional care vacancies are un- more women are joining the labor force. filled or underfilled. Thus, trained professionals Using Technical and Vocational Education and are in short supply in Saudi Arabia. Of all occu- Training to train individuals in Saudi Arabia for pations showing signs of shortage in the period the care economy is a strategic approach that studied (from 2013 to 2019), almost 50 percent offers numerous benefits for those receiving are withing the care economy. care, their families and the caregivers. It di- We estimate that 1.1 million additional trained rectly addresses the current skill gaps by pro- care workers will be needed in Saudi Arabia viding practical, job-ready skills, crucial for the to maintain a ratio of trained care workers expanding demand in the care sector. TVET’s fo- to the care dependency ratio commensurate cus on intermediate skills fills the critical “miss- with other high-income countries. The trained ing middle in care skills”, offering a pathway to care workforce was 2.2 million workers in 2016, professionalize and elevate the quality-of-care whereas we estimate that about 3.3 million services. Additionally, the adaptability of TVET care workers are needed. This indicates a need programs allows for the integration of special- to train or hire non-Saudis to fill the 1.1 million ized training tailored to the unique needs of Sau- worker shortage. In addition, the professional di Arabia’s diverse care recipients, thereby im- care workforce will need to rise over time to proving service delivery and accessibility. This The Care Boom 17 Executive summary report highlights the need for this expansion, To increase the supply of a professional care suggesting that with strategic enhancements, workforce, we propose the A.I.D.E frame- Saudi Arabia’s TVET system could effectively work (see Figure ES 4). The framework has four support the development of a skilled care work- main components. First, Assess skills needs, force. A better skilled workforce can provide and training and education supply. Second, In- higher quality services for groups of the popu- crease the number of people trained, to attract lation needing care, improve work satisfaction, young men and women into care professions, improve working conditions of caregivers, and or to hire trained care professionals from oth- improve life quality through improve the work- er countries. Third, Diversify training and edu- life balance, in particular of women. cation programs, both in terms of proficiency While emphasizing TVET in training care work- level and specialization, and for initial training ers, we recognize that this approach alone will and education and continuous training (for up- not address all challenges in the care sector. skilling current care workers, including migrant Issues like quality of care, cost, and social norms workers, and for specializations). Finally, En- significantly affect the uptake of care services. gaging with a wide range of public and private Other structural challenges such as regulatory organizations and stakeholders, including those environments, funding mechanisms, and pub- that hire labor in other countries and verify, rec- lic awareness also need consideration. Despite ognize, and certify skills. these limitations, the scope of this report is fo- cused on TVET, acknowledging its substantial potential to enhance the care workforce. Figure ES 4 Framework for meeting demand for care through TVET education WHAT? WHY? HOW? Diversify professions in care Unburdens current unpaid A.I.D.E. framework to include intermediate-skilled care providers Assessing current professionals training needs and existing Promotes job creation training provision Train more care professionals Increases the quality Increasing training of care services opportunities for care Contributes to worker professions formalization, higher earnings, Diversifying curricula better working conditions, and courses to include and higher status care and care modules Engaging with partners to respond to emerging skills needs in care Source: authors’ elaborati The Care Boom 18 1. Introduction: The care economy is important Shutterstock.com / Aljohara Jewel The Care Boom 19 1. Introduction: The care economy is important 1 INTRODUCTION: THE CARE ECONOMY IS IMPORTANT All families face care needs, for children, older persons, people with disabilities, fragile and vulnerable people. However, those needs are underemphasized by policymakers in most countries. This underemphasis is leading to significant hidden costs, in the form of non-participation in the labor market, sub-optimal career choices, and lower human capital investments. Every human needs care at some point in their other individuals of all ages who may temporar- life—when very young or old, when sick or dis- ily or permanently require care due to illness, in- abled, or when coping with social problems jury, or other life events or their socio-econom- and life risks. Following the International Labor ic situation (see Figure 1)15 . The care economy Organization’s (ILO) definition13 , individuals gen- is the sum of all forms of work, paid of unpaid, erally in need of care are children, especially the dedicated to taking care of people. very young; older persons, especially the very old;14 people of all ages with disabilities requir- ing assistance to conduct daily activities; indi- viduals with chronic illnesses or medical condi- tions who need help managing their symptoms, medications, and medical appointments; and 13 ILO, 2018. 14 The level of independence and need for care among children and older persons varies significantly across countries and regions. These differences are influenced by numerous factors, including healthy life expectancy, quality of nutrition, human development, and the presence of illnesses. In this report we focus on two specific populations: children under the age of 14 and older persons aged 65 and above. 15 ILO, 2018; UN Women, 2018; OECD, 2020; UN Women, 2020; ILO, 2022; Redaelli et al., 2023. The Care Boom 20 1. Introduction: The care economy is important Figure 1 Infographic: Who are the main care recipients? R MAIN CARE RECIPIENTS Children People with Elderly people Other fragile / disabilities vulnerable people Source: authors’ categorization. A well-functioning care economy brings sig- largest group of providers, are family or friends nificant positive benefits, which have attract- who assist voluntarily without remuneration. ed increasing attention from policy makers in Paid care providers, on the other hand, can be developed economies. The growing attention categorized into trained professionals with for- given to the development of the care economy mal qualifications and untrained workers who stems from a collective recognition that care offer paid care services without official qual- services enhance the well-being and life qual- ifications (Figure 2) . Although training is mea- ity of the population while also contributing to sured on a continuum, and not necessarily as economic growth. For example, quality profes- a binary state, when assessing and quantifying sional childcare and older persons care enable the workforce, we define trained care workers more efficient use of the workforce, particularly as care workers in education, care workers in female workers who are often the main provid- health and social work, care workers in non- ers of care services. Supporting the provision of care sectors, and non-care workers in care sec- formal care services, whether at home or in in- tors, excluding domestic workers.17 stitutions, enhances work-life balance and alle- viates the double burden borne by working peo- ple with care responsibilities—typically women. This, in turn, leads to higher female labor force participation, a smaller gender pay gap, and ul- timately improved well-being for families.16 Care providers are broadly divided into two groups, those who are unpaid and those who are paid. Unpaid care providers, often the 16 Kramer and Kipnis, 1995; Lewis, 2006; Thévenon, 2013; Del Boca, 2015; OECD, 2016; Morrissey, 2017; OECD, 2017c; Olivetti and Petrongolo, 2017; Kunze, 2018; Cortes, 2019; Kleven et al., 2019; Girgis, 2021; Goldin et al., 2022a; Goldin et al., 2022b; Neuberger et al., 2022; and Ahmed et al., 2023. 17 All component terms for care workers are as defined by ILO, 2018—also available in Annex I. The Care Boom 21 1. Introduction: The care economy is important Figure 2 The main care providers are unpaid or paid P MAIN CARE PROVIDERS Unpaid Paid • Parents Trained Untrained • Other family • Healthcare • Domestic members • Social services workers • Support network • Education Source: authors’ categorization. Quality care promotes young people’s human This report explores the importance of ad- capital formation and is crucial to the health dressing care challenges in Saudi Arabia and and quality of life at all ages. Well-trained staff proposes a strategic approach centered on in early childhood care and education (ECCE) technical and vocational education and train- contribute significantly to children, families, and ing (TVET) to enhance the professional care the economy by equipping children with litera- workforce. Care occupations encompass a cy, numeracy, socialization, and cultural aware- wide range of tasks conducted at various pro- ness skills. 18 This investment in ECCE benefits ficiency levels by workers with multiple spe- children by making them school-ready and has cializations. Training is offered by higher edu- long-term positive effects on a country’s human cation institutions, vocational training systems, capital development.19 Similarly, quality care for and continuing education providers. This re- adults and older persons is vital for their health port examines the role of TVET in middle-level and well-being. Professional services improve roles within care occupations; it examines the the quality of life of individuals facing illness or current composition and size of the care work- frailty and improves the quality of life for family force in Saudi Arabia, explores the population members.20 Caregivers with diverse knowledge of care recipients, and identifies occupations and skills address the myriad of health issues of facing shortages. The report also compares older persons, promoting social integration, la- Saudi Arabia with other countries, especially to bor market participation, and emotional well-be- Organisation for Economic Co-operation and ing among care recipients and their families.21 Development (OECD) countries, and reviews international experiences in training the care workforce, particularly through TVET. Based 18 As shown, for example, for the European Commission, developing literacy skills in early-childhood education and care predicts better achievement in mathematics at school (in fourth grade) (Soto-Calvo et al., 2016). 19 Camilli et al., 2010 ; Haque et al., 2013; García, et al., 2016 ; and Pholphirul, 2017. 20 OECD/European Union, 2013; and OECD, 2023b. 21 UNICEF, 2018; OECD and ILO, 2022; Rocard and Llena-Nozal, 2022. The Care Boom 22 1. Introduction: The care economy is important on the resulting insights, recommendations are • The labor market is experiencing a transfor- provided to address current and projected care mative shift as women join the workforce in challenges in Saudi Arabia and to serve as a unprecedented numbers. With women tradi- roadmap for strengthening the care sector. tionally serving as the primary caregivers, this shift is tightening the availability of care provid- Investing in TVET to train ers, with female labor force participation climb- care workers is a crucial part ing from roughly 20 percent in 2017 to over 34 of Saudi Arabia’s strategy to percent in 2021.24 address the rising demand for quality care services. These pressures are not unique to Saudi Ara- bia: many other high-income countries face In Saudi Arabia, training additional care work- similar issues. Generally, the need for care ers is becoming increasingly urgent because workers increases with national income25 and of two main trends: economic development26 because of factors in- • The population of potential care recipients is cluding higher life expectancy and better child- rising rapidly: over the past decade, the pop- care, healthcare, and education systems (as ex- ulation of young children has expanded signifi- plored in Chapter 3). As Saudi Arabia improves cantly, from 7 million in 2010 to 8.5 million by in all these dimensions, the demand for care 2020, an increase of over 20 percent. 22 More workers will inevitably grow. dramatic is the projected growth among the older persons, which is expected to increase sharply from 860,000 to over 10 million by 2050, an increase of more than 1000 per- cent23(Figure 3). Unsurprisingly, the increase in the population of older persons is also expect- ed to significantly impact the population of peo- ple with disabilities in Saudi Arabia. 22 GASTAT data 23 Population Estimates and Projections database, World Bank 24 Labor force participation rate, female (% of female population ages 15+) (national estimate), ILOSTAT. 25 For instance, Moore and Newman (1992) find that “income is the most important determinant of health care spending, explaining well over 90 percent of the variance in expenditures across countries.” More recently, Özkaya et al. (2021) reach similar findings at the individual level, which is also supported by a literature review. 26 As discussed, for example, by Razavi, 2011. The Care Boom 23 1. Introduction: The care economy is important Figure 3 Key challenges in Saudi Arabia’s care economy R P A pool of care recipients that has been The current structure of care provision growing and expected to increase further already places a significant burden on women and more rapidly. and excessively depends on untrained providers, primarly domestic workers. Source: authors’ elaboration. Enhancing Saudi Arabia’s care more balanced workload, and promoting a more economy can create jobs, boost efficient allocation of resources. These strat- economic inclusion, and improve egies, focusing on continuous training, TVET, gender equality by professionalizing and tertiary education, address the evolving and diversifying skills. needs of the care economy and maintain or im- prove care quality to manage the growing de- This shift toward professionalization and mand for services. training requires policy intervention at multi- ple levels. While higher education is important, TVET could be crucial in readying the care work- force, given that many near-future job opportu- nities in the care economy will require inter- mediate skills (see Chapters 4 and 5). The pro- posed approach (Figure 4) diversifies the care workforce and paves the way for middle-edu- cated professionals to contribute significant- ly through TVET, in turn improving healthcare access, cost-effectiveness, and overall effi- ciency. Simultaneously, it offers relief to highly educated healthcare professionals, creating a The Care Boom 24 1. Introduction: The care economy is important Figure 4 Framework for meeting demand for care through TVET education WHAT? WHY? HOW? Diversify professions in care Unburdens current unpaid A.I.D.E. framework to include intermediate-skilled care providers Assessing current professionals Promotes job creation training needs and existing Train more care professionals training provision Increases the quality of care services Increasing training Contributes to worker opportunities for care formalization, higher earnings, professions better working conditions, Diversifying curricula and higher status and courses to include care and care modules Engaging with partners to respond to emerging skills needs in care Source: authors’ elaboration. By enhancing the care economy, Saudi Ara- Our proposal advocates a strong focus on bia could reap substantial economic and so- TVET to improve the care economy. Howev- cial benefits. These benefits include job cre - er, it is important to acknowledge that TVET ation, diversification, and economic inclusion. alone cannot resolve all the existing challeng- The care economy can be a direct employer of es within the care sector. Factors such as the workers, often moving workers from the un- overall quality of care, the cost of services, and paid fringes to paid work that contributes to entrenched social norms play significant roles GDP. Expanding the care sector can, by defi- in influencing the uptake and effectiveness of nition, lead to diversification. In addition, the care services. Moreover, there are several other care economy is crucial for gender equality and structural challenges that require attention, in- socioeconomic development, by increasing cluding the adequacy of care infrastructure, the female labor force participation and mitigate alignment of regulatory framework, the avail- women’s double burden of employment and ability of sustainable funding models, and the care duties. By focusing on workforce devel- need for greater public awareness and accep- opment and TVET education to professionalize tance of professional care roles. Despite these and diversify skills, this strategy also aligns with challenges, this report is specifically limited to societal and economic trends in the country. exploring the potential of TVET. While acknowl- Finally, professionalization with TVET can lead edging the limitations of focusing solely on to “right-skilling,” thereby, reducing the depen- TVET, enhancing vocational training programs dance on high skilled workers for all activities, can significantly contribute to equipping the and promoting fiscal prudence for services pro- care workforce with the necessary skills and vided by the government. competencies. This focus is crucial for address- ing some of the immediate skill gaps and for laying a foundation for more systemic changes in the care economy in the future. The Care Boom 25 1. Introduction: The care economy is important BOX 1 THE TECHNICAL AND VOCATIONAL TRAINING CORPORATION The Technical and Vocational Training Corpora- technical colleges, international technical col- tion (TVTC) is a key government institution in Sau- leges, secondary industrial institutes, and voca- di Arabia dedicated to enhancing the country’s tional training facilities in prisons, all designed to workforce by providing comprehensive TVET. Or- address different needs and sectors within the ganized across various specialized institutes and economy. Through strategic partnerships with the colleges, TVTC offers a range of programs aimed private sector, TVTC aligns its training programs at equipping Saudi nationals with the skills neces- with industry demands, ensuring that its gradu- sary to meet both local and international employ- ates are well-prepared to contribute effectively ment standards. Its extensive network includes to the national economy. TVTC Enrollment and Facility Data (as per Q2 2023): Technical Colleges: TVTC’s Technical Colleges program. Notably, the Trainers Preparation Tech- are geared towards high school graduates or nical College offers an undergraduate Applied those with equivalent qualifications. These col- Engineering program. leges offer diploma programs aligned with the Secondary Industrial, Architecture, and Con- sixth level of the National Qualifications Frame- struction Institutes: Catering to intermediate work and last two and a half years. Some colleges school graduates and first and second-grade also provide applied undergraduate programs at secondary students, these institutes offer a the seventh level to prepare students as techni- three-year diploma in industrial, architectural, cal engineers or trainers within TVTC facilities, and construction disciplines. They also provide with these programs requiring an additional two evening programs that are responsive to the and a half years. business sector’s needs. International Technical Colleges: These gov- Vocational Training Institutes in Prisons’ Fa- ernment-operated technical colleges deliver cilities: In collaboration with the General Direc- high-quality, skill-based training through inter- torate of Prisons, these institutes aim to rehabili- national experts with substantial industry expe- tate inmates by offering specialized training pro- rience. The programs focus on graduating qual- grams during their incarceration. Certifications ified cadres who adhere to international stan- are awarded upon completion without any indica- dards. Training includes a one-year preparatory tion of the prison context, ensuring broader soci- course in English, followed by a two-year diploma etal reintegration opportunities. Strategic Partnerships Institutes: These non-profit institutes are established in partner- ship with the private sector and are designed to serve high school certificate holders or their equivalents. The programs, which include pre-job The Care Boom 26 1. Introduction: The care economy is important training, are influenced by private-sector partners • Secondary Industrial Institutes: 17,217 enrolled who help steer the training directions. Notable across 65 facilities. partnerships include those with the Saudi Elec- • Prisons Vocational Institutes: 9,999 enrolled tricity Company and Saudi Aramco. across 33 facilities. • Technical Colleges: 246,883 enrolled across • Strategic Partnership Institutes: 12,998 enrolled 140 facilities. across 48 facilities. • International Technical Colleges: 6,794 enrolled • Private Sector Training Facilities: 53,810 en- across 8 facilities. rolled across 1,285 facilities. Source: TVTC institutional website. Available at: https://tvtc.gov.sa/en/Pag- es/TVTC.aspx and https://tvtc.gov.sa/en/statistics/pages/default.aspx TVTC offers training for jobs in the healthcare the care economy. Its placement as an institution sector that require technical skills. This includes within the government, added to the infrastruc- training in medical-device technology and medi- ture and reach, makes it a pivotal player in shaping cal supplies and in occupational health and safe- and coordinating around a skills strategy to devel- ty (see Figure 5). The TVTC also offers training in op the care workforce in Saudi Arabia. non-care-related occupations that are relevant to Figure 5 TVTC training offer related to the care economy Courses offered Courses offered TVTC by TVTC by private sector network Applied Biomedical Occupational health Equipment Engineering and safety specialist Biomedical Equipment Food and environment technology Technology specializing in occupational safety and health Chemical Laboratories Engineering Tourism and Hospitality Occupational Safety and Health Technology Hospital management Food Production and health services Technology Health insurance Food Processing Technology Electronic technology specializes Food Safety in medical device technology Technology Environment Protection Technology Beauty and Skincare Technology Hair Care Technology Hospitality Skincare Skills The Care Boom 27 2. The demand for care: it’s growing rapidly TVTC Archive The Care Boom 28 2. The demand for care: it’s growing rapidly 2 THE DEMAND FOR CARE: IT’S GROWING RAPIDLY The demand for care services is expected to grow sharply because the population of older persons and disabled people in Saudi Arabia is expected to increase, together with an increase in female labor force participation. This chapter shows that population dynamics meet the needs of their parents. Consequently, in Saudi Arabia has profound implications for the share of the overall dependent population the demand for care. Saudi Arabia is experi- is expected to outpace the growth of the work- encing a significant demographic shift. In the ing-age population. Importantly, these projec- past 10 years, the population of children has tions do not account for the expected increase steadily increased, and projections indicate that in the population of older persons with disabil- the population of children will remain stable. ities. All these together imply that the demand The King Khalid Foundation estimates a cur- for care services is poised to soar, presenting rent population of 8.2 million of care receivers substantial challenges for childcare, healthcare, in the Kingdom.27 The population of older per- and social-support systems. sons is projected to increase sharply ( Figure 6). The population of 65+ year olds was barely 828,000 in 2020 is projected to increase more than ten-fold to over 9.6 million in the next three decades. This increase in the population of old- er persons is leading to the next generation be- ing termed the “sandwich generation” because prime aged people (mainly women) will have to take care of their children while also having to 27 Their numbers include 1.3 million older persons, 6.2 million children and 700 thousand people with disabilities (not double counting children and older persons). The estimates do not include people with chronic diseases, which could significantly increase this pool. (King Khalid Foundation, 2023). The Care Boom 29 2. The demand for care: it’s growing rapidly Figure 6 Population under 14 and over 65 years old, historical and projected, Saudi Arabia 20,000,000 18,000,000 16,000,000 Historical Projected population numbers 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 2010 2015 2020 2035 2050 0-4 5-9 10-14 65-69 70-74 75-79 80 or more Source: authors’ calculations using data from the Population Estimates and Projections database, World Bank. RECENT GROWTH IN THE old, is distinctively different from the care re- POPULATION OF CHILDREN quired for children alder then 6 years. Children between the ages of 0 and 6 years primarily re- HAS ADDED PRESSURE TO quire daycare solutions and physical, cognitive, SAUDI ARABIA’S CARE SECTOR linguistic, and socio-emotional development activities. 28 The increase in that demograph- The population of children in Saudi Arabia ic necessitates an increase in accessible and has grown steeply in the last decade. Ac- affordable childcare centers and the recruit- cording to the General Authority for Statistics ment and training of qualified caregivers.29 Ad- in Saudi Arabia’s (GASTAT) data, the popula- ditionally, the education sector needs to pre - tion aged 0–14 increased from about 7 million pare to accommodate more students by ensur- in 2010 to 8.5 million in 2020 (Figure 7 ). Break- ing sufficient school infrastructure, resources, ing it down, the population of children aged and qualified teachers. The healthcare system 0–4 grew 20.9 percent; 5–9, 22.9 percent; and also must adapt to the need for more pediatric 10–14, 22.4 percent. healthcare services and specialized care for This rapid growth in the population of children children with medical needs. has various implications for the care econo- my. First, the nature of care required for chil- dren, particularly those between 0 and 6 years 28 Devercelli, and Beaton-Day, 2020. 29 UNESCO, 2012; and Shaeffer, 2016. The Care Boom 30 2. The demand for care: it’s growing rapidly Figure 7 Population in Saudi Arabia by age group, children aged 0–14, 2010–20 9,000,000 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 0-4 5-9 10-14 Source: authors’ calculations using data from GASTAT. Saudi Arabia’s child population is expected to Figure 8 Projected population in Saudi Arabia decrease slightly, ensuring that the recent surge by age group, children aged 0–14, 2020–50 in demand for care services will continue. In line 10,000,000 with global trends, fertility rates in Saudi Arabia are 9,000,000 expected to decrease. However, the decline is not expected to significantly reduce the number of chil- 8,000,000 dren. Projections indicate the population of children 7,000,000 aged 0–4 will decrease by 8.7 percent by 2050; 6,000,000 5–9, 8.2 percent; and 10–14, 2.5 percent. The over- all population of children is anticipated to slightly 5,000,000 decrease until 2035, then stabilize (Figure 8). But 4,000,000 this modest decline will not offset the 20 percent increase over the past decade. Consequently, the 3,000,000 demand for care services that emerged in the pre- 2,000,000 vious decade is likely to persist. 1,000,000 0 2020 2035 2050 0-4 0-9 10-14 Source: authors’ calculations using data from OECD.Stat. The Care Boom 31 2. The demand for care: it’s growing rapidly THE POPULATION OF OLDER older persons grew from 915,000 in 2010 to PERSONS IS INCREASING over 1.12 million people 10 years later, a 22.5 percent increase. During 2010–2020, the popu- The population of people over the age of lation aged 65–69 grew by 23.9 percent, 70-74 65, who sometimes need assistance, grew grew by 21.7 percent, 75-79 grew by 23.8 per- steadily in Saudi Arabia.30 The population of cent, and 80+ grew by 27.7 percent (Figure 9). Figure 9 Population aged 65+ in Saudi Arabia, by age group, 2010–20 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 65-69 70-74 75-79 80 or more Source: authors’ calculations using data from GASTAT. According to World Bank projections, 31 Figure 10 Projected population aged 65+ in Saudi Arabia’s population of older per- Saudi Arabia, by age group, 2020–50 sons is expected to grow significantly be- 10,000,000 tween 2020 and 2050 (Figure 10). The pop- 9,000,000 ulation aged 65 and older is projected to in - 8,000,000 crease dramatically – a 1,069 percent between 7,000,000 2020 and 2050. The most significant expan- 6,000,000 sions are forecasted for the 70-74 age group, 5,000,000 with a 1,550 percent cumulative increase, and 4,000,000 the 80+ age group, with a 1,070 percent rise. 3,000,000 These figures highlight a substantial shift to - 2,000,000 wards an older demographic over the next 1,000,000 three decades. 0 2020 2035 2050 65-69 70-74 75-79 80 or more Source: authors’ calculations using data from the Population Estimates and Projections Database, World Bank. 30 See further in this section more detailed discussions on which population sub-groups are expected to need more assistance, according to the Healthy Life Expectancy model, disability prevalence and noncommunicable diseases prevalence. 31 Data set: Population Estimates and Projections, World Bank Data, 2022. The Care Boom 32 2. The demand for care: it’s growing rapidly Population aging is a global trend. Projections African countries, traditionally characterized suggest that the population of older persons will by their youthful populations, the number of increase across all regions. However, the most older individuals is expected to rise sharply. Re- significant increase in the size of the population gions with a substantial existing population of of older persons is anticipated in the MENA re- older persons are also projected to experience gion—resulting in a tripling of the population continued growth in this age group. of older people by 2050 ( Figure 11). Even in Figure 11 Population composition by region, current and projected Population 65 and above by World Bank region, absolute numbers 700,000,000 300% 269.4% 600,000,000 250% 500,000,000 201.1% 190.2% 200% 170.8% 400,000,000 147.7% 150% 300,000,000 109.6% 100% 200,000,000 62.5% 52.5% 50% 100,000,000 0 0% Africa Western Africa Eastern Middle East North America Latin America Europe & South Asia East Asia and Central and Southern & North Africa &Caribbean Central Asia & Pacific 2020 2035 2050 Growth 2020-2050 Source: authors’ calculations using data from the Population Estimates and Projections database, World Bank. 60-year-old Saudi Arabians can expect about the European average of 17.1 years, below the 14 years of healthy life – significantly less than global average of 15.8 years, and even lower Europeans. Healthy Life Expectancy (HALE) at than the regional average for MENA countries, age 60 is the expected number of additional of 14.93 years.32 This also means that, accord- years a person who has reached 60 years old is ing to the projections shown above, by 2050 anticipated to live in good health. For Saudi Ara- about 4 million people in Saudi are going to bia, a HALE score of 14 means that the average be over the threshold of a healthy life expec- 60-year-old is projected to enjoy 14 more years tancy, compared to the current population of of healthy life. This figure is significantly below 300,000 people. 32 Simple average for MENA (World Bank) countries. Data retrieved from World Health Organization: https://apps.who.int/gho/data/ view.main.HALEXv The Care Boom 33 2. The demand for care: it’s growing rapidly This demographic shift has far-reaching con- persons to acquire some type of disability high- sequences for costs and healthcare, long- lights the necessity of personalized care ser- term care (LTC), home-based care, and palli- vices provided by trained caregivers to ensure ative-care services (see, for instance, Box 2). the well-being and quality of life of older individ- Factoring in the greater tendency of the older uals and those with disabilities. BOX 2 PROJECTED IMPACT OF AGING POPULATION ON NONCOMMUNICABLE DISEASE BURDEN AND COSTS IN SAUDI ARABIA, 2020–30. Noncommunicable diseases (NCDs) are medical heart disease, stroke, diabetes, and cancer con- conditions or diseases not caused by infectious tributing significantly. In 2011, key NCDs constitut- agents. They last for long periods and progress ed 72.8 percent of the kingdom’s health expendi- slowly. NCDs include cardiovascular diseases, ture, equivalent to 2.7 percent of GDP. cancer, diabetes, and chronic respiratory diseas- Life expectancy in the kingdom rose from 70.5 years es. They usually create a need for long-term care in  2000  to  74.3  years in  2019, with the num - because of their chronic nature and the potential ber of individuals aged over  65  per  100  peo - for complications and disabilities. ple aged 20–64 expected to nearly double be - Boettiger et al. (2023) examine the esca- tween 2020 and 2030. Boettiger et al. (2023) lating burden of NCDs in Saudi Arabia be- project a consequent substantial rise in NCD preva- tween 2020 and 2030, emphasizing their impact lence, estimating the total cost of managing priority on the national health budget. NCDs accounted NCDs to increase from USD 19.8 billion in 2020 to for 67.4 percent of all disability-adjusted life-years USD 32.4 billion in 2030 (Figure 12). lost in 2019, with conditions such as ischemic The Care Boom 34 2. The demand for care: it’s growing rapidly Figure 12 Annual healthcare costs for priority noncommunicable diseases among people aged ≥ 15 years, 2020–30 35 32.4 31.0 30 29.6 28.2 26.8 25.5 24.3 Annual healthcare costs, USD Billions 25 23.2 22.1 20.9 19.8 20 15 10 5 0 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Osteoarthritis Diabetes Dementia COPD Depression CKD Stroke IHD Colorectal Cancer Breast Cancer Note: Values at top of columns represent the annual sum for all priority noncommunicable diseases. IHD = isch- emic heart disease; CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease. The findings underscore the critical challenge posed by the growing burden of NCDs in Saudi Arabia, necessitating a substantial increase in healthcare expenditure. Source: Boettiger DC, Lin TK, Almansour M, Hamza MM, Alsukait R, Herbst CH, Altheyab N, Af- ghani A, Kattan F. Projected impact of population aging on non-communicable disease burden and costs in the Kingdom of Saudi Arabia, 2020–2030. BMC Health Serv Res. 2023 Dec 8;23(1):1381. doi: 10.1186/s12913–023–10309-w. PMID: 38066590; PMCID: PMC10709902. The Care Boom 35 2. The demand for care: it’s growing rapidly THE POPULATION OF Figure 13 Prevalence of disabilities among Saudis facing some level of difficulty, by age group PEOPLE WITH DISABILITIES IS EXPECTED TO GROW AS 80+ 76.16% 75-79 59.68% THE POPULATION AGES 70-74 65-69 39.47% 47.98% 60-64 28.73% In Saudi Arabia, population aging will likely 55-59 18.73% increase the number of people with disabili- 50-54 13.55% 7.87% ties. As of 2017, around 7 percent of the total 45-49 40-44 6.33% Saudi population had at least one disability: 35-39 4.81% difficulty seeing, hearing, moving, communi- 30-34 3.98% 25-29 3.18% cating, remembering, or concentrating. 33 Lat- 20-24 3.04% est estimates show an amount of circa 700 15-19 3.04% thousand people only between the ages 15- 10-14 3.15% 5-9 2.22% 59. 34 Notably, disability prevalence grows as 0-4 1.22% the country’s population ages (see Figure 13). 0% 20% 40% 60% 80% The prevalence is almost 60 percent for those Note: Difficulty means people with disabilities present mild, between 75 and 79 years old and over 76 per- severe, or extreme difficulty in seeing, hearing, moving, cent for those 80+ years old. This reinforces communicating, or remembering and concentrating. the need for care for the older persons. These Source: Saudi Arabia Disability Survey 2017. difficulties can, most times, be alleviated by care professionals. Although disabilities can occur at any age, older individuals are more likely to have health conditions and impairments. 35 Aging often brings about heightened healthcare needs and limitations that necessitate additional care and assistance. This leads to increased healthcare use and need for personal support services. Aging also makes individuals more prone to de- veloping disabilities that require intensive and specialized care. Thus, the provision of ade - quate healthcare and long-term care services and personalized support is crucial to ensure the well-being and quality of life of older indi- viduals and those with disabilities. Given older people’s greater tendency to have some form of disability and given demographic trends, the demand for care will certainly be higher than 33 Of the total Saudi population in 2017, 4.1 percent were estimated to have at least one mild difficulty, while 2.9 percent had at least one severe or extreme difficulty. Total percentages sum more than 7.1 due overlapping disabilities at different degrees. People with severe or extreme difficulties are more likely to require assistance, although people with mild difficulties might also require, depending on nature of disability and task-specific needs. For more information on the International Classification of Functioning, Disability and Health (ICF), see World Health Organization, 2013. 34 King Khalid Foundation, 2023. 35 WHO, 2017. The Care Boom 36 2. The demand for care: it’s growing rapidly the dependency ratio suggests. For example, Figure 15. Change in prevalence of health the prevalence of health conditions associated conditions associated with moderate and severe with moderate and severe levels of disability levels of disability, globally, 2010 and 2021 has increased worldwide in the past decade, Musculoskeletal conditions which can be at least partially attributable to a Mental health conditions globally aging population (Figure 15 ). Neurological conditions Sense organ conditions Figure 14 Prevalence of disability, by World Cardiovascular diseases Health Organization region, 2021 Respiratory infections Injuries 25% Other non-communicable diseases Chronic respiratory diseases Maternal and neonatal conditions 20% 20% 19.4% Skin and subcutaneous diseases Substance use disorders Diabetes and kidney diseases 15.3% 15.6% Neglected tropical diseases and… 15% 14.7% Neoplasms 12.8% Digestive diseases HIV/AIDS and sexually transmitted… 10% Nutritional deficiencies Other infectious diseases Enteric infections 0 100 200 300 400 5% 2010* 2021 (In millions) (In millions) Source: WHO 2022b, based on 2021 Global 0% Burden of Disease data. Africa Eastern Mediterranean Western Pacific South-East Asia Americas Europe The demand for care services will be affected by the growing population of people with dis- abilities. In 2021, an estimated 1.3 billion indi- viduals, or 16 percent of the global population, Source: WHO 2022b, based on 2021 Global Burden of Disease data. had one or multiple types of disabilities.36 Dis- abilities affect a significant share of the popu- lation everywhere, reaching up to 20 percent in Europe (see Figure 14). Importantly, disabili- ties affect individuals of all age groups, including working-age individuals. While most people with disabilities lead independent lives, some require assistance with everyday activities such as read- ing, listening, moving, feeding, and bathing. 36 WHO, 2022b. The Care Boom 37 2. The demand for care: it’s growing rapidly THE SHIFTING POPULATION older, which represented 2.4 percent of the Saudi population in 2020, could grow to 12.8 percent COMPOSITION IS INCREASING by 2040 and 20 percent by 2050. Meanwhile, the THE DEMAND FOR CARE population of children is expected to decrease from 26 to 18 percent from 2020 to 2050. Most The share of dependents is projected to in- concerning, the working-age population is pro- crease in Saudi Arabia. The shifting population jected to decrease from 71.6 to 61.1 percent. numbers by age group will change the subpop- That means the population in need of support (0– ulations’ proportions of the overall population 14 and 65+) will increase from 28.4 to 38.9 per- (Figure 16). According to World Bank projec- cent, which has major consequences for care. tions, the population of people aged 65 years and Figure 16 Population composition in Saudi Arabia, current and projected 100% 2.2 2.4 5.7 12.8 90% 20.7 80% 70% 68.4 60% 71.6 71.7 67.8 50% 61.1 40% 30% 20% 29.5 26.0 22.6 10% 19.3 18.1 0% 2010 2020 2030 2040 2050 0-14 15-64 65 and above Note: Population numbers until 2020 are adjusted using country census data. Projections start from 2020 onwards. Source: authors’ calculations using data from Population Estimates and Projections database, World Bank. As a result of the changes in the population active, and who is in need for care, it allows us composition, the dependency ratio will grow to imply the burden of younger and older pop- significantly. The age dependency ratio is the ulations on the working-age population. A high- ratio of the population younger than 15 or older er age dependency ratio indicates two things: than 64 to the working-age population (ages 15– more people need care relative to the population 64).37 Although the indicator bears limitations able to provide it; and social-welfare and health- regarding measurements of who is economically care systems face higher pressure, as they must 37 Data are presented as the proportion of dependents per 100 working-age population. Source: World Bank Metadata Glossary. The Care Boom 38 2. The demand for care: it’s growing rapidly cope with increasing demand for support and Figure 18 Age dependency ratios (% of working-age services while fewer people contribute, both fi- population) in Arab states—current and projected nancially and with work, to the system. 100 Saudi Arabia has one of the steepest projected 90 growth rates in the dependency ratio among 80 Arab states. Saudi Arabia’s dependency ratio 70 in 2020 was about 40 percent, below the aver- 60 age in all world regions, but is projected to rise 50 to over 63 percent by 2050. This corresponds 40 to growth of 59.9 percent (or 23.8 p.p.) (Figure 30 17 ). Compared to the rest of the region, Sau- 20 di Arabia’s dependency ratio is growing at the 10 fourth-highest rate, behind only Kuwait (185 per- 0 cent), Qatar (87.7 percent), and the United Arab United Arab Emirates Qatar Oman Syrian Arab Republic Bahrain Yemen, Rep. Jordan Egypt, Arab Rep. Iraq Libya Morocco Algeria Tunisia Saudi Arabia Lebanon Kuwait Emirates (78.2 percent) (Figure 18). However, those three countries have much smaller popula- tions, and therefore their population composition is more sensitive to changes in population size.38 2020 2035 2050 Figure 17 Age dependency ratios (% of working-age Source: authors’ calculations using data from Population population) in Saudi Arabia—current and projected Estimates and Projections database, World Bank. 70 60 Today’s relatively low dependency ratio in Saudi Arabia is driven by the large popula- 50 tion of foreign workers, who are of working age. According to the latest Saudi census, the 40 overall dependency ratio is 37.3 percent, with 30 the children dependency ratio at 33.7 and the older persons ratio at 3.7. These numbers are 20 low compared to other regions and countries ( Figure 17 and Figure 18), mostly because of 10 the large foreign population concentrated in 0 the 24-55 age group, with very few children (see Figure 19). 2020 2035 2050 Age dependency ratio, Age dependency ratio, old (65+) young (0-14) Source: authors’ calculations using data from Population Estimates and Projections database, World Bank. 38 The age composition of a country is the distribution of its population across different age groups. Countries with smaller populations are particularly prone to changes in this composition. For example, even a relatively small influx of migrants, which might be insignific ant for a large country, can have a significant impact on smaller countries by introducing a substantial proportion of new individuals. This alters the age composition, potentially leading to shifts in the demographic structure and socioeconomic dynamics. The Care Boom 39 2. The demand for care: it’s growing rapidly Among Saudis, however, the total dependency Figure 20 Percentage of households ratio is 62 percent, the old-age ratio 5.69 per- with dependents, 2022 cent, and the young-age ratio 56.3 percent. The 38.2% young-age ratio is above the average for most Dependents (any age) 60.7% world regions, including the Middle East and 9.7% North Africa. The shares of dependents in all age One dependent child 14.9% groups are higher for Saudi households when 11.6% compared to countrywide numbers (Figure 20). Two dependent children 17.7% Three or more dependent children 16.9% Figure 19 Population in Saudi Arabia 28.1% by age and nationality, 2022 One elderly dependent 7.2% 11.0% 12,000,000 Three or more elderly dependents 0.1% 2.4% 10,000,000 Two elderly depentents 1.5% 0.1% 8,000,000 0% 20% 40% 60% Saudi households Total 6,000,000 Source: authors’ calculations using data from Saudi Census, 2022. 4,000,000 2,000,000 0 0-14 15-19 20-24 25-54 55-64 65-69 70-74 75+ years years years years years years years years Saudi Non Saudi Source: authors’ calculations using data from Saudi Census, 2022. The Care Boom 40 3. The care provision landscape: too many untrained and unpaid workers and too few professionals TVTC Archive The Care Boom 41 3. The care provision landscape: too many untrained and unpaid workers and too few professionals 3 THE CARE PROVISION LANDSCAPE: TOO MANY UNTRAINED AND UNPAID WORKERS AND TOO FEW PROFESSIONALS Too often, Saudi Arabia’s care provision landscape depends on untrained (with some semi-trained individuals) or unpaid care service providers to alleviate shortages in professional care workers. This observed service provision model, however, limits labor market participation and human capital investments. This chapter presents the care provision land- • The burden of unpaid care predominantly falls scape observed in Saudi Arabia ( Figure 21). on women, who may be forced to make difficult As discussed earlier, a significant share of care choices such as leaving the workforce or endur- providers in Saudi Arabia is unpaid – mainly con- ing the double burden of work and caregiving stituting family and friends. Paid caregivers, on responsibilities. the other hand, are usually trained profession- • The quantity of trained providers in the Saudi als, such as those found in the healthcare, so- Arabia is often lower than the quantity of trained cial service, or education fields; and untrained providers in other high-income countries. workers such as domestic workers. • Saudi households continue to depend exten- This chapter addresses three key problems sively on domestic workers for caregiving, yet associated with a care provision landscape the quality of services offered by untrained indi- that depends heavily on unpaid care provision: viduals may fall short of the standards achieved by trained professionals. The Care Boom 42 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 21 Visual of classification of care providers P MAIN CARE PROVIDERS Unpaid Paid • Parents Trained Untrained • Other family • Healthcare • Domestic members • Social services workers • Support network • Education Source: authors’ categorization. UNPAID CARE WORK: high-quality childcare. 41 These findings suggest WOMEN DO MUCH OF THE that the global pattern of women conducting most informal care and household duties holds CARE WORK WITHOUT PAY true for Saudi Arabia. 42 Societal expectations In Saudi Arabia, unpaid care provision is siz- and traditional gender roles contribute to this able, and women are the main service pro- pattern, in which women are expected to prior- viders. Around 98 percent of women outside itize caregiving and household responsibilities of the labor market self-identified as engag- over paid employment. 43 ing in domestic activities in 2018. 39 Similarly, Globally, and especially in Arab states, women a 2022 report issued by United Nations Eco - spend disproportionately more time on un- nomic and Social Commission for Western Asia paid care work and domestic work than men. identified household and childcare responsibil- For all countries for which data is available, the ities as the main reason why women stay out proportion of time spent by women in unpaid of or exit the labor force. 40 In a survey conduct- domestic and care work exceeds time spent by ed by Harvard University in 2018, researchers men (Figure 22). The reason why women spend found that the reasons for not searching for a more time on care work include societal norms job among non-working mothers with children and expectations according to which women younger than 18, were: 45 percent wanted to have the primary responsibility for care and focus on their children, 37 percent noted their other domestic tasks. As a result, the burden family or husband was opposed to them work- of unpaid care and domestic work conducted in ing, and 20 percent noted a lack of affordable or the household setting falls disproportionately 39 Household income and expenditure survey. 40 UNESCWA, 2022. 41 Cortes, 2019. 42 This is also discussed in and supported by Alrashed, 2017. 43 Lewis, 2006; and Maume, 2006. The Care Boom 43 3. The care provision landscape: too many untrained and unpaid workers and too few professionals on women. This includes cooking, cleaning, to that shouldered by men is steep. Globally, childcare, older persons care, and caring for women spend 3.2 times more time than men the sick. 44 According to findings from a multi- on unpaid care work. 45 In Arab states, the ratio country comparison conducted by the UN, the is fully 4.7. 46 In Jordan, the ratio is 19; Egypt, 12; ratio of unpaid care work shouldered by women Palestine, 7; and Tunisia, 6. 47 Figure 22 Proportion of time spent on unpaid domestic and care work, female (% of 24-hour day)—latest available year 30 MEX 25 PER ARG Proportion of time spent on unpaid domestic and care work, EGY CRI CHL DZA ALB MAR SLV ITA CUB 20 PSE ECU ETH URY MDA TUR KAZ MNG ESPSRB BLR ROU GTM RUS BGRPOL GRC female (% of 24 hour day) PAN NZL PRT HUN KGZ EST DOM TZA CHE FRA DEU CMR BEL SWE JPN MKD ZAF NLD CHN USA FIN NOR 15 FJI BTN PRY UGA CAN KOR LUX LAO GBR THA BRA HKG 10 QAT LBR 5 COL 0 0 5 10 15 20 25 30 Proportion of time spent on unpaid domestic and care work, male (% of 24 hour day) Note: Data are from 66 countries from 2010 to 2019. Each dot represents a country, with the y-axis representing time spent by women on unpaid domestic and care work and the x-axis the same number for men. Dots above the reference line mean women spend more time than men on those activities. The further left and higher up a dot, the bigger the discrepancy between men and women, with women bearing more of the burden of care and domestic work. Source: authors’ calculations using data from national statistical offices or national databases and publications compiled by United Nations Statistics Division. 44 UN Women, 2020. 45 ILO, 2018. 46 ILO, 2018; and UN Women, 2020. 47 ILO, 2018; and UN Women, 2020. The Care Boom 44 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Women face numerous problems due to the people.52 The lack of necessary tools and skills excess burden of care duties. First, it affects increases the burden on family members caring their physical and mental health. 48 The respon- for those with chronic illness.53 Similar findings sibility for taking care of children and older par- have been found in Saudi Arabia.54 Likewise, in- ents and managing household chores can be formal caretakers, such as relatives, who take significant, leading to exhaustion and chron- on caregiving roles within the household often ic stress. This can result in psychological dis- have multiple responsibilities and limited time tress, psychiatric illnesses (including depres- and resources, which can also affect the quality sion), worse health habits, adverse physiologic of care they provide. Trained care providers, in responses, and physical illness. 49 Second, the contrast, have the knowledge and skills to pro- excess burden often limits women’s opportuni- vide high-quality care based on evidence-based ties for education, employment, self-care, and practices, and they have the dedicated time and personal growth—often referred to as time pov- resources to focus solely on providing quali- erty.50 Women may have to sacrifice their career ty care. Additionally, they may have access to aspirations or put them on hold to fulfill their specialized equipment, facilities, and support caregiving responsibilities. This can lead to fi- systems that can enhance the quality of care. nancial dependence and a lack of economic em- Female labor force participation in Saudi Ara- powerment. Additionally, the unequal distribu- bia has increased sharply in recent years. It in- tion of care work reinforces gender stereotypes creased from 20.1 percent in 2017 to 34.5 per- and perpetuates gender inequality. 51 Women cent in 2022 among people aged 15 years or are often expected to bear the primary respon- more (Figure 23). Among Saudi women, as op- sibility for caregiving, which hinders their ability posed to among Saudi and non-Saudi wom - to participate fully in other areas of life. en, the increase was even more pronounced: For more vulnerable care recipients, it may from 19.4 percent in Q4 2017 to 36 percent be that specific technical skills, which un- in Q4 2022 55 and reaching almost double the paid and untrained providers may not have, regional average of 19 percent for the Mid - are needed. Several factors explain this. First, dle East and North Africa. 56 Although the in- family members, among other informal care - crease can be observed in all age groups, it is takers, may lack formal training or education pronounced among people of prime age (25– in caregiving techniques and practices, which 54 years). According to the most recent la - can result in suboptimal care, especially for the bor force survey (LFS)57 data on Saudi women, older persons, people with disabilities, and sick the age brackets with the highest labor force 48 Bratberg et al., 2002; Väänänen et al., 2005 ; and Angelov, 2013. 49 These effects are widely documented. See, for example, summaries by Schneiderman et al. 2005; Goldberg and Rickler, 2011 and Schulz and Eden, 2016. 50 Hyde et al. 2020. 51 UN Women, 2018 and 2020; ILO, 2018; UNESCWA, 2022. 52 See, for example, Grobre et al., 1981; Given et al., 2008; Burgdorf et al., 2019. 53 Goldberg and Rickler, 2011. 54 Alshammari, et al., 2017. 55 Gastat LFS data—available at https://www.stats.gov.sa/en/814. 56 World Bank data, labor force participation rate, female (% of female population ages 15+) (modeled ILO estimate)—Middle East & North Africa for 2022. 57 Labour Market Statistics Fourth Quarter 2023, Gastat. The Care Boom 45 3. The care provision landscape: too many untrained and unpaid workers and too few professionals participation are 24–34 and 34–44, at 50.6 per- cent and 29.6 percent. Around the world, includ- ing Saudi Arabia, women in these age brackets are most likely to have children at home.58 Figure 23 Labor force participation rate in Saudi Arabia, female, by age (%) 50 45 40 35 30 25 20 15 10 5 0 2017 2018 2019 2020 2021 2022 2023 Total (15+) 15-24 25-54 55-64 65+ Source: authors’ calculations using GASTAT LFS data. As more women enter the labor market, the caregiving and labor market outcomes for need for alternatives to unpaid care grows. caregivers.60 These outcomes include reduced This trend has two impacts. First, the supply participation in the labor force, less working of unpaid care reduced because women are hours, and lower wages. Other research reveals still the main source of household care. Re - the long-term effects of informal caregiving search finds that increasing weekly working on wages and employment: women caregivers hours leads to a decrease in the likelihood of have a lower likelihood of returning to work or providing informal care, with stronger decreas- increasing their working hours after a period of es for same-household provision and time-in- caregiving. 61 All of these challenges (including tensive care provision. 59 Conversely, studies time poverty, mental and physical distress, and demonstrate a negative relationship between labor market outcomes) tend to be exacerbated 58 Although ages vary by country and year, the trend for the age groups between 25 and 44 years remains true for all OECD countries. Source: “Indicator 1: The structure of families (SF)”. OECD Family Database, oecd.org/els/family/database.htm. For Saudi Arabia, the age brackets with more women having given birth in the past year are 25–39. Source: Saudi Census, https://portal.saudicensus. sa/portal/public/1/19/100737?type=TABLE 59 He and McHenry, 2016. 60 Van Houtven, et al., 2013; and Nguyen and Connelly, 2014. 61 Skira, 2015. The Care Boom 46 3. The care provision landscape: too many untrained and unpaid workers and too few professionals when no alternative care solutions are pres- population poses severe challenges in ensuring ent— for instance, older persons care, child- quality healthcare services for the community. care and healthcare facilities or home-based, Additionally, the scarcity of data with which to or else. Second, demand for care increases as assess social workers exacerbates the problem new entrants to employment demand care ser- and highlights the need for comprehensive in- vices. Precisely because women remain the formation on the social service sector. Trained main source for informal care provision, when care providers play a crucial role in ensuring the they start working the first effect is the need to effectiveness, quality, and consistency of care look for an alternative arrangement, which usu- across all these domains, underscoring the im- ally includes paying for care services.62 portance of investing in, training, and empow- ering a skilled care workforce to address the wide-ranging care demands in the kingdom. PAID CARE WORK: UNTRAINED PROVIDERS CARE WORKERS MAKE UP ALMOST HALF IN CHILDCARE THE CARE WORKFORCE Childcare aims to ensure children’s safety and foster learning and positive interactions. In Saudi Arabia, the limited care workforce Types of care include home-based (nannies or and limited data on the care workforce af- group care in a caregiver’s home), center-based fects the accessibility and quality of crucial (daycares, nurseries, preschools), and informal care services. The country’s over-reliance on arrangements (friends or family). Preschools domestic workers for care services indicates prepare children for elementary school and a substantial need for trained care workers can fulfill the role of providing care, but often across many sectors of the care economy. Ac- only cater to ages 3-6 and may provide limited cording to King Khalid Foundation’s estimates, hours, posing challenges for working parents. 64 there are currently 2 million care economy em- ployees, including 1.2 million in the education sector and 800,000 in health and social work.63 Combined, they represent 14 percent of the labor market, with a nationalization rate of 76 percent. In comparison, there are 3.6 million domestic workers in the country, or, 1.8 times the population of care workers. We investigate the care provision landscape across three important subsectors, name- ly ECCE, healthcare, and social services . Early-childhood care and education, which are fundamental for child development, lack availability and affordability. The limited num- ber of healthcare workers in proportion to the 62 ILO, 2018; and Redaelli et al., 2023. 63 King Khalid Foundation, 2023. 64 Devercelli, and Beaton-Day, 2020. The Care Boom 47 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Good quality childcare is crucial for developing In the absence of comprehensive formal data foundational cognitive, socio-emotional, and on childcare availability, we examine pre-pri- physical skills. Quality childcare can promote mary enrollment rates to shed light on ear- better nutrition, health, and educational out- ly childhood education (ECE). Although ECE comes. It can lead to improved school readiness, comprises only a part of childcare, the numbers higher achievement, and reduced dropout rates. below paint a picture of services for education Long-term benefits include enhanced employ- and care of children in Saudi Arabia.69 Gross ment prospects and potential to break the cycle enrollment rates (GER) show the total number of poverty, making early childcare a significant of students enrolled in a specific level of educa- investment in a child’s future success.65 66 tion, regardless of their age, as a percentage of the official age group for that educational lev- Saudi Arabia faces a shortage of el. A GER of 100 percent or more, shows that a affordable, high-quality childcare. country can potentially supply education for all This shortage hinders women’s its kids who should be in school, in a given edu- labor market participation and cation level.70 Saudi Arabia underperforms rela- exacerbates socioeconomic tive to OECD countries and also under performs disparities by limiting access compared to countries in MENA (Figure 24).71 to early childhood education, particularly for disadvantaged families and those in rural areas. There is shortage of childcare in Saudi Ara- bia. Issues concerning affordability, quality, and geographic accessibility are often raised. 67 So far, the main sources of provision of childcare remain through families and domestic workers. Although there has been progress, evidence still points that childcare remains a main con- tributor to women not joining the labor market – and pre-primary schools often failed to meet the need for accommodating the full working hours of employed mothers and the full need of care for children.68 65 Devercelli, and Beaton-Day, 2020. 66 UNICEF, 2019. Multi-country statistic al analyses by UNICEF indic ate that raising pre-primary enrollment rates from 25 to 75 percent is linked to a 27 percent rise in the proportion of children who achieve minimum mathematics competencies in primary school and a 25 percent rise in the proportion of children who meet the minimum reading competencies. Likewise, in low-income countries, the same increase in pre-primary enrollment rates is linked to an increase of 28 p.p. in completion rates for primary education and a decrease of 18 p.p. in cumulative dropout rates. 67 Rabaah, et al., 2016; Alrashed, 2017; Cortes, 2019; UNESCWA, 2022. 68 UNESCWA, 2022. 69 See Annex III for concepts and definitions within education and care for children. 70 Unesco Institute for Statistics. Glossary. Gross enrolment ratio. 71 27 out of 38. Namely, Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, and United Kingdom. The Care Boom 48 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 24 School enrollment, pre-primary (% gross), by World Bank region 90 80 70 60 50 40 30 20 10 0 Saudi Arabia Africa Eastern Africa Western Middle East East Asia South Asia Latin America North America Europe and and Southern andCentral and NorthAfrica and Pacific and Caribbean Central Asia 2005 2010 2015 2020 Note: The gross enrollment ratio is the ratio of total enrollment, regardless of age, to the population of the age group that corresponds to the level of education shown. Pre-primary education consists of programs at the initial stage of organized instruction, designed primarily to introduce very young children to a school-like environment and to provide a bridge between home and school. Source: authors’ calculations using data from UNESCO Institute for Statistics. Within the education sector, particularly with- countries shows that children from the wealth- in the private sector, Saudi Arabia’s reliance iest households are approximately seven times on foreign labor is pronounced. According to more likely to participate in ECE programs than the Saudi General Organization for Social Insur- those from the poorest households.73 Addition- ance, by the fourth quarter of 2024, 43.7 per- ally, ensuring high-quality standards in accessi- cent of those employed in the education sector ble early-childhood care and education is cru- were non-Saudi nationals.72 cial for health and educational outcomes. Limit- Early-childhood education constraints signifi- ed access to ECCE exacerbates socioeconomic cantly affect children and families, particu- disparities, as children without access to these larly those from disadvantaged backgrounds programs have lower chances of succeeding in and those in rural areas. According to UNICEF primary education and beyond. Parents, par- (2019), children in urban areas are 2.5 times ticularly women, without childcare options are more likely to participate in ECE programs than less likely to participate in the labor market, re- those in rural areas, due to issues of availability ducing families’ economic outcomes and con- and affordability. Childcare services are often tributing to lower labor market participation and non-existent in many regions, and private op- gender equality.74 This perpetuates the cycle of tions are often unaffordable. A sample of 64 72 GOSI data provided by GASTAT. Available at: https://www.stats.gov.sa/en/814 73 UNICEF, 2019. 74 Morrissey, 2017; Halim et al., 2023. The Care Boom 49 3. The care provision landscape: too many untrained and unpaid workers and too few professionals inequality, as children from poorer families are delivering services through both public and pri- less likely to participate in ECE programs, af- vate sectors in community-based, home-based, fecting their future opportunities. 75 or institutional environments. In Saudi Arabia, the ratio of CARE WORKERS IN healthcare professionals to the HEALTH AND SOCIAL WORK population is low compared Healthcare is a critical part of the care econ- to high-income countries. omy and faces significant supply bottlenecks Given the overlap between healthcare and worldwide, a challenge starkly highlighted long-term care, we discuss them jointly in this during the COVID-19 pandemic. In Saudi Ara- report. The care workforce for older persons, bia, there is a notable disparity in the proportion sick individuals, and people with disabilities is of workers employed in health and social work often counted together in internationally com- activities compared to other high-income coun- parable and reported numbers.78 By examining tries (Figure 25). Specifically, Saudi Arabia has healthcare and long-term care together, we aim about half the ratio of workers in -health and so- to provide a comprehensive understanding of cial work activities relative to total employment the care workforce availability. We separate the compared to high-income countries in Europe discussion on social services whenever pos- and the Americas. sible. This approach ensures that our analysis Long-term care is an essential component of reflects the interconnected nature of these es- the broader healthcare system, particularly sential services and highlights the importance for older people and individuals with perma- of integrated care strategies. nent disabilities . Quality long-term care ser- vices integrate healthcare and social services to support older, sick, and frail individuals in their autonomous living. long-term care work- ers, encompassing nurses and personal-care workers, are crucial in providing these services. According to the OECD, over 70 percent of long- term care workers are personal caregivers, with services ranging from 24/7 surveillance and as- sistance to ad hoc and respite care. 76 Approxi- mately half of personal caregivers work in insti- tutions, while the other half provide home-based care. More than half of nurses and personal-care workers are employed in institutional settings,77 75 UNICEF, 2019. 76 Respite care is defined by the UK NHS as care provided by professionals to relieve primary caretakers from their duties for a short period. This allows caretakers, who are normally in unpaid family/household settings, to take a break, conduct their own activities, and take care of themselves. 77 OECD, 2020a. 78 For instance, labor force surveys often report the size of the workforce by economic activity based on the International Standard Industrial Classification of All Economic Activities (ISIC) – which bundles “human health and social work activities” together. Consequently, we often rely on these aggregated numbers due to the lack of more disaggregated reliable data. The Care Boom 50 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 25 Distribution of employment by economic activity, human-health and social work activities (ISIC REV 4)—high-income countries by region, 2021 15% 14.1% 13.6% 12.8% 12.8% 12.1% 12.2% 12.3% 11.8% 10.6% 10% 7.0% 6.6% 5.6% 5% 4.2% 0% Arab States: High income Saudi Arabia Eastern Europe: High income Latin America and the Caribbean: High income Central and Western Asia: High income Europe and Central Asia: High income World: High income Eastern Asia: High income Asia and the Pacific: High income South-Eastern Asia and the Pacific: High income Northern, Southern and Western Europe: High income Americas: High income Source: authors’ calculations using data from ILOSTAT. Northern America: High income Saudi Arabia has a low ratio of healthcare OECD countries. Finally, for pharmacists, the professionals to the overall population. Ac- comparison is a little closer, with 8.6 pharma- cording to the World Health Statistics 2022, cists in Saudi Arabia per 100,000 people and per 10,000 people in the population, there are 9.6 pharmacists in OECD countries (Figure 26). about 27.4 medical doctors in Saudi Arabia, while there are about 39.9 medical doctors in OECD countries. Similarly, per 10,000 people in the population, there are about 58 nursing and midwifery professionals in Saudi Arabia while there are 106 in OECD countries. For dentists, there are about 5.6 dentists in Saudi Arabia per 100,000 people, compared to 7.9 dentists in The Care Boom 51 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 26 Density of health personnel (per 10,000 population), 2012–20, in OECD countries and Saudi Arabia Belgium Norway Switzerland Ireland Iceland Sweden Germany United States of America Australia Lithuania Israel Austria Japan Luxembourg New Zealand France Netherlands OECD Average 7.9 9.6 39.9 106.5 Denmark Canada Slovenia Portugal Hungary Czechia United Kingdom Spain Poland Greece Italy Korea (Republic of) Estonia Slovakia Saudi Arabia 5.6 8.6 27.4 58.2 Latvia Chile Turkey Mexico 0 50 100 150 200 250 300 350 Density of dentists Density of pharmacists Density of medical doctors Density of nursing and midwifery personnel (per 10 000 population) (per 10 000 population) (per 10 000 population) (per 10 000 population) Note: Calculations use latest available data from period 2012–20. Source: authors’ calculations using data from World Health Statistics. The supply of healthcare in high income coun- professionals to migrate from low- and mid - tries is often characterized by high shares of dle-income countries to upper-income coun- foreign labor and a broad spectrum of skill lev- tries. High-income countries very often rely els. Differences in wages incentivize healthcare on migrant workers to supply their healthcare The Care Boom 52 3. The care provision landscape: too many untrained and unpaid workers and too few professionals systems. 79 World Health Organization data diploma nurses are not considered, the com- from 2011 to 2020 show that around 15 per- bined density of Saudi physicians and nurses cent of healthcare and care workers world - falls to 1.4 per 1,000 population, a stark con- wide worked outside of their country of origin. trast to the 3.0 per 1,000 population when they The proportion of foreign-trained physicians are included. 84 This shows the importance of in- reached 36 percent in eight high-density OECD termediate-level educated professionals in the countries, while the proportion for nurses and Saudi healthcare provision. physicians reached 80 percent in Gulf Cooper- Saudi Arabia has an ambitious healthcare re- ation Council countries. 80 Additionally, in OECD form plan, which is likely to increase the need countries, the healthcare workforce boasts a for middle-skilled healthcare professionals more varied composition of professionals, en- when implemented. The country’s new model compassing not just those with bachelor’s de- of care, which is part of Vision 2030, aims to shift grees but also individuals with technical-lev- the focus from medical treatment to primary care el qualifications (see Chapter 5). This diversi- and prevention. Preventive- and primary-health- ty implies a broader spectrum of skills, which care settings require a more multiprofessional in turn expands the pool of available workers. approach, that includes exercise workers, nutri- Consequently, this varied skill set allows for a tion workers, life-quality educators, and commu- more effective division of tasks within health- nity workers. 85 This in turn, makes participation care teams, alleviating the workload on highly of intermediate-skilled workers more important. educated professionals, such as doctors and These workers play a crucial role in preventive nurses, who are often in shorter supply. care and in early detection and management of Like many other high-income countries, Saudi chronic conditions. They serve as the first point Arabia has a large portion of migrant workers of contact for patients, diagnosing and coordinat- in its care workforce. According to the Minis- ing treatment of common illnesses and providing try of Health’s statistical yearbook from 2021, necessary care. Intermediate-skilled workers are around 50  percent of medical doctors essential for community-based healthcare de- and 37 percent of nursing staff were migrant livery, establishing strong patient relationships, workers. 81 This is in line with private employ- and addressing the social determinants of health. ment data, where 49.6 percent of the employed Overall, they are vital in meeting the diverse in health and social work 82 are non-Saudi. 83 A healthcare needs of individuals and communities. significant portion of the nursing workforce is composed of “diploma nurse” technicians, who represent 80 percent of the Saudi nursing staff. They are trained in a technical two-year pro - gram, as opposed to bachelor nurses who un- dergo a four-year training regimen. When these 79 Toyin-Thomas et al., 2023.; and WHO, 2020. 80 WHO, 2022c. 81 Almansour et al., 2023. 82 ISIC Rev 4 classification 83 GOSI data provided by GASTAT. Available at: https://www.stats.gov.sa/en/814 84 Alghaith et al., 2021. 85 Kellermann, 2013; Schor et. Al, 2019; and Fowler et. Al, 2020. The Care Boom 53 3. The care provision landscape: too many untrained and unpaid workers and too few professionals BOX 3 SAUDI ARABIA’S NEW MODEL OF HEALTHCARE Saudi Arabia’s Vision 2030, with its healthcare labor force within the healthcare sector to meet transformation goal, signals a pivot toward a the demand for comprehensive, continuous care more inclusive healthcare system that requires that extends beyond acute medical treatment. a diverse array of intermediate-skilled healthcare With the introduction of 42 interventions aimed at professionals. As part of the National Transfor- enhancing preventive health and optimizing care mation Program, a new model of care has been pathways, there is an inherent increase in the need introduced to revamp the healthcare landscape. for a diversified workforce skilled in these inter- This model of care is designed to be comprehen- mediate roles. Such a workforce will be essential sive and adaptable, focusing on six systems of to operationalize the key enablers of workforce care that span the spectrum of healthcare needs, development, e-health, and increased private sec- from keeping well to end-of-life care (Figure 27). tor participation identified for the transformation’s The model of care envisions a holistic approach, in- success, and to make the healthcare system more tegrating 42 interventions that cover individual and responsive to the needs of the Saudi population. cross-cutting programs, emphasizing preventive health, optimized care pathways, and digital integra- tion. This holistic model of care emphasizes the role of individuals and communities in their health man- agement, underpinned by self-care and empower- ment, facilitated by digital integration. This shift toward primary and preventive care within the National Transformation Program seeks to decentralize focus from traditional reli- ance on doctors and nurses, recognizing the need for a broader spectrum of healthcare workers. As the kingdom moves to tackle existing limitations in healthcare accessibility, quality, and preven- tive measures, the new care model envisions a multi-tiered workforce. This encompasses roles like health coaches and technicians proficient in using virtual education tools and other e-health applications, reflecting a progressive strategy that requires intermediate-level professionals. It calls for a significant expansion in the middle-skilled The Care Boom 54 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 27 The new model of care Prioritized Six Designed to support Across six Systems of Care people with service layers (SOC) Specialized 6 hospital care Last Phase of life Social General Chronic Conditions wellbeing 5 hospital care Primary 4 care Urgent Care Mental Virtual wellbeing 3 care Planned Care Healthy 2 communities Safe Birth Physical Activated wellbeing 1 person Keep Well Source: authors’ adaption from Ministry of Health, 2019. Sources: MOH. Health Sector Transformation Strategy V.3. Saudi Arabia: Ministry of Health. 2019. https://www. moh.gov.sa/en/Ministry/vro/Documents/Healthcare-Transformation-Strategy.pdf, and Chowdhury S, Mok D, Leenen L. Transformation of health care and the new model of care in Saudi Arabia: Kingdom’s Vision 2030. J Med Life. 2021 May-Jun;14(3):347–54. doi: 10.25122/jml-2021–0070. PMID: 34377200; PMCID: PMC8321618. The Care Boom 55 3. The care provision landscape: too many untrained and unpaid workers and too few professionals SOCIAL SERVICES help connect people in need of assistance with Social workers play a crucial role as counsel- the right services and programs. Social workers ors and facilitators in various sectors of the often supervise children’s school attendance, care economy, such as childcare, education, work to prevent parental neglect, and manage healthcare, and long-term care. This diverse adoption processes. Social workers cover the workforce includes professionals from both the programs provided to children and orphans, juve- governmental and nongovernmental sectors. nile welfare, older persons care, combating beg- Their primary focus is on providing preventive, ging, and persons with disabilities—and all these responsive, and promotive services. Social work- programs’ beneficiaries need case-specific as- ers actively engage with individuals, institutions, sessments. Further, myriad social-protection and and community organizations to ensure access care programs in Saudi Arabia depend on, or at to essential services, combat poverty, address least benefit from, the work of social workers.87 discrimination, and prevent or respond to issues The scope of work varies and hence, the works such as violence, abuse, exploitation, neglect, are mapped to various ministries across coun- and family separation. 86 For instance, in public tries (Figure 28). For example, eleven countries employment services, they often act as career report that their social services fall within the counselors and facilitate jobseekers’ access to ministry of social affairs, while in nine countries jobs or to government programs providing train- these fall within the ministry of health, in other ing and unemployment assistance. In the field nine countries these services are mapped to the of healthcare, they might assess disabilities and ministry of law and justice, and so forth. Figure 28 Mapping of social service workforce by type of ministry under which they operate (number of countries, by region and by type of ministry) Social Affairs (and Empowerment, Welfare, Local Development) Health Law and Justice (and Judiciary) Gender (and Family, Women, Children) Home Affairs (and Interior) Labor (and Human Resources, Employment) Education Social Protection (and Social Development) Youth and Sports Religious Affairs 0 2 4 6 8 10 12 SA EAP MENA ECA Note: Countries included in this graph, per region, are as follows. East Asia and Pacific (EAP): Cambodia, Fiji, Indonesia, Kiribati, Mongolia, Philippines, Solomon Islands, Thailand, Timor, Vanuatu. Europe and central Asia (ECA): Albania, Georgia, Kazakhstan, Romania. Middle East and North Africa (MENA): Djibouti, Jordan, Lebanon, Morocco, Palestine, Tunisia. South Asia (SAR): Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan. Source: Global Social Service Workforce Alliance, 2018. 86 Global Social Service Workforce Alliance, 2018. 87 See Gov.sa—Social Welfare System. The Care Boom 56 3. The care provision landscape: too many untrained and unpaid workers and too few professionals A lack of well-defined roles and responsibilities progress, the absence of such comprehensive of social workers is a challenge in many coun- data throughout the region still poses notable tries. Increasing attention has been drawn to the challenges.92 It restricts the ability from govern- widespread absence of a well-defined normative ments and international organizations to assess framework regarding social workers’ roles and essential needs and develop comprehensive, in- responsibilities and the lack of enforcement of formed policies to enhance these services. these norms in many countries. 88 This is con- nected to a vacuum of standards and criteria governing practice, training curricula and con- UNTRAINED CARE tent, and job descriptions, among other things. 89 PROVIDERS: DOMESTIC The absence of standardized definitions pos- WORKERS ARE THE es a problem for collecting, harmonizing, and analyzing data. Mapping the social workforce DOMINANT SOURCE (i.e. who conducts social services in the country, OF PAID CARE where, under which supervision, circumstances Saudi Arabia, along with other Gulf Cooper- and with what capacity) is one of the first chal- ation Council countries, has a large share of lenges raised by the Global Social Service Work- domestic workers among the care workforce force Alliance in its 2018 report.90 Understanding (Figure 29). The fraction of trained profession- the size and composition of this workforce is key als in Saudi Arabia’s paid care workforce, which to assessing social workers’ geographical cover- excludes domestic workers, is 57 percent. This age, areas of practice (for example, health, educa- share of professionals is below most high-in- tion, youth, migration, labor), and density (number come countries for which we have data—includ- of social workers per citizen). It is important to ing Saudi Arabia’s high-income peers. 93 Saudi understand whether the number of social work- Arabia also has a relatively small share of the ers per target population (for example, children) is care workforce in healthcare and social work high enough, as it reflects on workers’ caseloads (9.5 percent), less than half of Cyprus (22 per- and ability to perform their jobs.91 cent), which is the lowest among OECD coun- Countries across the Middle East and North tries. Additionally, Saudi Arabia has a small Africa, including Saudi Arabia, lack centralized share of noncare workers 94 in care sectors, databases for social workers. While countries which can indicate a deficit of workers in care such as Lebanon, Tunisia, Morocco, and Jordan, sectors or a weak care economy overall. have taken steps in this direction and made some 88 For example, according to the GSSWA (2018), “In South Asia (SA), there were 127 distinct titles documented across eight countries. In East Asia and the Pacific (EAP), 39 unique titles were identified among five countries. Within the Middle East and North Africa (MENA), 58 distinct titles were found among four countries, while in Europe and Central Asia (ECA), 17 titles were recorded across four countries.” 89 UNICEF and GSSWA, 2019. 90 GSSWA, 2018. 91 GSSWA, 2018. 92 UNICEF and GSSWA, 2019. 93 Data is available for 99 countries, of which only seven have higher shares of domestic workers in their workforce. Namely, Ethiopia, Qatar, UAE, Kuwait, Zambia, Rwanda, and Madagascar. 94 According to the ILO report on care work and care jobs (2018) “Non-care workers working in health and social work and in education sectors contribute to the delivery of care services in care sectors: they are administrative officers, cooks or cleaners, for example, whose occupations are not in care but whose work is integral to the provision of care services, and are therefore part of the care economy […]”. The Care Boom 57 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 29 Care-workforce composition by country 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Qatar Kuwait Saudi Arabia Uruguay Cyprus Spain Portugal Greece Luxembourg Romania France Switzerland Canada Germany United States Korea Finland Ireland Poland Austria Malta United Kingdom Hungary Croatia Latvia Australia Belgium Netherlands Sweden Iceland Czechia Norway Denmark Lithuania Slovenia Estonia Slovakia Russia Japan UAE Italy Domestic Careworkers Careworkers in health Careworkers in Non-careworkers workers in education and social work non-care sectors in care sectors Note: We use as a proxy for trained care workers the sum of care workers in education, care workers in health and social work, care workers in noncare sectors, and noncare workers in care sectors as percentages of the total employed population. We exclude domestic workers. Source: authors’ calculations using data from ILO, 2018. Saudi Arabia depends heavily on domestic workers in other sectors (Figure 31). Of the total workers for care service. The overall number workforce in the country (from 2012 to 2016), of domestic workers95 in Q4 2022 was 3.6 mil- around 12.5 percent were domestic workers, lion, over 11 percent of the overall population against 16.9 percent of trained97 care workforce. of 32.1 million (Figure 30).96 Among the work- This means that 43 percent of its care work- ing-age population in the country (15–64 force is comprised by domestic workers. Trained years)—23.4 million in 2020—this share rises workers in the care economy make up the re- to 15.3 percent. The ILO estimates that around maining 57 percent of the care workforce, below 29.4 percent of all employees in Saudi Arabia the ratio in many other high-income countries. were either working in a care sector or were care 95 Defined by GASTAT methodology as “individuals who provide a household with services for a salary and live with it, such as the female domestic worker, driver, gardener, and building guard who lives with in the household.” 96 GASTAT LFS data (https://www.stats.gov.sa/en/814) for domestic workers and Saudi Census data for overall population (https:// portal.saudicensus.sa/). 97 Trained care workers are defined here as care workers in education, care workers in health and social work, care workers in noncare sectors, and non-care workers in care sectors, excluding domestic workers. These are, therefore, professionals in occupations pertaining to the care economy. For the purpose of this analysis, we assume they are at some degree trained to occupy these positions, although it is not possible no verify this. All component terms are as defined by ILO, 2018—also available in Annex I. The Care Boom 58 3. The care provision landscape: too many untrained and unpaid workers and too few professionals Figure 30 Number of domestic The practice of employing domestic workers workers in Saudi Arabia to mitigate the dual burden of household and 4,500,000 caregiving responsibilities, while providing some relief, raises concerns about the qual- 4,000,000 ity and affordability of care. Many domestic 3,500,000 workers, though not exclusively engaged in care 3,000,000 work, often assist with childcare, older persons care, or support for family members of people 2,500,000 with disabilities in addition to their other house- 2,000,000 hold duties.98 However, care work often involves a range of technical and specialized tasks for 1,500,000 which many domestic workers are not ade - 1,000,000 quately trained. This lack of formal training can 500,000 lead to situations where the most vulnerable in- 0 dividuals are not receiving the attentive, knowl- edgeable, and compassionate care they require. 2019 Q1 2019 Q2 2020 Q1 2020 Q2 2020 Q3 2020 Q4 2021 Q1 2021 Q2 2022 Q2 2019 Q3 2019 Q4 2021 Q3 2021 Q4 2022 Q1 2022 Q3 This is especially true when medication, medical devices, or special diets and health conditions Source: authors’ calculations using data from GASTAT LFS. are involved. The absence of proper skills in care work can have dire consequences for these vul- nerable groups, who depend on skilled care to Figure 31 Care workers as a share of ensure their safety and well-being. total employed (%), 2012–16 Moreover, the families most in need of high-quality care are often those who can least afford it, further exacerbating the is- 8.8% sue. This economic barrier prevents them from 70.6% 29.4% 2.8% hiring trained professionals, leaving them to 0.9% Other workers Care workers rely on domestic workers who may not have 12.5% 4.4% the necessary competencies. This gap in the care economy underscores the critical need for accessible, high-quality training programs that can equip workers with the essential skills Domestic Care workers Non-care workers to provide safe and effective care. workers in health and social work in care sectors Care workers Care workers in education in non-care sectors Source: authors’ calculations using data from ILO, 2018. 98 ILO, 2017. The Care Boom 59 4. Professional care services are falling short: Labor shortages and skills are to blame Shutterstock.com / Alsanqer Abdullah H The Care Boom 60 4. Professional care services are falling short: Labor shortages and skills are to blame 4 PROFESSIONAL CARE SERVICES ARE FALLING SHORT: LABOR SHORTAGES AND SKILLS ARE TO BLAME Professional care services, provided by trained workers, are in high demand and demand is expected to increase over time. However, to date, trained professionals are in short supply. This chapter focuses on missing profession- providers, the mismatch between supply and als and skills in the labor market of Saudi demand becomes obvious. Much of the care Arabia, compared with other countries and work is carried out by family members, often regions. Considering current and projected women, but with women entering the labor trends increases in demand by children, older force, this raises concerns. persons, and people with disabilities, along- side the existing supply of professional care The Care Boom 61 4. Professional care services are falling short: Labor shortages and skills are to blame CARE SERVICE PROVISION: norms, Saudi Arabia would need to increase the size of its care workforce from 16.9 percent THE MISSING PROFESSIONALS to 24.9 percent of its total workforce. In a la- Saudi Arabia has a low share of profession- bor market of around 13 million workers,101 the al care workers but considerable demand trained care workforce was 2.2 million work- for care services. The size of the professional ers in 2016, whereas our regression suggests care workforce can be expressed as the share that about 3.3 million workers would be more of care workers, excluding domestic workers, appropriate. This indicates a need to train an out of the total employed population. We mea- additional 1.1 million care workers. This finding sure the demand for care services by the care is not surprising, as there were approximate- dependency ratio—a variation of the age de- ly 2.3 million domestic workers in the country at pendency ratio adjusted for health indicators the time these data were collected,102 indicating to capture heterogeneity among countries. 99 that families were employing domestic workers High-income economies tend to react to de- to mitigate their care needs. As more women mand for care by offering more care services enter the workforce, the demand for reliable and preparing more professionals to work in the care services is expected to rise even further. care economy. Figure 32 shows that the ratio of the trained care workforce as a share of the total employed population in Saudi Arabia is significantly lower than the ratio that would be expected given Saudi Arabia’s care dependen- cy ratio. This means that in comparison to other high-income countries, Saudi Arabia has a high demand for care while having a relatively small, trained workforce to respond to it. We estimate that an additional 1.1  million workers are needed in Saudi Arabia’s care sector. To assess the trained care worker needs, we estimate an equation that relates the size of the trained care workforce to the care dependency ratio.100 A 1 percentage point increase in the care dependency ratio is asso- ciated with a 0.67 percentage point increase in the trained care workforce. To lie on the regres- sion line and have a trained care workforce size that’s more in line with high-income country 99 See the full methodology in ILO, 2018. 100 The sample includes high income countries for which both data points (size of care workforce as percentage of total employed in the country, and care dependency ratio) were simultaneously available. The sample includes Australia, Austria, Belgium, Canada, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Kuwait, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Qatar, Romania, Russia, Saudi Arabia, Slovakia, Slovenia, Spain, Sweden, Switzerland, UAE, United Kingdom, United States, and Uruguay. 101 At the time of data collection, the total employed population in Saudi Arabia was 13.18 million according to ILO data. 102 See GASTAT labor market statistics for 2016. Available at: https://www.stats.gov.sa/en/814. The Care Boom 62 4. Professional care services are falling short: Labor shortages and skills are to blame Figure 32 Size of trained care workforce x care dependency ratios 35% y = 0.6752x - 0.5025 NOR 30% SWE DNK GBR FIN BEL ISL Trained care workforce (% of total employed) 25% AUS NLD FRA CHE USA DEU IRL MLT CAN 20% AUT PRT LTU LUX SVN JPN ITA RUS ESP SAU LVA EST KOR SVK CZE GRC 15% HRV URY CYP HUN POL KWT 10% ROU 5% QAT ARE 0% 15% 20% 25% 30% 35% 40% Care dependency ratio Notes: (1) We use as a proxy for trained workers the sum of care workers in education, care workers in health and social work, care workers in noncare sectors, and noncare workers in care sectors as percentages of the total employed. We exclude domestic workers. (2) The care dependency ratio differs from the usual dependency ratio, in which both active and dependent populations are defined according to fixed age ranges. The care dependency ratio makes use of the healthy life expectancy at 60 years, as defined by the World Health Organization’s Global Health Observatory (2018), accounting for each country’s demographic heterogeneity. Sources: authors’ calculations using data from ILO, 2018 (Care workforce) and ILO calculations based on United Nations, 2017c and WHO, Global Health Observatory, 2018 (Care Dependency Ratio referring to 2015 data). The mismatch between the demand for care shortages” in the European Labour Authority’s services and the number of trained profession- 2022 Report on Labour Shortages and Surplus- als extends beyond Saudi Arabia. The World es. Care occupations such as early-childhood Health Organization’s Health Workforce Sup- educators, cooks, cleaners, and helpers are in port and Safeguards List 2023 lists 55 coun- short supply. Some of these occupations, in- tries that are confronting the most pressing cluding nursing professionals and general med- health-workforce difficulties associated with ical practitioners, have consistently appeared universal health coverage. Even in Europe, as severe-shortage occupations since 2017. which boasts the highest density of health per- Skills gaps among the trained workforce re- sonnel globally according to World Health Orga- duces effectiveness of the care provided. In ad- nization data, there is still a shortage of health dition to a lack of professional carers, skills gaps professionals. Nursing professionals, generalist of the trained workforce reduce the effective- medical practitioners, specialist medical prac- ness of the provision of care. A recent study car- titioners, healthcare assistants, psychologists, ried out in Saudi Arabia shows that interviewed and physiotherapists are among the occupa- care practitioners lack specializations and often tions listed as facing “widespread and severe complain about the lack of appropriate training The Care Boom 63 4. Professional care services are falling short: Labor shortages and skills are to blame and qualification programs.103 This lack of spe- The shortage of healthcare workers along cialists puts an additional burden on already with the lack of quality of work has been high- stressful working conditions of care workers. In lighted by others. Long hours, a need for pro- interviews practitioners reported that they felt tective equipment, physical and mental illness stressed under high caseload and lacking exper- among workers, and high burnout rates existed tise was adding to the stress. They blamed a lack in the healthcare sector before the pandemic of psychological counselling at their workplac- but increased during it.106 The reasons behind es to handle psychological stress linked to their the shortage of health workers and thus the jobs, and felt that their risky working conditions overburdening of workers include long-stand- was not financially compensated (in particular ing inadequate funding for healthcare systems, in the field of social work, where the lack of spe- unsatisfactory work conditions, and insufficient cialized education of training was more often education and training.107 Health workers must mentioned). Without options for specializations be equitably distributed and accessible, and career paths are less straightforward. 104 they need good work conditions to be able to deliver quality services.108 Unsatisfactory work- New evidence also finds a critical shortage of ing conditions have also been mentioned in in- mental health professionals in Saudi Arabia. A terviews with care practitioners in Saudi Arabia. recent study indicates that Saudi Arabia is expe- riencing a significant shortage of 10,400 health We estimate that 1.1 million additional workers required to treat mental disorders. To trained care workers will be needed meet the demand, an additional 100 psychia- in Saudi Arabia to maintain a ratio trists, 5,700 nurses, and 4,500 psychosocial of trained care workers to the care care providers are needed beyond the current dependency ratio commensurate levels. The deficit is especially acute for nurs- with other high-income countries. es and psychosocial workers, who together ac- Long-term care, one of the key areas of care count for 98.9 percent of the total shortage105 . to address the needs of an aging population, Skills mismatch also becomes apparent faces the same problems as the healthcare through over-education. As in Saudi Arabia sector. The shortage of long-term care workers, the mid-level qualifications for caregivers are coupled with increasing demand due to an aging scarce. Therefore, in cases, lower qualified population, presents a significant challenge for caregivers take on tasks that would require the sector. In many OECD countries, the num- more training, and in other cases, higher qual- ber of long-term care workers has not kept pace ified staff have to take on tasks that could be with the growing population of older persons. performed by caregivers with an intermediate The projected rise in the number of individu- professional qualification level. This induces in- als aged over 80 years further highlights the efficiencies in public spending. need for additional workers, with an increase of 13.5 million workers needed by 2040 to 103 King Khalid Foundation, 2023. 104 King Khalid Foundation, 2023. 105 Lee et Al., 2024. 106 Giacomo et al., 2021; and WHO, 2022a. 107 OECD, 2023a. 108 WHO, 2016. The Care Boom 64 4. Professional care services are falling short: Labor shortages and skills are to blame maintain the current worker-to-population ra- OECD countries, education is the area that suf- tio.109 Long-term care workers earn lower wages fers from the most severe skills shortage by compared to those in similar occupations in hos- far ( Figure 34). pitals, and nonstandard employment arrange- Data from  33  economies show that skills ments such as part-time and temporary work shortages are greater in care sectors than in are common.110 Additionally, inadequate train- other sectors. The OECD Skills for Jobs data- ing and qualifications for personal-care workers base measures skills shortages across those threaten the quality of care. Low job quality, in- economies based on shortage occupations and cluding low wages and limited career prospects, skills necessary to perform these jobs. The in- contributes to dissatisfaction among long-term dicator ranges from −1 to 1, with positive values care workers and leads to recruitment and re- indicating shortages and negative values indi- tention difficulties. cating surpluses. In this measure, 1 indicates Pre-primary education faces a shortage of the biggest shortage in each skill, and −1 the workers, as access remains a global chal- largest surplus. The database shows skills lenge. Creating the necessary workforce to shortages112 by country and industry.113 Stacking satisfy current and future demands will require the skills shortage by industry, it is evident that massive, coordinated, and global training ef- among the countries assessed,114 the industries forts, in addition to other efforts such as im- with most severe skills shortages are education, proving working conditions. As shown in pre- health and social work activities, and profession- vious chapters, the regions with the lowest en- al, scientific, and technical activities (Figure 33). rollment rates in pre-primary school have the The first two industries are the main parts of highest current and projected shares of young the care economy, and the third includes many people in their populations. The rising share of health and education associate occupations.115 the older persons obscures the rising absolute number of children in need of care. World Bank projections show expected growth in the num- ber of young children (0–4 years) in all sub-Sa- haran Africa in the next three decades. The numbers in the Middle East and North Africa and in North America are expected to remain stable and in South Asia and Latin America to decrease slightly.111 OECD data on the skills shortage by industry confirm that even among 109 OECD, 2020a. 110 OECD, 2020a. 111 Population Estimates and Projections. World Bank Data, as of 2023. 112 Broadly categorized in arts and humanities knowledge, attitudes, business processes, cognitive skills, communication skills, digital skills, law and public safety knowledge, medicine knowledge, physical skills, production and technology knowledge, resource management, scientific knowledge, social skills, training, and education. Within the database, more detail can be found by type of skill within each category of skills. 113 For the full methodology of the database, see OECD, 2017a. 114 Australia, Austria, Belgium, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Mexico, Netherlands, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Türkiye, United States, Argentina, Bulgaria, Cyprus, Peru, Romania, and South Africa. 115 See Annex I. The Care Boom 65 4. Professional care services are falling short: Labor shortages and skills are to blame Figure 33 Skills shortage by industry in 33 countries Education Human Health and Social Work Activities Professional, Scientific and Technical Activities Information and Communication Public Administration and Defence; Compulsory Social Security Financial and Insurance Activities Electricity, Gas, Steam and Air Conditioning Supply; Water Supply;… Construction Mining and Quarrying Agriculture, Forestry and Fishing Arts, Entertainment and Recreation Manufacturing Real Estate Activities Transportation and Storage Administrative and Support Service Activities Wholesale and Retail Trade; Repair of Motor Vehicles and Motorcycles Other Service Activities Accomodation and Food Service Activities -25 -20 -15 -10 -5 0 5 10 15 20 Source: authors’ calculations using data from OECD skills for jobs database. Note: Each color within the stacked bars represents the shortage or surplus calculated for a given country. Countries included in this analysis are Australia, Austria, Belgium, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germa- ny, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Mexico, Netherlands, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Türkiye, United States, Argentina, Bulgaria, Cyprus, Peru, Romania, and South Africa. The classes of skills include arts and humanities knowledge, attitudes, business processes, cognitive skills, communication skills, digital skills, law and public safety knowledge, medicine knowledge, physical skills, production and technology knowledge, re- source management, scientific knowledge, social skills, and training and education. A closer look at the industries that are in- values; history and archaeology; fine arts; au- tegral to the care economy,116 namely edu- ditory and speech abilities; originality; psychol- cation and health and social work activities ogy, therapy, and counseling; sociology and allows us to see what skills are missing with- anthropology; and management of personnel in those industries . Within health and social resources ( Figure 35). work activities, the top 10 skills by shortage (across all countries) are counseling, therapy, psychology; medicine and dentistry; training and education; learning; sociology and anthro- pology; judgment and decision-making; rea- soning and problem solving; chemistry; histo- ry and archaeology; and auditory and speech abilities ( Figure 34). Within the education in- dustry the top 10 skills by shortage (across all countries) are learning; training and education; 116 According to NACE Rev.2 first-letter classifications. (See Eurostat, 2008). The Care Boom 66 4. Professional care services are falling short: Labor shortages and skills are to blame Figure 34 Shortage and surplus of skills Figure 35 Shortage and surplus of by country and type of skill, health, skills by country and type of skill, and social work activities (NACE) education industry (NACE) Psychology, therapy, counselling Learning Medicine and dentistry Training and education Training and education Values Learning History and archaeology Sociology and anthropology Fine arts Judgment and decision making Auditory and speech abilities Reasoning and problem-solving Originality History and archaeology Psychology, therapy, counselling Auditory and speech abilities Sociology and anthropology Management of personnel Chemistry resources -1 0 1 2 3 4 5 -2 0 2 4 6 8 9 Source: authors’ calculations using data from OECD skills for jobs database. Note: Each color within the stacked bars represents the shortage or surplus calculated for a given country. The countries are the same as in Figure 33. The skills most closely related to care jobs professionals feature among the skills for which are in high demand in many countries. Look- there are more severe shortages in the coun- ing at the overall skill shortage by country, irre- tries examined. spective of industry, the skills in which coun- tries have a more severe shortage are (1) learn- ing; (2) psychology, therapy, and counseling; (3) CARE PROFESSIONS ARE IN training and education; (4) geography; (5) med- HIGH DEMAND: JUST LOOK AT icine and dentistry; (6) digital content creation; and (7) chemistry. Skills (1), (2), (3), (5), and (7) WAGE GROWTH AND HIRING are directly related to care-economy jobs. Ac- This section analyzes the shortage of workers cording to the OECD and ILO (2022), the skills in the Saudi labor market by examining wage most closely related to health professionals are growth and hirings as indicators of labor scar- psychology, therapy, and counseling; medicine city. In previous sections, we established the in- and dentistry; learning; and judgment and deci- creasing demand for care services, which is be- sion-making. Meanwhile, chemistry, medicine ing met mostly by unpaid or untrained workers. and dentistry, judgment and decision-making, Additionally, by studying dependency ratios and and psychomotor abilities are the closest re- purchasing power, we demonstrated the signifi- lated to health associate professionals. Overall, cant potential for expanding the care workforce. three out of four skills for health professionals In this section, we examine the occupations that and two out of four skills for health associate are experiencing shortages in the labor market. The Care Boom 67 4. Professional care services are falling short: Labor shortages and skills are to blame We employ a labor-market-pressure approach, shortage of workers in that field. The indication in which scarce worker profiles command high- becomes stronger when both wages and hirings er wages. Therefore, we use wage growth by oc- grow simultaneously. Conversely, if wages de- cupation (ISCO-08) as a proxy for labor short- cline or both wages and hiring decreases, it may age. This indicator represents stronger evidence indicate surplus workers in the economy in that of a labor shortage when accompanied by si- occupation (see Table 1).117 multaneous growth in hirings. When wages for an occupation increase, it suggests a potential Table 1 Labor-market-pressure-analysis framework Labor market pressure Wage growth Employment growth Shortage (+) (+) Shortage (+) (—) Surplus (—) (+) Surplus (—) (—) Source: OECD, 2017a. The market-pressure analysis confirms the same time as hirings. Among occupations that predicted shortages in care-economy jobs. feature both wage and hiring growth, more than In Saudi Arabia from 2013 to 2019, approx- half were in the care economy or in care-related imately  28  percent of all occupations with jobs. All in all, when looking at all occupations wage growth were in the care economy. As dis- together, 34.1 percent of those showing signs cussed, although wage growth alone can indi- of shortage are within the care economy and cate a shortage, this interpretation becomes 15.4 percent are occupations related or sup - more straightforward when wages grow at the porting care ( Table 2). Table 2 Summary of observations for the market-pressure analysis N % Overall 60 100% Shortage based on wages only Within the care economy 17 28.3% In occupations related to or supporting care 10 16.6% Overall 31 100% Shortage based on both wage Within the care economy 14 45.1% and jobs growth In occupations related to or supporting care 4 12.9% Source: authors’ analysis using General Organization for Social Insurance data. 117 OECD, 2017a. The Care Boom 68 4. Professional care services are falling short: Labor shortages and skills are to blame The occupations that exhibit the greatest other personal services workers; personal care shortages are the occupations most close- workers in health services; protective services ly related to personal care. Figure 36 stacks workers; car, van, and motorcycle drivers. growth in jobs and wages to ease visualization Most of the occupations shown in Figure 36 of the occupations considered in shortage. The experienced both an increase in hiring and analysis confirms the previous findings: a high wage growth. Importantly, all the occupations demand for care work that is not met in the labor listed in the figure experienced an increase in market but by families and domestic workers. wages during the specified period, although The occupations within the care economy (ex- not all of them saw growth in hiring. In some cluding supporting occupations) that featured cases, there is a shortage of workers, making the highest wage increase during 2013-2019 it impossible to increase hiring. Another possi- were nursing and midwifery professionals, per- ble reason for the combination of rising wages sonal-care workers in health services, paramed- and declining employment is technological ad- ical practitioners, medical and pharmaceutical vancements, such as automation. In this case, technicians, other health professionals, other fewer workers are needed, but the jobs them- personal-services workers, and medical doctors. selves tend to be more productive and possibly Our market pressure analysis, more complex (for example, involving control of observing occupations that exhibit machinery). However, this case is relatively un- wage growth and increased common in the care economy. hiring, shows that care sector occupations are over-represented. Half of these occupations require intermedi- ate skills – meaning the can be trained at the TVET education level. Thirteen out of twen- ty-seven occupations in shortage fall with- in skills levels 2 and 3 of the ISCO-08 skills mapping. These correspond to secondary and short-cycle tertiary education levels, respec- tively.118 Those are also the same levels of ed- ucation under which TVET education is pro- vided. Namely, the following occupations: Life science technicians and related associate pro- fessionals; medical and pharmaceutical tech- nicians; other health associate professionals; administrative and specialized secretaries; le- gal, social, and religious associate profession- als; artistic, cultural and culinary associate pro- fessionals; information and communications technology operations and user support tech- nicians; general secretaries; numerical clerks; 118 For reference, see “ISCO-08 Skill model in brief”. Retrieved from: https://isco-ilo.netlify.app/en/isco-08/ The Care Boom 69 4. Professional care services are falling short: Labor shortages and skills are to blame Figure 36 Shortage occupations in care (or care-related) industries based on wage and job growth for Saudi nationals (2013–19) Medical doctors Retail and wholesale trade managers Paramedical practitioners Other health professionals Refuse workers Medical and pharmaceutical technicians Nursing and midwifery professionals Life science professionals Software and applications developers and analysts Legal, social and religious associate professionals Vocational education teachers Other health associate professionals Other personal services workers Professional services managers Hotel and restaurant managers Life science technicians and related associate professionals Information and communications technology operations and… Business services and administration managers Artistic, cultural and culinary associate professionals Vehicle, window, laundry and other hand cleaning workers Protective services workers Food preparation assistants Administrative and specialised secretaries Numerical clerks Personal care workers in health services Car, van and motorcycle drivers Secretaries (general) -1 -0.5 0 0.5 1 1.5 2 2.5 Growth jobs Growth wage Note: We use data from Q3 2013  to Q2 2019  to calculate growth in wages and jobs, expressed as log deviations in different three-digit industries (International Standard Classification of Occupations) compared to national trend of Saudi nationals across all industries. Source: authors’ analysis using General Organization for Social Insurance data. Saudi Arabia’s labor market exhibits clear seg- Arabia’s capacity to tap into the global labor mentation between Saudi nationals and non-na- pool, especially for lower-skilled jobs. These tionals, characterized by differences in skill re- findings highlight our concerns regarding the quirements, wage expectations, and job supply shortage of professionals in the care sector and demand. This division required conducting in Saudi Arabia. Even with theoretical access our analysis separately for non-Saudis. This to an unlimited pool of foreign workers, 3 oc- second analysis revealed that only 19 out of 115 cupations demonstrate a higher likelihood of scrutinized occupations show signs of short- scarcity: personal-services workers, building age, with four within the care economy ( Fig- and housekeeping supervisors, and nursing and ure 37 ).119 This can be explained due to Saudi midwifery professionals. 119 Protective-services workers, other personal-services workers, building and housekeeping supervisors, and nursing and midwifery professionals were considered as within the care economy; life-science professionals and life-science technicians and related associate professionals were considered as related to or supporting care services. The Care Boom 70 4. Professional care services are falling short: Labor shortages and skills are to blame More than a third of all occupations can be attributed to the implementation of Sau- showing signs of labor shortages dization quotas. In the case of “nursing and mid- within Saudi Arabia are within wifery professionals” and “life science tech- the care sector. Shortages are nicians and related associate professionals,” more acute in personal care, the increase in employment could indicate ex- nursing, and health services. ceptions to the Saudization policies, in turn due to internal shortages and a lack of these skills Saudization quotas may be exacerbating the among Saudis. However, the combination of shortage of care workers. These quotas re- wage pressure and increases in hiring strongly strict the hiring of expatriates to a percentage indicates a shortage in these occupations. As of Saudis employed. These percentages are set for “building and housekeeping supervisors,” by firm, occupation, and economic activity.120 these roles are generally considered relatively The increase in wages and decrease in hirings low-skilled, and therefore low quotas have been observed in “other personal services workers” assigned to them. and “protective services workers”, for example, Figure 37 Shortage occupations in care (or care-related) industries based on wage and job growth for non-Saudi nationals (2013–19) Nursing and midwifery professionals Building and housekeeping supervisors Life science technicians and related associate professionals Life science professionals Other personal services workers Protective services workers -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 Jobs Wages Note: We use data from Q3 2013 to Q2 2019  to calculate growth in wages and jobs, expressed as log deviations in three-digit industries (International Standard Classification of Occupations) compared to national trend of Saudi nationals across all industries. Source: authors’ analysis using General Organization for Social Insurance data. Therefore, the greatest professional needs are economy were divided into care workers em- within the core sectors of care. Using the same ployed in core sectors, care workers employed method of analysis, occupations in the care in non-care sectors, and non-care workers 120 See, for example, Ministry of Human Resources and Social Development, 2021: Procedural Guideline Nitaqat Mutawar Program. Retrieved from: https://www.hrsd.gov.sa/sites/default/files/2023-06/E20210523.pdf The Care Boom 71 4. Professional care services are falling short: Labor shortages and skills are to blame employed in care sectors (following the ILO’s mostly to the professions highlighted above methodology—see Box 4 in the Annex). By far, as related to or supporting care. This probably the greatest need within the care economy in confirms the assessment that Saudi Arabia has Saudi Arabia is care workers in core sectors, a deep need for care workers, besides a need followed by non-care workers employed in care for workers that support the care economy. sectors (Figure 38). The second group relates Figure 38 Market-pressure analysis applied to the care economy, Saudi Nationals 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 -0.05 -0.1 Care workers employed Care workers employed Non-care workers employed in care sectors in non-care sectors in care sectors Wage growth Employment growth Source: authors’ analysis using General Organization for Social Insurance data. The Care Boom 72 4. Professional care services are falling short: Labor shortages and skills are to blame SKILLS DEVELOPMENT FOR THE CARE ECONOMY Wealthier countries tend to have a high- er proportion of care workers in their work- IN SAUDI ARABIA force (Figure 39 ). These investments in the The case for developing the care economy, as care economy respond to heightened demands discussed earlier, includes improving human due to longer life expectancies, improved liv- development, healthcare quality, early-child- ing conditions, and complex social issues. Ad- hood education, assistance for care recipi- ditionally, investments in the care economy ents, employment opportunities, and gender significantly contribute to inclusive economic balance. The care economy is vital for ensuring growth.122 Quality childcare enhances educa- older people and those with disabilities receive tion outcomes, future income, and labor mar- the support they need, improving overall health ket participation,123 while care services for older quality and life expectancy, and supporting chil- persons support their economic participation dren’s development and education outcomes. and reduce family caregiving burdens.124 In the The Saudi Vision 2030 acknowledges this need realm of healthcare, investments promote a and aims for a comprehensive transformation healthier population, which drives productivity of care services in the country. It focuses on and spurs innovation in medical technology, re- accessible, high-quality healthcare, expand- search, and development. 125 As an example, the ing modern facilities, increasing telehealth op- ILO projects that investing in care could create tions, and prioritizing preventative care. Vision 13 million jobs in the MENA region by 2035. 126 2030 also emphasizes social care, communi- In Saudi Arabia, projections show a potential for ty strengthening, and mental health improve- 1.5 to 1.6 million direct jobs, plus 500 thousand ment, aiming to empower women to participate indirect ones, being created in the care econ- more fully in the workforce and enhance child- omy until 2030. 127 In addition, care is a field in hood education, reflecting a commitment to a which technology more often complements stronger care system for Saudi Arabia. 121 rather than replaces human workers, making it a “future proof” employment area.128 Formaliz- ing care work increases the formal economy’s size, leading to higher tax revenues, economic diversification, and improved quality of life, with each dollar invested potentially tripling GDP.129 Thus, purchasing power and the care work- force size reinforce each other, strengthening the economy’s resilience. 121 All objectives, programs, documents, and targets regarding the Saudi Vision 2030 are available at: vision2030.gov.sa 122 Ahmed et al., 2023. 123 See, for instance, Fraym, 2022 a, b, c, and d; De Henau, 2022; 124 Cicowiez and Lofgren, 2021. 125 Boyce and Brown, 2019. 126 12 MENA countries include Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Qatar, Saudi Arabia, Tunisia and United Arab Emirates. ILO, 2024. 127 King Khalid Foundation, 2023. 128 WEF, 2020 and 2022. 129 ILO, 2024. The Care Boom 73 4. Professional care services are falling short: Labor shortages and skills are to blame Figure 39 Size of care workforce × GDP per capita (2015 USD PPP) 30% NOR DNK Employment in Human health, social work and education activities as share of total employment DJI SWE y = 2E - 06x + 0.0766 NLD ISL R² = 0.4875 25% ISR GBR AUS CUB BEL FIN USA CHE FRA CAN NZL IRL PRI DEU 20% BLR PRT JPN MLT LBY KAZ SVN MDV AUT RUS LTU EST ESP KOR HKG SUR LVA URY SVK SAU 15% CHL HRV GRC ITA PSE DZA POL CZE MKD ARG HUN IRQ ZAF TTO BHS SGP KGZ MNG UZB SWZ BRB GEO BRA TUR CYP JOR EGYAZEMNE MUS TUN BWA SRB BRN TJK GAB TKM BGR MYS PAN ROUCRI 10% SOM MDA PRY TLS BIH DOMVCT GUY PNG KWT LBR VUT NAM CPV COL MEX COM ARM IRN JAM LCA KEN WSM SLB ALB PYF SDN BLZ LSO LKA NIC FJI CHN STPBOL GNQPER QAT YEM ECU ARE GHA CMRHTI IDN NGA GMBBEN PAK HND MRT SLV GTM COG NER MAR PHL THA TGO RWABGDIND VNM ZWE SLE AGO NPL SEN BHR 5% ZMB ETH MMR CIV MDG MOZ CAF MWI UGA TCD BFA LAO TZA MLI COD KHM BDI GIN OMN GNB 0% $0 $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 GDP per capita (constant 2015 US$) Note: For employment in health, social work and education activities as share of total employment we use Employment by sex and economic activity (ISIC Rev 4) -- ILO modelled estimates, Nov. 2023 (thousands). We exclude domestic workers. For GDP per capita we use USD, in 2015 constant prices. The graph includes all countries (172 economies) for which both datapoints were available. Sources: authors’ calculations using ILOSTAT for employment data and World Bank national accounts data, and OECD National Accounts data files for GDP per capita. Improvements in the care economy can sig- nationals, especially women, to enter and contrib- nificantly alleviate the burden of care on wom- ute to the workforce. Currently, the percentage of en. Specialized and formal care options not only women in education and health and social work create a sense of security for families130 but also industries in Saudi Arabia is lower than the av- generate job opportunities, particularly for work- erage in other regions, including Arab countries, ers with intermediate-level skills.131 This devel- indicating an opportunity to boost female partic- opment presents a promising prospect for Saudi ipation in these sectors (Figure 40 and Figure 130 Two surveys conducted in Egypt in 2020 show that the 76 percent of respondents who were willing to hire childcare providers required the providers to be trained in both childcare and basic health services. Similarly, 85.4 percent of all respondents in the second survey thought care providers for the elderly must be specialized. Both surveys indicate lack of trust in providers and their levels of training as a major concern (Girgis and Adel, 2021; and Girgis, 2021). 131 As further discussed in Chapter 5 The Care Boom 74 4. Professional care services are falling short: Labor shortages and skills are to blame 41). Empirical evidence shows that the growth of Training Corporation (TVTC), there is an opportu- service sectors, particularly the care economy, nity to expand and diversify training programs for is a significant driver of female employment.132 both men and women, addressing existing gaps Therefore, for the Technical and Vocational and promoting workforce inclusivity. 133 Figure 40 Women, % of total employed Figure 41 Women, % of total in health and social work employed in education 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% Saudi Arabia Arab States Sub-Saharan Africa Asia and the Pacific Latin America and the Caribbean Eastern Asia Northern America Europe and Central Asia Saudi Arabia Arab States Sub-Saharan Africa Asia and the Pacific Latin America and the Caribbean Eastern Asia Northern America Europe and Central Asia Female Male Female Male Source: authors’ calculations using data from ILOSTAT. In Saudi Arabia, education, early-childhood ed- which professions are trained for, and to diversi- ucation, healthcare, and social work lies with fy the professions themselves, in the care econ- different ministries and different institutions. omy—which is where TVET plays a crucial role. With that, the responsibility for regulating and The composition of care teams is a critical training some occupations are falling through the factor in addressing the shortage of care pro- cracks, especially those that fall in more than one fessionals at the tertiary degree level. A clear field, as with many intermediate-education care example for that is the Saudi healthcare sys- professions. Additionally, most care professions tem. A recent World Bank study134 outlines a are currently trained exclusively through bach- need for more physicians and bachelor-level elor’s and master’s degrees. There is, therefore, nurses, particularly in primary care settings. In potential to diversify the level of education in 132 Jaumotte, 2003; Thevenon, 2013; and Christiansen et al., 2016. 133 Rivera, Azam, and Ajwad, 2022; and Pankratova et. Al, forthcoming. 134 Alghaith et al., 2021. The Care Boom 75 4. Professional care services are falling short: Labor shortages and skills are to blame Saudi Arabia, for example, diploma nurses135 are home-based visits and assisting highly educat- the most prevalent cadre in both hospitals and ed social workers in all other tasks that do not primary care facilities. The Ministry of Health require a tertiary-education diploma. (MOH) data indicates that 80 percent of outpa- Transitioning Saudi Arabia’s care workforce tient visits occur at primary health care centers, from a heavy reliance on domestic workers underscoring the demand for primary care and to a more skilled and trained workforce could the vital role of diploma nurses in meeting this also have a positive impact on wages. Trained need, especially in rural areas.136 care workers generally receive superior remu- In social services too, much of the work is car- neration compared to unskilled laborers ( Fig- ried out by workers with intermediate skills. ure 42). By favoring a shift toward a more qual- The social service workforce comprises both ified workforce, wages within the care sector professional and paraprofessional workers. Pro- should improve. This transition would also open fessionals are generally classified as workers more job prospects for Saudi nationals. Accord- having completed accredited diploma or degree ing to a tracer study conducted by the World programs in areas including social work, child Bank in 2022,138 medical-supplies training ranks and youth social care, pedagogy, or counseling. among the specializations that has high returns Paraprofessional workers operate alongside or for workers. Professionalization and training not support professionals but have completed less only raise wages but improve job prospects for training, such as certificate courses or brief pre- Saudi nationals while raising quality of care, ben- service or in-service training.137 Paraprofession- efiting both care recipients and the workforce. als are essential for conducting fieldwork and Figure 42 Average monthly wage by education and nationality, Saudi Arabia, 2022 (in SAR) $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 Early childhood education Primary education Lower secondary education Upper secondary education Post-secondary non-tertiary education Short-cycle tertiary education No schooling Saudis Non Saudis 135 These are not trained at the bachelor’s degree level, but in technical setting, within 2 years. 136 Alghaith et al., 2021. 137 GSSWA, 2018. 138 Rivera, Azam, and Ajwad, 2022. The Care Boom 76 5. Equipping the care workforce: international experience has lessons for Saudi Arabia TVTC Archive The Care Boom 77 5. Equipping the care workforce: international experience has lessons for Saudi Arabia 5 EQUIPPING THE CARE WORKFORCE: INTERNATIONAL EXPERIENCE HAS LESSONS FOR SAUDI ARABIA Like Saudi Arabia, almost all countries around the world have faced the challenge of professionalizing their care services. There are good practice cases that can be applied when addressing the issue of professionalization of care. This chapter outlines how countries enhance nursing to support in daily and administrative the efficiency, effectiveness, and skill sets of tasks—and explores comprehensive strategies paid care workers working in institutional care to balance the care supply-demand and boost and home-based care sectors, and the private service quality and affordability, emphasizing and public sectors, focusing on intermediate the role of training. skills and technical and vocational education Professionalization of the care economy and training (TVET). It highlights policies aimed is likely to payoff. A study by the World Eco- at addressing labor and skill shortages within nomic Forum indicates that most near-future the care economy, touching on the overlapping job opportunities will be within the care econo- skills and occupations across education, health, my, with high demand for roles such as medical and social services sectors. Specific attention is transcriptionists, physical-therapist aides, radia- given to the development of caregiver skills for tion therapists, athletic trainers, medical-equip- diverse groups including young people, the older ment preparers, exercise physiologists, recre- persons, those with health issues or disabilities, ation workers, personal-care aides, respiratory and those in need of social services. The chapter therapists, medical assistants, fitness trainers, reviews various care needs—from tutoring and occupational-health-and-safety technicians, The Care Boom 78 5. Equipping the care workforce: international experience has lessons for Saudi Arabia orderlies, and healthcare support workers. 138 activities in non-care professions consists in, Although demand varies by country, most of for example, continuous training for cooks to these high-demand professions require inter- become specialized in dietetics to serve per- mediate-level skills, 139 highlighting the need for sons with specific health issues. This type of technical and vocational training. Addressing the continuous training is offered in Germany for “missing middle” in care proficiency by includ- cooks through 14-month-long vocational train- ing middle-educated professionals will diversify ing in the hospitality sector.140 Other occupa- the workforce and improve healthcare access, tions may also be relevant for the care econo- affordability, and sustainability. This approach my—for example, managers of care institutions. promises gains in cost-effectiveness, efficien- For management roles, a university degree is cy in service delivery, job creation, and reduced often required, although it may be possible to workload for highly educated healthcare profes- hold some management positions after gradu- sionals. Diversifying the workforce with more ating from the TVET system and obtaining con- TVET professionals will enhance health and ed- tinuous-training certificates. ucation outcomes, create jobs, and expand ca- Countries choose different education path- pacity to meet the growing demand for care ser- ways and require different qualification lev- vices, including long-term care. els for care occupations. These choices are linked to the organization of work and division Experiences from other countries of tasks for caring, diversification of tasks, the show that employing care workers traditional role of healthcare, and regulation of trained through the TVET system care occupations. And the choices affect the complement university-trained qualifications of care workers. An examination staff. Easing shortages in care of 10 high-income economies in Figure 44 sug- by training workers in TVET is a gests that educational levels are on average valuable strategy to ensure care higher for care workers in education than care workers are trained to deliver quality workers in health and social work.141 care services for the benefit of the individual demanding care and In some EU countries, health services are to expand quality service offer. among the major subjects in the TVET sys- tem at the ISCED 4 level (this level refers to Plans for expanding the supply of care profes- postsecondary nontertiary education). The sionals through TVET and tertiary education shares of various majors among graduates are could include offers of continuing training so shown in Figure 43. On average, in the Europe- workers can obtain specialized knowledge. an Union, 40 percent of TVET graduates at the Such offers allow workers to become special- ISCED 4 level have been trained in the fields of ist nurses, to gain specializations in the techni- health and welfare, with Austria, Germany, and cal medical field, or to learn relevant software Romania showing higher shares, while a small and tools linked to digitalization, among other share have completed TVET in education. benefits. Continuous training for care-relevant 138 WEF, 2020. 139 This can also be verified by consulting the O*Net database. Retrieved from: https://www.onetonline.org/. 140 Deutsche Hotel Akademie (dha-akademie.de). Retrieved from: https://www.dha-akademie.de/lehrgaenge/diaetkoch?gclid=C- jwKCAiAv9ucBhBXEiwA6N8nYHvPEyOSZoIFZyBBZ7o1BdB1hoyuyYmZJmzAAVZOcX58cstItwxq2xoCDU4QAvD_BwE 141 The measured educational level of care workers is only a proxy for educational requirements. Issues of under- and overqualification are not addressed. The Care Boom 79 5. Equipping the care workforce: international experience has lessons for Saudi Arabia Figure 43 Examples from Europe in training care and care-related occupations in TVET settings Distribution of graduates by education level and field of education: Postsecondary nontertiary education (2020) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% North Macedonia Portugal Iceland Italy Luxembourg Bulgaria Estonia Belgium Denmark Malta Finland France Slovakia Lithuania Hungary Ireland Latvia Sweden Spain Greece Poland Norway EU 27 Germany Romania Austria Engineering, manufacturing Information and Natural sciences, mathematics Arts Services and construction Communication Technologies and statistics and humanities Agriculture, forestry, Business, administration Social sciences, journalism Education Health fisheries and veterinary and law and information and welfare Source: authors calculations using Eurostat data. SKILLS DEVELOPMENT and the US (84 percent), while in France and Bel- FOR CARE WORKERS IN gium most have TVET-level (“intermediate”) ed- ucation. In Australia, 31 percent of these work- CHILDCARE AND EDUCATION ers have only basic skills, the highest share of While, in general, teachers hold university de- the ten high-income countries shown in Figure grees and work in highly regulated professions 44. Other countries with a very high share of care (ISCED levels 6 to 8), the qualification level of workers with tertiary education include the Re- teaching associates varies significantly across public of Korea (97 percent), the Russian Federa- countries and job roles. The educational attain- tion (93 percent), Portugal (81 percent), and Croa- ment of care workers, who do not teach, in the tia (71 percent). A comparatively high share of care education sector also varies quite significantly workers with TVET-level education can be found between countries. For example, care workers in Greece (83 percent), Hungary (52 percent), Lith- in education mainly have tertiary education (“ad- uania (48 percent), and Spain (42 percent).142 vanced” education level) in Canada (92 percent) 142 ILO, 2018. The Care Boom 80 5. Equipping the care workforce: international experience has lessons for Saudi Arabia Figure 44 Education-level profiles of care workers in education and in healthcare and social work 100% 100% 10 12 13 16 15 20 22 21 23 90% 23 90% 21 31 36 35 24 36 42 38 80% 80% 17 55 70% 70% 40 41 33 27 45 26 60% 60% 51 84 44 49 92 88 50% 50% 51 43 40% 61 58 40% 30 38 41 48 55 34 53 40 30% 30% 50 38 34 41 20% 20% 27 16 19 30 31 10% 19 26 10% 7 13 9 13 15 7 10 7 10 3 2 1 2 1 3 2 6 1 4 2 8 17 7 12 10 10 4 0% 0% Australia Austria Belgium Canada France Iceland Ireland Luxembourg Switzerland United Kingdom United States Australia Austria Belgium Canada France Iceland Ireland Luxembourg Switzerland United Kingdom United States Less than basic Basic Intermediate Advanced Note: Levels of education are identified using the International Standard Classification of Education (ISCED 11). Less than basic: no schooling or early childhood education. Basic: primary and lower secondary education. Intermediate: upper and post-secondary non-tertiary education. Advanced: short-cycle tertiary education, bachelor´s, master´s and doctoral or equivalent levels of education. Source: ILO, 2018. Calculations based on labour force and household survey microdata. The educational profile of care workers in ed- the educational system of a country and the ucation is more diverse when looking at spe- overall role of VET. They are more often VET cific job roles. In childcare institutions across trained for working with younger children (un- OECD countries, the educational level differs der the age of three). Childcare assistants are between childcare professionals, childcare usually TVET trained (see Annex III. Care work- assistants, childcare nurses, and baby-sitters ers in education for details and examples). (who are mainly employed for home-based High-quality ECCE requires a balanced cur- childcare). Managers of childcare institutions riculum with roughly equal emphasis on play, mainly hold higher education degrees. Pre-pri- self-regulation, and pre-academic activities. mary teachers also often hold university de- However, across the OECD, too few adults grees, but in countries with strong TVET sys- have the necessary skills to enable optimal tems they are more likely to be TVET trained. learning and emotional support for children’s Core practitioners in institutional childcare are development.143 This indicates the need to im- predominantly university or VET (Vocational prove curricula. Education and Training) trained, depending on 143 OECD, 2017b. The Care Boom 81 5. Equipping the care workforce: international experience has lessons for Saudi Arabia SKILLS DEVELOPMENT FOR Workers who care mostly for older persons and people with disabilities and chronic dis- LONG-TERM CARE OF OLDER eases, are often personal-care workers and PERSONS AND PEOPLE have intermediate qualifications. Long-term WITH SEVERE ILLNESSES care workers for the older persons specialize in geriatric care. Services provided to older per- In the European Union, personal-care workers sons may include follow-up treatment, physical in health services provide assistance with mo- therapy, dealing with hearing- and speech-im- bility and activities of daily living to patients pairment problems, psychological care, and and older persons, convalescent, and people empowerment to promote health and preven- with disabilities in healthcare and residential tion. Often long-term care workers perform settings.144 Tasks performed usually include case-management tasks.147 There is a danger assisting patients with mobility, personal care, that long-term care workers are not trained and communication needs; sterilizing surgical well enough to perform these complex tasks. and other instruments and equipment; observ- Among countries that require training for long- ing and reporting concerns to the appropriate term care workers, the requirement varies from medical or social service workers; and prepar- vocational training (Hungary, Latvia, Luxem - ing patients for examination and treatment and bourg, the Netherlands) to a high school cer- participating in planning care. Personal-care tificate (Belgium and Sweden) or a technical workers in health services do not perform qualification after high school (Ontario (Cana- tasks requiring extensive medical knowledge da), Malta, and, after 2020, Estonia). or training, such as administering medications Portugal offers a curriculum for two-year- and cleaning and dressing wounds; where tasks long vocational training in gerontology148 and of this type are performed they are simple and long-term care. The training involves a wide routine.145 Specific occupations in this catego- variety of modules: ergonomics and hygiene ry include healthcare assistants, home-based at work, basics of gerontology, leadership and personal-care workers, and other person- management, pathology of adults and older al-care workers in health services.146 Home- persons, promotion of well-being and quality of based personal-care workers perform a wide life, self-care mobilization, communication and range of tasks and therefore need a wide range interpersonal relationships, entrepreneurship of additional skills. For example, they need to and social projects, nutrition and feeding tech- provide psychological support, support to par- niques, pharmacology principles, adult and old- ents, and care for newborns during the post- er persons psychology, information technology, partum period and prescribe specific diets that ethics and deontology, social and community match the patient’s requirements, in addition the above-described caring tasks. 144 According to the European System of Classification of Occupations classification. This classification is like the International Standard Classification of Occupations classification. 145 ESCO. Health care assistants. Retrieved from: https://esco.ec.europa.eu/en/classification/occupation?uri=http://data.europa.eu/ esco/isco/C5321 146 ESCO. Personal care workers in health services. Retrieved from: https://esco.ec.europa.eu/en/classi- fication/occupation?uri=http%3A%2F%2Fdata.europa.eu%2Fesco%2Fisco%2FC532 147 OECD, 2020°. 148 Refers to the field of study of aging and the various aspects that affect the elderly, including the biological, psychological, social, and cultural impacts on individuals as they grow older, as well as the related care to these conditions. The Care Boom 82 5. Equipping the care workforce: international experience has lessons for Saudi Arabia interventions, disability-intervention practices, free-of-charge training courses for informal first aid, support products and equipment, and family caregivers. These courses are certi- long-term social responses.149 fied and can be offered in online and in flexi- A variety of continuous training certificates ble way.152 The recipients of this informal care enable professionals to develop expertise may apply for an allowance of up to 125 euros, in specialized fields such as palliative care for them to financially compensate the infor- or hospice care. In Germany, individuals with mal caregivers for the services.153 Germany is a vocational education and training (VET) de- home to around five million caregiving family gree in healthcare can build on their qualifica- members. To allow older people to be cared tions through certified continuous vocational for at home, ambulatory care services can be training courses. These courses offer path- used, depending on the level of long-term care ways to become specialists in areas like geron- needed. In 2021, this involved employment tic psychiatric care or dementia, qualify as a of 442,900 long-term care workers (a 134 per- pain management nurse, or pursue a career cent increase over 2001).154 A large majority of as a manager in institutional care, focusing on them have been VET trained. health and social services. Nurses typically attain a higher qualification SKILLS DEVELOPMENT FOR level but usually have no training in geriatric care.150 International experience shows that CARE WORKERS IN THE there are ways to increase nursing students’ HEALTH SECTOR FOR PEOPLE geriatric-care training by offering scholarships WITH HEALTH ISSUES AND for long-term care education (Austria, Israel, and Japan), providing internship and mentorship op- PEOPLE WITH DISABILITIES portunities (Canada and Korea), and developing The workforce in the healthcare sector is curricula for advanced nursing professions.151 highly diverse and ranges from high-skilled Some countries offer (certified) courses to specialists to roles that only require upper individuals who seek to care for their ill or old- secondary education. A distinction can be er family members. Such care cannot replace made between health professionals and health professional ambulatory care delivered at home associate professionals. Occupations in the when needed; however, it does allow informal healthcare workforce include the following:155 caregivers to improve their skills. In Germany, • Health professionals: medical doctors, nurs- the Social Code (§ 45 SGB XI) stipulates that ing and midwifery professionals, traditional the long-term care insurance funds (under the and complementary medicine professionals, Long-Term Care Insurance Act) must provide 149 Escola Superior Saude Santa Maria. Gerontologia e Cuidados de Longa Duração. Retrieved from: https://www.santamariasaude.pt/ cursos-tecnicos-superiores-profissionais/gerontologia-cuidados-longa-duracao/ 150 OECD, 2020a. 151 OECD, 2020a. 152 Pflegegrad-beantragen. Kostenloser Online Pflegekurs. Retrieved from: https://www.pflegegrad-beantragen.de/pflegekurs-online 153 German Federal Ministry for Family Affairs, Senior Citizens, Women and Youth. Retrieved from: https://www.serviceportal- zuhause-im-alter.de/english/programmes/funding/longterm-care.html 154 Destatis. Presse. Retrieved from: https://www.destatis.de/DE/Presse/Pressemitteilungen/2023/05/PD23_N029_23.html 155 OECD and ILO (2022) The Care Boom 83 5. Equipping the care workforce: international experience has lessons for Saudi Arabia paramedical practitioners, and other health pro- health-related tasks. Needed skills include fessionals such as dentists, pharmacists, nutri- also basic digital technology skills to handle tionists, and speech therapists relevant software.” • Health associate professionals: medical and • Short programs for nursing assistants are pharmaceutical technicians, nursing and mid- available, and certificates may differ within wifery associate professionals, traditional- and countries. Short VET programs are offered, complementary-medicine associate profes- for example, by the American Red Cross, which sionals, and other health associate profession- provides training that lasts from four to eight als such as medical-records and health-infor- weeks to certify professionals as nurse as- mation technicians. sistants.158 Another scheme for issuing nurs- Skills level and education range widely among ing-care certificates is the nursing-care-as- health associate professionals. In most of a sam- sistant program (for example, implemented in ple of twenty-five high-income countries, often Minnesota).159 This nurse-assistant program professionals have basic or intermediate educa- consists of sixty hours of classroom instruction tion (with the exception of Canada (where 88 per- and one hundred hours of externship. Certifi- cent of care workers in health and social work cate holders can work in hospitals, retirement have an advanced education), the Russian Feder- communities, assisted living homes, and oth- ation (88 percent), Korea (71 percent), and the US er skilled-nursing facilities under doctors’ and (55 percent). In a few countries, some care work- nurses’ supervision. ers have less than basic education.156 • Other medical professionals are trained by In the US, 41 percent of workers in health- US colleges by taking short programs. These care and social care have an intermediate-lev- programs include the Medical Assistant Pro- el education and 4 percent have a basic edu- gram (16 weeks; it emphasizes back-office cation .157 These care workers include nursing skills and teaching students how to measure vi- assistants and related professions. Some ex- tal signs, input patient history, perform physical amples of the training arrangements for this examinations, calculate and administer medical group are the following: doses, and conduct lab procedures, EKGs, and emergency medical procedures), Phlebotomist • Nursing assistants work with professionals Program (16 weeks; the program teaches how on patient care, diagnostic procedures, and to draw blood and handle clinical specimens), treatments. The job description of nursing and Emergency Medical Technician Program assistants reads: “Provide or assist with basic (8 weeks; this program is for individuals seeking care or support under the direction of on-site employment as entry-level emergency medical licensed nursing staff; perform duties such as technicians at hospitals, as ambulance drivers, monitoring of health status, feeding, bathing, or as ambulance attendants).160 dressing, grooming, toileting, or ambulation of patients in a health or nursing facility; and may include medication administration and other 156 ILO, 2018. 157 ILO, 2018. 158 Red Cross. Nurse Assistant/CNA Training. Retrieved from: https://www.redcross.org/take-a-class/cna 159 Minnnesota Office of Higher Education. Retrieved from: https://www.ohe.state.mn.us/dPg.cfm?pageID=2481 160 US Colleges. EMT Training. Retrieved from: https://www.uscmed.com/healthcare-programs/ The Care Boom 84 5. Equipping the care workforce: international experience has lessons for Saudi Arabia • A range of other care professions require aid devices can require more advanced abilities, one to two years of training. Examples of skills, and knowledge to guarantee their safety such professions within the heading of med- or effectiveness. ical technical assistants are given in the fol- Continuous education and training plays an lowing table. increasing role for getting specialized. For ex- ample, in Finland, a competency based continu- Table 3 Medical technical assistant ous vocational education and training system is length of training examples expanded. This includes, for example, the offer of the following continuous training courses to Average length of Profession training (US) allow for specialization within the TVET system: further vocational qualification in intellectual dis- Magnetic resonance ability services, further vocational qualification imaging (MRT) 1–2 years technician in mental health and intoxicant abuse welfare work. Further vocational qualification offered in Radiological the area of health care is based on four compe- technologists 2 years tence areas and gives education to qualification and technicians titles such as Orthopaedic Technician (FQ), Chi- Pharmacy technician 2 years ropodist (FQ), and Autopsy Technician.162 Health information / medical-records 2 years administration SKILLS DEVELOPMENT FOR Medical and CARE WORKERS IN SOCIAL clinical laboratory technicians 2 years SERVICES FOR FRAGILE AND Source: based on information of O*Net online, https://www. VULNERABLE GROUPS onetonline.org/ Healthcare social workers need a complex set of skills. A general job description for health- • VET for medical technical assistants takes care social workers in the US is available online longer in some other countries (for example, through O*Net. They provide individuals, fami- three years in Germany161). lies, and groups with the psychosocial support Frequently, personal-care workers need to needed to cope with chronic, acute, or termi- use specific tools, such as medical tools or nal illnesses. Services include advising family monitoring systems, to treat and monitor caregivers, providing patients with information care recipients. Technical training on how to and counseling, and referring them to other ser- operate these tools is essential for care work- vices. These workers may also provide case and ers to adequately assist their patients. While care management or interventions to promote many of these tools (such as bedpans, canes, health, prevent disease, and address barriers to and back braces) do not require advanced com- access to healthcare. Job titles include clinical petency, the use of oxygen-delivery equipment, social worker, hospice social worker, licensed automatic blood pressure machines, or hearing master social worker, medical social worker, 161 Medi-Karriere. MTA Medizinisch-technische/r Assistent/in—Ausbildung & Beruf. Retrieved from: https://www.medi-karriere.de/ medizinische-berufe/mta/ 162 Virolainen, 2022. The Care Boom 85 5. Equipping the care workforce: international experience has lessons for Saudi Arabia nephrology social worker, oncology social work- healthcare social workers, mental health and er, psychosocial coordinator, renal social work- substance abuse social workers, mental coun- er, social work case manager, and social worker. selors, and rehabilitation counselors. Required skills include social perceptiveness, Demand for all these occupations is expected active listening, coordination, critical thinking, to increase more than average, for child, family, complex problem solving, communication, ac- and school social workers. In some of these spe- tive learning, judgment and decision-making, cialized occupations, the share of workers with and case monitoring. Knowledge areas include a bachelor’s or master’s degree is high (84 per- psychology, therapy and counseling, English cent, for example, for rehabilitation counselors), language, sociology and anthropology, and cus- but VET remains an important avenue for skills tomer and personal service. Seventy percent development.165 Vocational training in social work of these job roles requite a master’s degree, exists in some countries. For example, in Portugal 15 percent a bachelor’s degree, and 11 percent a two-year program training workers in family and a post-master’s certificate.163 community services is available at a polytechni- Others work as social and human services as- cal institute. The program contains a wide range sistants. For example, in the US they assist oth- of subjects, from legal framework, social policies, er social and human service providers in pro- social work, palliative care, clinical emergency sit- viding client services in a wide variety of fields, uations, and special educational needs to coun- such as psychology, rehabilitation, or social seling and professional guidance.166 work, including support for families. They may also assist clients in identifying and obtaining available benefits and social and community DEVELOPING A services. They may assist social workers with COMPREHENSIVE developing, organizing, and conducting pro- grams to prevent and resolve problems rele- CARE STRATEGY vant to substance abuse, human relationships, The European Commission has launched a rehabilitation, or dependent care. Survey re- comprehensive strategy that advocates ex- sults indicate that 39 percent of these assis- panding quality and affordable care services. tants have job roles for which a bachelor’s de- The European Care Strategy was published in gree is required, 18 percent have roles needing September 2022.167 The European Commission an associate’s degree, and 16 percent obtained proposed the ambitious goals that by 2030 at qualifications through college without needing least  50  percent of children below the age a degree.164 Job openings for these profession- of three will be in early-childhood education and als are expected to increase. Related occupa- care and that 96 percent of children between the tions are child, family, and school social workers, age of three and the starting age for compulsory primary education will be in childhood education and care. Regarding long-term care, the strategy 163 https://www.onetonline.org/link/summary/21–1022.00 164 O*Net. Social and Human Service Assistants. Retrieved from: https://www.onetonline.org/link/summary/21–1093.00. 165 O*Net. Rehabilitation Counselors. Retrieved from: https://www.onetonline.org/link/summary/21–1015.00 166 Instituto Politecnico da Maia. Serviço Familiar e Comunitário. Retrieved from: https://www.ipmaia.pt/pt/ensino/oferta-formativa/ ctesp/servico-familiar-e-comunitario 167 European Commission. A European Care Strategy for caregivers and care receivers. Retrieved from: https://ec.europa.eu/ commission/presscorner/detail/en/ip_22_5169 The Care Boom 86 5. Equipping the care workforce: international experience has lessons for Saudi Arabia recommends, among other things, increasing Ministries of Labor, Health, and Families) joined the offer and mixing professional long-term care forces with the federal states, employer or- services (home care, community based, and res- ganizations and unions, and church organiza- idential care), offering training and counseling to tions, care institutions, and hospitals to work informal caregivers, setting stringent quality cri- on the Concerted Action in Care plan. This plan teria and standards for long-term care providers, includes measures to increase labor supply and mobilizing sufficient resources. The strate- (including targeted immigration policies) and gy includes several other policy areas including make improvements in working conditions.171 an investment strategy, skills development, VET Comprehensive strategies include analysis of training, and working conditions. training needs and organization of work. This is OECD countries have also individually tried the case with the care strategy in Germany dis- to improve the quality of care. Efforts include cussed above. In addition, as part of its continu- accreditation systems and constant refinement ing education and training curricula for nurses of standards. However, some quality issues re- should be adapted following recent reforms and main, and evidence points to the existence of should emphasize the skills needed to estab- high-quality long-term care only in a few coun- lish quality outcomes in the nursing profession. tries, such as Denmark and Sweden.168 In Nor- The Federal Institute for Vocational Education way, the Norwegian Health Workforce Commis- and Training set up an expert panel composed sion is investigating whether different groups of field experts, education providers, employ- of health workers could start sharing tasks or ers, and researchers to develop the new curricu- change the way they share tasks. This investi- lum.172 The German care strategy also examines gation requires analyzing tasks and assessing work and task allocation and working conditions. the impact of new technologies on these tasks. This information will be used to estimate the number of different groups of health workers TRAINING that will be needed in the next twenty years.169 A key component of the European Care Strat- In Australia, skills forecasts in the healthcare egy is the skills partnership for the long-term sector are used to update training packages for care sector under the Pact for Skills, a flag- vocational training in healthcare. For instance, ship initiative that is in turn under the Europe- skills-anticipation exercises showed increasing an Skills Agenda. The European Care Strategy demand in the older persons-care sector for seeks to improve the quality of services in the training for dementia and palliative care, which care economy. This effort includes support for was then incorporated into the training pack- continuous training of care workers. On April 20, age for the older persons care sector.170 2023, long-term care service providers, social Germany launched an action plan for the care partners, and education and training providers, economy, with a focus on long-term care. In with the support of the European Commission, summer 2018, several federal ministries (the set up a large-scale skills partnership for the 168 Spasova et al., 2018 169 OECD, 2020a. 170 OECD 2020a. 171 Eurofound, 2021; and Bundesgesundheitsministerium. Konzertierte Aktion Pflege. Retrieved from: https://www.bundesgesundheitsministerium.de/konzertierte-aktion-pflege.html 172 OECD, 2020a. The Care Boom 87 5. Equipping the care workforce: international experience has lessons for Saudi Arabia long-term care sector. This partnership aims nursing assistants and advanced nursing assis- to improve both career paths and the quality of tants were trained in full-time vocational schools. care provided, making the long-term care sec- Upskilling to universities of applied sciences is tor more attractive. The partners are commit- possible.174 For individuals who want to retrain in ted to training at least 60 percent of the long- a care occupation or who are reentering the labor term care workforce (3.8 million workers) every market after a career break, a care scholarship, year by 2030. Training courses will focus on implemented through the public employment digital skills and person-centered care. service, will be introduced in 2023.175 Vocational training for nursing-care occupa- Experiences from other countries tions in Germany now provides trainees with also show that providing access flexibility by starting with a general curric- to TVET for nationals as well ulum. In 2020, Germany undertook a signif- as migrants can be an effective icant reform in the vocational education of way of increasing the supply of nursing-care occupations through the Nurs- trained care workers. Furthermore, ing Professions Act. This reform introduced a other countries have found the three-year generalist vocational-training pro- need to provide flexible skilling gram leading to qualification as nursing special- options for continuous training ists. The training focuses on imparting skills for in care occupations as part of independent and process-oriented care across their lifelong learning system. all age groups and care areas. A specialization in Several countries have decided to reform voca- old-age care opens avenues for employment in tional training of care workers to attract more long-term care institutions, while pediatric-care people into care occupations. One example is specialization caters to early-education institu- Austria. To meet the high demand for care work- tions and children’s hospitals. The foundational ers in the healthcare sector, a new apprenticeship training common to all care occupations facili- program was introduced in 2023. The Healthcare tates transitions between different care areas. and Nursing Act173 defines three qualification lev- This reform enhances local employment oppor- els for nursing: (1) a VET degree for nursing assis- tunities for nursing staff and provides avenues tants; (2) a VET degree advanced nursing assis- for additional employment and career advance- tants; (3) bachelor’s degree for certified health ment. In the third year, trainees can opt for con- and nursing care (offered by universities of ap- tinued general training leading to qualification plied sciences). An apprenticeship model for the as care specialists or specialization as geriatric first two qualification levels has been introduced, nurses or health and pediatric nurses. Quality im- in line with the dual VET system. To become a provement is a key goal to be achieved through nursing assistant, three years of apprenticeship modernized training content, improved equip- will be necessary, and a fourth year will be needed ment in nursing schools, and increased practical to become an advanced nursing assistant. The re- instruction at the company level. Furthermore, form allows apprentices to receive an apprentice- to broaden career opportunities, nursing studies ship wage during vocational training. Previously, have been introduced at universities of applied 173 Gesundheits- und Krankenpflegegesetz 174 Alexander Hölbl, Apprenticeship in the care sector and social economy Establishing Nursing Apprenticeship in Austria, Federal Ministry of Labour and Economy, EAfA Webinar: Apprenticeships in the care sector and social economy 4th May 2023 175 Bundesministerium für Soziales, Gesundheit, Pflege und Konsumentenschutz. Ausbildung in der Pflege. Retrieved from: https:// www.sozialministerium.at/Themen/Pflege/Pflegereform/Ausbildung-in-der-Pflege.html The Care Boom 88 5. Equipping the care workforce: international experience has lessons for Saudi Arabia sciences, health academies, and a few tradition- knowledge, and abilities in family caregiving. al universities.176 These programs offer bach- Twenty-one competencies are categorized elor’s and master’s degrees in advanced-care within the following four domains: the nature of practices, care management, pedagogics in care family caregiving; family caregiving identifica- and care sciences, gerontology, health sciences tion and assessment; providing family-centered and management, palliative care, and psychiat- care; and the context of family caregiving.180 The ric care. Some of these courses of study follow patients and the family carers are both benefit- the dual VET model, combining company-based ing from skills development of the family carer. training with university education at applied-sci- For example, a study conducted in Florida on ences or health academies.177 family care training for those caring for a family Several countries provide information and ca- member during the last year of life shows how reer counseling, including for care occupations. beneficial the training is also for the caregiver.181 In Australia, for example, online information has Lower levels of qualification and obtained com- been provided to allow young people to make petencies are leading to poorer services for the more informed career choices. One example is people in need and increases costs for the edu- the website MySkills,178 established by the Na- cation, medical, rehabilitation and social sectors tional Careers Institute, which falls under the De- in the long term. For example, quality long-term partment of Education, Skills, and Employment. care, which can be carried out to a great extent The website also allows users to check the avail- by caregivers with an intermediate qualification ability of VET places. The training is provided by level who received specialized training, is likely certified private providers. The website contains to reduce costs for the medical sector that in- information on prices, curricula, training length, cur when a growing number of older frail people end certification, and locations. Financial support need treatment. Quality ECCE is likely to improve is available through the Job Trainer Fund, public human capital development of young people. assistance, or loans from the VET providers. Including family training is essential to making MIGRATION, SKILLS-MOBILITY a training strategy comprehensive. A need for PARTNERSHIPS, AND skills development of caring family members TRAINING OF MIGRANTS (and other untrained carers in households) has Several countries, mainly in the EU, have been identified in many advanced economies. formed skills-mobility partnerships with se- For example, in the US179 , the Family Caregiv- lected non-EU countries, focusing on a few ing Institute at the Betty Irene Moore School sectors and occupations, including health-re- of Nursing at UC Davis developed the Interpro- lated ones. Examples include the Triple Win fessional Family Caregiving Competencies as program implemented by the German govern- a framework to guide the development of cur- ment in the healthcare sector to recruit and train ricula to enhance health care providers’ skills, 176 Bundesministerium für Familie, Senioren, Frauen und Jugend. Gesetz zur Reform der Pflegeberufe (Pflegeberufereformgesetz). Retrieved from: https://www.bmfsfj.de/bmfsfj/service/gesetze/ gesetz-zur-reform-der-pflegeberufe-pflegeberufereformgesetz—119230 177 Pflegestudium.de/ 178 Australian Government. Your Career. Retrieved from: https://www.myskills.gov.au/JobTrainer/ 179 Kwak et al., 2007. 180 Harvath et al. 2023 181 Kwak et al., 2007. The Care Boom 89 5. Equipping the care workforce: international experience has lessons for Saudi Arabia nursing staff from various countries. In addition, attach to core job attributes including salary, the German development agency GIZ imple- work hours, training opportunities and skills mented and piloted a project called Global Skills development, the number of staff, processes Partnerships Nursing. The focus of this project for managing work-related stress, and freedom is to shorten recognition of qualifications pro- on the job. The results show that nurses value cesses in Germany by inserting relevant training pay raises less than their care worker counter- content in the curricula of partner countries and parts, as nurses are better paid and more qual- fostering knowledge exchange with partner in- ified. Personal-care workers attach lower value stitutions.182 Another example is in Luxembourg, to training and skills development than nurses. where migrants from outside the EU can obtain Care workers for older persons are more likely short-term permission for nurses to complete to choose jobs that offer higher salaries, op- the skills-recognition process in Ireland, with the portunities for training and skills development, goal of taking up longer-term employment.183 adequately staffed workplaces, stress-man- agement mechanisms, and autonomy.186 These WORKING CONDITIONS findings are probably also relevant for other countries and should guide policies and com- A key reason for labor shortages in care occu- pany practices for retaining care workers, at- pations concern working conditions and com- tracting workers, and improving the reputation paratively low pay levels in several care oc- of the care economy as a place to work. cupations.184 These issues relate to high turn- over.185 Reasons for high staff turnover relate to Examples of activities to improve working the stress of working in healthcare and old-age conditions include the above-mentioned care care and the presence of foreign temporary mi- strategy in Germany. New personnel-allocation grant workers in long-term care. Increase in pay plans are being developed and tested in care and improvement in working conditions have institutions. Occupational-health programs at been requested by a variety of care providers. the establishment level are being introduced, These demands have received public attention, shift plans are being improved, and additional during the COVID-19 pandemic, and pay raises measures are planned to improve the work-life have been agreed upon. In its care strategy, the balance of employees. New technological tools European Commission recommends that EU will be developed to ease the administrative bur- member states promote collective bargaining dens on care staff, including advances in tele- and social dialogue with an eye to improving wag- care. The strategy calls for increasing pay levels es and working conditions and ensuring the high- in geriatric care and setting different minimum est standards of occupational health and safety. wages depending on the qualification levels of employees. Studies on working conditions have Staff turnover is an issue in the care econo- been conducted and confirm the need to im- my and is linked to poor working conditions. prove working conditions to attract and retain A study in Australia of care workers for older workers in care occupations.187 persons investigated the relative value workers 182 European Migration Network 2022 183 European Migration Network 2022. 184 Eurofound 2020; and WHO and ILO, 2022. 185 Eurofound, 2021. 186 Mavromaras et al. 2022 187 Bundesgesundheitsministerium. Konzertierte Aktion Pflege. Retrieved from: https://www.bundesgesundheitsministerium.de/ The Care Boom 90 6. Policy reform areas: TVTC can play an important role TVTC Archive The Care Boom 91 6. Policy reform areas: TVTC can play an important role 6 POLICY REFORM AREAS: TVTC CAN PLAY AN IMPORTANT ROLE Saudi Arabia has much to gain from a stronger care economy. Diversifying the care workforce and leveraging intermediate skills is an important step toward improvements. In this scenario, TVTC is a key player in the care economy’s future in the country. The formal care economy in Saudi Arabia has on policies and strategies to leverage TVET to been steadily developing, yet, significant mar- fill intermediate-skilled roles in care. TVTC is a ket potential remains. A recent 2023 study pivotal actor in this transformation. The goal is by the King Khalid Foundation indicate a like- to reduce supply shortages, making the sec- ly increase in government investments in the tor more accessible, efficient, and gender-bal- care economy, alongside a rise in private house- anced, while also attracting skilled care workers hold consumption of care services. A prevailing from abroad and improving working conditions trend in government programs, strategies, and to retain domestic talent. policies is the shift towards delegating service provision to the private and non-profit sectors. This approach aims to improve service quality and reduce costs by making government as- sets available to these sectors.188 This chapter explores ways for Saudi Arabia to develop the care economy by enhancing skills across healthcare, ECCE, and social ser- vices. Recognizing the need for a diverse and skilled workforce, the focus of this chapter is 188 King Khalid Foundation, 2023. The Care Boom 92 6. Policy reform areas: TVTC can play an important role RECENT REFORMS This includes the one-year Patient Care Techni- cian Program. The program offers instruction IN THE COUNTRY in clinical settings for trainees working under Saudi Arabia has started to reform and mod- registered nurse supervision to provide direct ernize its healthcare training system. In 2021, personal care in ambulatory and inpatient set- in line with Vision 2030, the Makken Healthcare tings. This program has been benchmarked to Model Program was launched to build compe- the American Red Cross’s evidence-based work tencies within the community of healthcare on nurse-assistant training and has been adapt- practitioners in Saudi Arabia.189 An integral part ed to the Saudi context.193 The curriculum in- of the program is to train and develop health- cludes one module on age-specific-care nursing. care managers.190 The program includes inter- Saudi Arabia, in collaboration with the World national partnerships with educational institu- Bank, is currently implementing significant tions including universities. The new model of reforms with the introduction of a Saudi Best care is based on six systems of care: “keeping Fit Disabilities Assessment Model. This ini- well, planned procedure, women & children, ur- tiative aims to establish an enhanced adminis- gent problems, chronic conditions, and the last trative recognition of disabilities. This reform phase of life.” Different planned activities are is crucial for more accurately identifying the spread across these systems of care. They are needs of persons with disabilities in terms of based on an analysis of previous needs. One key care. Following the implementation of this func- element is enhancing the quality and quantity of tional assessment, it will be possible to better the workforce through increasing and improving quantify the individuals requiring care and sup- licensing criteria and making professions more port. It is important to clarify, however, that this attractive.191 Another key element is enlarging disability assessment reform will not affect the the number of activities intended to strength- disability prevalence rates reported by the Gen- en health prevention (for example, through eral Authority for Statistics (Chapter 2), which workplace and school wellness programs and uses the Washington Group model. The prima- a health-coaching program) and to improve the ry aim of the new model is to assist the Ministry quality of care (for example, care coordination of Human Resources and Social Development and continuing-care services for patients with in designing more tailored services through a chronic conditions, patient and family support, more precise assessment framework. hospice-care service, and multidisciplinary team Recently, efforts have been made in Sau- development for the last phase of life). di Arabia to address the lack of public child- The new model of care aims to enhance pri- care provision and enhance accessibility for mary care and home-care services, among working women. Article 159 of the Private others.192 Regarding healthcare associates, the Sector Law mandates that companies employ- Health Academy is providing courses for nurses. ing 100 or more women in a single city must 189 Arab News. “Saudi Arabia launches new healthcare model program. September 16, 2021. Retrieved from: https://www.arabnews. com/node/1929641/saudi-arabia 190 Daijiworld Media Network. “New healthcare model programme launched in Saudi Arabia.” September  16, 2021. https://www. daijiworld.com/news/newsDisplay?newsID=874067 191 Chowdhury, Mok, Leenen, 2021., based on information provided by the Ministry of Health 192 Chowdhury, Mok, Leenen, 2021. 193 Saudi Health Academy. Patient Care Technician Program. Retrieved from: https://objectstorage.me-jeddah-1.oraclecloud.com/n/ axovx8rlacme/b/ats-scfhs-bucket/o/public_json/static-files/patient_care_technician.pdf The Care Boom 93 6. Policy reform areas: TVTC can play an important role establish or contract with nurseries for their Reflecting these limitations, until 2021 only employees’ children. Some ministries, includ- around 3,000 women were benefiting from the ing the Ministry of Education, have also sup - program.197 Additionally, there is no information, ported the establishment of daycares con- even on the number of beneficiaries, on home- nected to government institutions and private based daycare programs. In conclusion, inade- girls’ schools. The Qurrah program, introduced quate availability, and affordability of ECCE pro- in 2018, provides childcare subsidies for chil- grams seem to remain key constraints for wom- dren under six years old.194 Another initiative en and families in Saudi Arabia, who still rely on encourages Saudi women to establish home- domestic workers when they can afford to.198 based daycares to increase families’ options.195 Saudi Arabia has been addressing some gaps in Saudi Arabia is expanding its access ECCE provider training, which gives it momen- to care training programs in the tum to tackle the remaining gaps. The country area of health care, early childhood has set up the Early Childhood Care Program at education and care. If trends Princess Nourah Bint Abdulrahman University. observed in other countries are Based on Vision 2030, the Deanship of Commu- observed in Saudi Arabia, there will nity Service and Continuing Education, in collab- be continued need to expand access oration with the Paris Academy of the Sorbonne, to training programs in existing aims to meet the current and future needs of the areas as well as in new areas. ECCE job market as a caregiver, teacher at a nurs- ery, or supervisor at a nursery. This program of- Despite progress, childcare remains a chal- fers one-year training for applicants with a high lenge. For instance, a drawback from Arti- school certificate.199 Saudi Arabia has also made cle 159 is that private companies could easily efforts since 2016 to revise curricula and guid- hire under 100 women to not have to establish ance to teachers for three- to six-year-old chil- nurseries. The availability of Qurrah-registered dren, in line with Vision 2030,200 and the Ministry centers can be geographically limited, primar- of Education has introduced learning standards ily focusing on urban areas, which poses chal- for children aged zero to three years.201 lenges for families residing in rural or remote Further policy directions include increasing regions.196 Moreover, the amount of the Qurrah the network of providers and the quality of subsidy was often small given the high costs early childhood care in the country. Based of private childcare, especially in large urban on fieldwork and research conducted in 2018, centers, and beneficiaries’ low salaries, limit- the OECD recommended strengthening ECCE ing access of women from low-income families. and developing a central strategy for ECE for 194 See http://qurrah.sa/how-it-works 195 See https://www.hrsd.gov.sa/en/ministry-services/services/1163754 196 HRDF, 2021. 197 HRDF, 2021. 198 For instance, in the 2018 survey conducted by Harvard researchers, 56 percent of female respondents who work relied on domestic workers or nannies (Cortes, 2019). 199 Princess Nourah bint Abdulrahman University. Early Childhood Care Program. Retrieved from: https://www.pnu.edu.sa/en/ Faculties/socialservices/vt/Pages/cd.aspx 200 Soud Alotaibi, 2021. 201 Ministry of Education. Saudi Early Learning Standards. Children Birth to 3 Years Old. Retrieved from: https://www.naeyc.org/sites/ default/files/globally-shared/downloads/PDFs/our-work/global/sels_0–3_book.pdf The Care Boom 94 6. Policy reform areas: TVTC can play an important role children aged zero to eight. It also recommend- RECOMMENDATIONS ed increasing funding substantially. The OECD also recommends carefully monitoring the im- Given that the demand for care services is pro- plementation of the Saudi Early Learning Stan- jected to increase significantly, and that shortag- dards to understand their impact on teacher es are already evident, reforms to Saudi Arabia’s practice and student learning. Another key is- care sector are expected to have far-reaching sue identified is training capacity, which is in- impacts. The expected impacts include unbur- sufficient to meet the demand for early-child- dening the current care providers, who are dispro- hood education and care workers.202 portionately women; increasing the quality-of-care services; promote job creation for both women Finally, Saudi Arabia has ratified both the Con- and men; and improving the quality of jobs created. vention on the Rights of the Child (CRC) and These are in line Vision 2030 goals and therefore the Convention on the Rights of Persons with are important to consider when implementing the Disabilities (CRPD). These international agree- Vision Realization Programs. ments establish frameworks to protect and pro- mote the rights of specific groups. The CRC, ad- We recommend adopting the A.I.D.E frame- opted in 1989, is a widely-recognized treaty that work. The four main components of the frame- outlines the fundamental rights of all children, work are described in Figure 45. emphasizing their right to survive, develop, be protected from harm, and participate in deci- sions affecting them.203 Meanwhile, the CRPD, adopted in 2006, focuses on ensuring equal rights and opportunities for people with disabil- ities, promoting their dignity, independence, and inclusion in all aspects of society, including edu- cation, employment, and healthcare.204 By rati- fying these conventions, Saudi Arabia demon- strates its commitment to upholding these im- portant rights within the country. 202 OECD, 2020b 203 https://www.unicef.org/child-rights-convention 204 https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-persons-disabilities The Care Boom 95 6. Policy reform areas: TVTC can play an important role Figure 45 Framework proposed for meeting demand for care through TVET WHAT? WHY? HOW? Diversify professions in care Unburdens current unpaid A.I.D.E. framework to include intermediate-skilled care providers Assessing current professionals training needs and existing Promotes job creation training provision Train more care professionals Increases the quality Increasing training of care services opportunities for care Contributes to worker professions formalization, higher earnings, Diversifying curricula better working conditions, and courses to include and higher status care and care modules Engaging with partners to respond to emerging skills needs in care Source: authors’ elaboration. A SSESS CURRENT TRAINING NEEDS AND THE EXISTING practitioners, care recipients, and training providers—to pinpoint the precise competencies and qualifications that are in high demand but currently underserved. It TRAINING PROVISION is a core responsibility of TVTC to analyze To effectively address the evolving landscape training needs before introducing courses. of the care sector, Saudi Arabia could adopt The training needs analysis and design of new a strategic approach to workforce develop- training courses can be made in cooperation ment to bridge the skills gap, enhance training with other relevant stakeholders. programs, and integrate global best practices • Permanent advisory council for skills into the Saudi Arabian care economy. These analysis representing a cross-section of initiatives are designed to ensure that the care these stakeholders, could be established to workforce is equipped with the necessary skills ensure the skills gap analysis remains current and knowledge to meet the demands of a rapidly and responsive to changing industry needs. changing environment, ultimately leading to im- This council would facilitate ongoing dialogue proved care quality and accessibility. and collaboration, fostering a continuous • Comprehensive skills gap analysis could be feedback loop that informs training program informed by predictive analytics, anticipating development and updates. future sector demands driven by demographic shifts, technological progress, and evolving policy landscapes. Such an analysis requires active engagement with a broad spectrum of in d u s tr y s t a ke h o l d e r s— e m p l oye r s , The Care Boom 96 6. Policy reform areas: TVTC can play an important role I • Training program effectiveness evaluation NCREASE TRAINING of existing training programs is necessary and could be done through outcome-based OPPORTUNITIES WITHIN metrics that assess the employment rates THE CARE SECTOR of graduates, their career progression, and Saudi Arabia is poised to advance the capabili- employer satisfaction with the performance ties of its care sector workforce by broadening of newly trained workers. Quality assurance the scope and quality of training opportunities. mechanisms, such as accreditation systems, To achieve this, a strategic approach focused can ensure that training providers adhere to high on both scale and excellence is required. The standards in curriculum design and delivery. following recommendations are designed to • Learn from international best practice to amplify the number of skilled graduates and organize institutions. Countries such as Australia professionals within the care sector: and Norway provide examples of skills forecasts • Increase outreach and training opportunities in the healthcare sector to update training for Saudis. To increase outreach, activities packages for vocational training in healthcare. su ch a s t a rgete d yo u th e nga ge m e nt , In Germany, the federal institute for vocational including campaigns and incentive programs, education and training sets up expert panels to attract young Saudi men and women to composed of field experts, education providers, care professions can be effective. These employers, and researchers to develop new could include scholarships, career fairs, curricula, including for care occupations. In mentorship programs, and guaranteed job Norway, the Norwegian Health Care Commission placement assistance upon successful carries out an analysis of tasks of different training completion. In addition, training health workers and assess the impact of new opportunities can be expanded by focusing technologies to estimate the need of different on upskilling current caregivers and reskilling groups of care workers in the future. individuals transitioning from other sectors. • Assess migrant care workers skills to This could encompass certification programs strategically hire skilled workers from abroad. that formally recognize the value of informal Migrant workers have filled some of the critical caregiving experiences and on-the-job learning. and high demand gaps in the past and will likely Internships can enhance skills development continue to do so. If there is a system to verify through workplace-based learning. Long- skills and identify workers with the skills, the term internships could ease the transition system can be more efficient than currently from school to work, improving students’ observed in Saudi Arabia. By hiring migrant recruitment prospects. Empowering unpaid workers who possess relevant skills and caregivers, in particular family care givers by: certification, care economy needs can be met establishing formal training and certification more promptly. These workers bring valuable opportunities for unpaid caregivers, recognizing experience and can enhance the quality of care their contributions through certification, and through their diverse caregiving techniques opening pathways to integrate them into the and knowledge. professional care workforce. • O utl i n e c a ree r pathways a n d c a ree r advancement within the care economy to motivate individuals to pursue training and contribute to a more skilled workforce. This includes recognizing and validating the skills of migrant workers, which can be achieved The Care Boom 97 6. Policy reform areas: TVTC can play an important role through a system that verifies qualifications • Learn from other countries. The following are and matches workers with the skills needed in a few examples of lessons that might be useful the Saudi Arabian care economy. for Saudi Arabia to learn about: • Strategically increase non-Saudi migration i. Germany offers a robust system of vocational into occupations experiencing shortages. education and training (VET) degrees in Non-Saudis can play a vital role in alleviating healthcare, which professionals can extend shortages and engaging in activities that are through certified continuous vocational not pursued by Saudis. To effectively carry training courses, specializing in areas such this out, rigorous standards and accreditation as geriatric psychiatric care or palliative within the national framework for training and care. Similarly, Austria has responded to the certification in the care sector, informed by demand for care workers by establishing an international standards and best practices, apprenticeship program that outlines three c an be implemented . This will ensure qualification levels for nursing, integrating consistency and high quality across all training VET into their dual education system. This programs. A robust skills framework would also allows for a practical, work-based learning encompass clear regulations and standards approach alongside theoretical instruction, for the evaluation, acknowledgment, and a method that could be adapted to the Saudi certification of the competencies of migrant context to improve hands-on skills and care workers, especially for in-demand care employability in the care sector. roles. Setting high standards for training and ii. Portugal has a comprehensive two-year certification, for both migrants and locals, can vocational training in gerontology and further professionalize care work, enhancing long-term care, covering a wide array its appeal as a career choice. 205 Integration of modules from ergonomics to social training for migrant care professionals that interventions. The curriculum’s breadth focus on cultural competence and language ensures that workers are well-prepared support can also be useful. Finally, joint training for the multifaceted nature of care work. initiatives that facilitate knowledge exchange In the United States, a variety of short VET between native and migrant workers, can programs cater to healthcare and social foster a culture of continuous learning and care, with institutions like the American professional development. Red Cross providing training that certifies • Leverage public-private partnerships professionals as nurse assistants within to enhance training infrastructure, share weeks. These approaches demonstrate resources, and improve overall training the flexibility and responsiveness of TVET outcomes . To dates Saudia Arabia has to industry needs, suggesting a pathway considerable private provision of training, but that Saudi Arabia could follow to rapidly little is known about the scale and quality of the upskill its care workforce and ensure a high training provided. standard of care provision. • Advance educational technologies, including iii. Finally, European Skills Agenda is a good e-learning platforms and simulation tools, can example of how skills partnerships have been provide accessible, flexible, and comprehensive set up for the long-term care sector which training solutions. contains a commitment of partners to train significantly more long-term care workers. 205 See, for instance, Ratha et al., 2019 and World Bank, 2023. The Care Boom 98 6. Policy reform areas: TVTC can play an important role D IVERSIFY CURRICULA AND • Integration of care modules: embed care modules into non-care related TVET courses, COURSES TO INCLUDE such as hospitality, to prepare professionals CARE AND CARE MODULES for role s in c are set tings . This cros s- To date, course offerings are traditional, and disciplinary training can produce a workforce therefore, there is scope to fill demand gaps capable of providing high-quality service in by training workers in care fields that have diverse care environments, such as older not been offered in the past. To significantly persons care facilities. expand the care workforce, a diversification • Flexible learning pathways: offer modular and strategy could work towards a new mix of TVET stackable courses that allow for incremental trained and university-trained paid carers. learning and credentialing. This flexibility can Another avenue for diversification lies in inter- accommodate individuals with varying levels disciplinary approaches and specializations. of experience and commitments, making TVTC in Saudi Arabia already offers training for education in care more accessible. some occupations that are within the care econ- Austria, the United States, and Portugal offer omy, such as occupational safety and health some examples of countries that took steps to technology, hospital management and health diversify their training opportunities. In Austria, services, biomedical equipment technology, to meet high demand for care workers two new health insurance, hair and skin care, and food TVET apprenticeship programs have been intro- processing and safety. TVTC could, therefore, duced for nursing assistants and for advanced build upon modules that already exist to recom- nursing assistants, alongside the existing Bache- bine and complement, to create new curricula. lor degree for health and nursing care. In the US, • Interdisciplinary approaches: leverage existing short training courses are available for nursing TVET programs and modules to create assistants and 2-years courses for several med- interdisciplinary curricula that incorporate ical-technical professions, along the availability care principles. For example, programs in of advanced degree. In Portugal, a TVET course occupational safety, health technology, and for training care workers in family and community hospital management can be enhanced with services has been introduced. care-focused modules to produce graduates In various countries, the care economy is en- with a comprehensive skill set. riched by offering specialized training to pro- • Specialized care training: introduce specialized fessionals from different fields. For instance, training tracks within existing health and care cooks can pursue continuous training courses programs. TVTC could play a crucial role for in dietetics, equipping them to cater to individu- providing specializations in initial TVET as als with unique health requirements. Both TVET well as in continuous TVET. This could include and higher education institutions in OECD coun- specializations in ergonomic counselling to tries provide critical specializations within the prevent illnesses and to adapt workplaces care sector, such as palliative care programs in for people with disabilities, disability support, Germany and Australia. mental health services geriatric care, social care assistants, addressing specific segments of the care economy that require dedicated expertise. Furthermore, upskilling and skill adaptation programs play a pivotal role in the skills recognition process for migrants, particularly for specialized care professions. The Care Boom 99 6. Policy reform areas: TVTC can play an important role E NGAGE WITH PARTNER • Learning from international best practice on skills partnership programs. There are ORGANIZATIONS AND lessons to be learned from the European STAKEHOLDERS TO RESPOND system, which facilitates the integration of TO EMERGING SKILLS NEEDS migrant care workers by incorporating specific Involving a wider range of stakeholders can training elements into their home countries’ enhance efficiency and quality of care in Sau- curricula to expedite qualification recognition. di Arabia. This is necessary, as the care econ- Partnership programs, as implemented in some omy is spread over different sectors such as European countries, rest on the cooperation health, education, and social work. with countries of origins of migrant care workers to insert specific elements in their • Broad stakeholder involvement can enhance training curricula to speed up recognition of the efficiency and quality of care in Saudi qualifications and form partnerships with Arabia. The care sector involves a diverse national training providers to train migrant array of stakeholders across health, education, care workers. Partnerships are also needed and social work, but can also include links for an effective implementation of skills with institutions working on migration development. For example, in Germany, a wide issues, data collection bodies, etc. When, for range of actors as have been involved for the example, implementing an interdisciplinary elaboration of a comprehensive care strategy training approach, having a diverse set of and a concerted action plan for long-term care. stakeholders can be helpful when designing training programs and developing curricula. Or, for example, when international standards and skills recognition are being considered cooperation and partnerships with private and international providers will be useful. • Improving team design, which involves integrating midlevel providers such as advanced practice nurses, physician’s assistants, and diploma nurses, as well as health care assistants, into the care teams. This approach allows for task-sharing and enables, for example, physicians to concentrate on the most complex cases, thereby optimizing the delivery of care and aligning with the shift towards a stronger primary care system. Implementing bridge programs facilitate the advancement of diploma nurses to bachelor or advanced level to open up career pathways. This exercise needs close cooperation with care providers in the public and private sector. On their side, so they can make the necessary arrangements to improve the professional composition of teams with diverse skill levels. On TVTC side, to be sure that these skills can be provided and made available through training. The Care Boom 100 6. Policy reform areas: TVTC can play an important role IMPLEMENTATION new courses or modules could be introduced nationwide. Regular assessments of the train- CONSIDERATIONS ing’s quality and relevance, as well as tracer In the implementation of the A.I.D.E frame- studies on graduates’ employability, should be work, the Technical and Vocational Training conducted to ensure ongoing effectiveness. Corporation (TVTC) emerges as a pivotal There is potential for developing a compre- stakeholder, although other institutions will hensive national strategy that consolidates be necessary. TVTC is well-positioned to ad- the efforts of various ministries and stake- dress the workforce and skill needs of the care holders responsible for different aspects of economy, offering training for a range of roles the care economy. This strategy would address including assistant positions, occupational skills development, establish a framework health, medical technologies, and noncare oc- for recognizing and certifying skills obtained cupations that will strengthen the care econo- abroad, promote gender equity, and improve my. Our market-pressure analysis has revealed working conditions to retain skilled workers. a shortage in several middle-skilled occupa- To diversify the workforce, Saudi Arabia should tions within the care sector, with 17 out of 27 aim to attract skilled care workers from abroad, identified occupations requiring intermediate rather than focusing solely on domestic work- skills, and 3 requiring basic skills.206 These find- ers. For this strategy to be successful, a sys- ings indicate that the necessary skill levels for tem to recognize foreign qualifications, pro- these professionals are achievable through the vide training to migrant workers, and engage in technical and vocational education provided by skills-mobility partnerships with their countries the TVTC and other institutions like the Health of origin is essential. Academy. Therefore, the TVTC’s collaboration with these partners is crucial in addressing the Achieving a gender-balanced workforce re- shortage of care workers in Saudi Arabia, which quires attracting more women to the health- includes providing specialized training for those care and social work sectors and more men to in non-care-related roles within the care econ- childhood education, care, and long-term care omy. This could be achieved by integrating care roles in Saudi Arabia. Additionally, gender-sen- economy-focused training modules into exist- sitive training for caregivers and teachers in ing TVET courses, such as those tailored for pre-primary and early-childhood education and age-specific and illness-specific food services, care is vital to address gender stereotypes and housing adaptations, and IT for care. foster girls’ interest in technology. Research consistently shows the importance of challeng- After the curricula have been introduced or re- ing gender stereotypes from a young age. vised and new modules implemented, it would be wise to pilot these courses at a few select training institutions. The next step involves evaluating the training outcomes, assessing the quality and relevance of the curricula, and the effectiveness of the trainers. This evalua- tion will guide necessary changes to the curric- ula, course formats, and continuous training for trainers. 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Health Professionals Occupations) and ISIC (International Standard • 23. Teaching Professionals Industrial Classification of All Economic Ac- tivities) codes, as explained below. Based on • 32. Health Associate Professionals ISIC 4, care sectors are the following: • 53. Personal Care Workers • 85. Education There are other care occupations: • 86. Human health activities • 13. Production and Specialized Services • 87. Residential care activities Managers • 88 . Social work activities without • 26. Legal, Social and Cultural Professionals accommodation • 34. Legal, Social, Cultural and Related Associ- In several cases (notably in European data sets), ate Professionals health and social work were aggregated at the • 51. Personal Service Workers one-digit level. Domestic workers (employed by • 91. Cleaners and Helpers households) are identified by being classified in ISIC 4 97: “activities of households as employ- ers of domestic personnel.” The combination of care occupations, care sectors, and households as employers makes it possible to identify the care workforce and group it in four categories: 1. Care workers employed in care sectors 2. Domestic workers (employed by households) 3. Care workers employed in noncare sectors 4. Noncare workers employed in care sectors 207 ILO, 2018. The Care Boom 108 Annex Categories (1) and (4) can be further disaggre- 3. Care workers employed gated by sector. Indeed, sectoral employment in noncare sectors: is the addition of categories (1) and (4) for each • All other workers in ISCO 22 except for those care sector. The four categories are identified working in ISIC 75 (veterinary activities) in the following way: • All other workers in ISCO 23 1. Care workers employed in care sectors: • All other workers in ISCO 32 except for those • Workers in ISIC 85, 86, 87, 88 who are also in working in ISIC 75 (veterinary activities) ISCO 22, 23, 32, 53 (core care occupations) • All other workers in ISCO 53 • Workers in ISIC 85, 86, 87, 88 who are also in ISCO 13 4. Noncare workers employed in care sectors: • Workers in ISIC 85, 86, 87, 88 who are also in ISCO 26 and 34 • Workers in ISIC 85, 86, 87, 88 who are not in ISCO 22, 23, 32, 53, 26, 34, and 13 2. Domestic workers (employed by households): • All workers in ISIC 97 The Care Boom 109 Annex ANNEX II CARE WORKERS IN EDUCATION Educational profile of care workers in education Manager of certified childcare center • Managers of certified childcare centers usual- ly hold a university degree. Often a minimum number of years of experience is required (as in many EU countries).208 Core practitioners in institutional childcare • For core practitioners in institutional childcare, vocational school and internships). Still, for this there are mostly fixed requirements for qualifi- group, in a few countries qualification is provid- cation level, depending on the age of the child. ed through the VET system.209 In Germany, Es- • In European countries, when the systems are tonia, Greece, Luxembourg, the United Kingdom separated between (1) zero to three years and (2) (specifically Scotland), and Montenegro, core three to school age, education-qualification re- early-childhood and care workers have degrees quirements are lower for the younger children. at the postsecondary level (ISCED level 4). • For the younger age group, at least a bache - • For children above the age of three, three-quar- lor’s degree is required in many countries, and ters of education systems in Europe require in two countries a master’s degree is required core practitioners to have a bachelor’s degree for zero to three years old (for example, Portu- or higher level of qualification in early childhood gal, Iceland). In a few countries, qualification is education and care (or in education). In four provided through the VET system (for example, countries a master’s degree is the minimum re- in Germany, which requires two to four years of quirement (France, Italy, Portugal, and Iceland). Teachers at the pre-primary level • Teachers at the pre-primary level must earn a bach- degree. For example, in Germany the qualifi- elor’s or equivalent degree in 27 of the 37 OECD cation to become a state-recognized pre-pri- countries (or even a master’s degree as in England, mary educator takes three years of postsec- France, Iceland, Italy, Poland, and Portugal). ondary vocational training. Prior to accessing • In countries with a strong VET system, as in a vocational college to become an educator, Germany, Austria, and Ireland, these teachers students must either finish a two-year course earn a postsecondary-vocational-program as a childcare assistant (Kinderpfleger/in) or train and attain work experience in a related 208 European Commission/EACEA/Eurydice, 2019. 209 European Commission/EACEA/Eurydice, 2019. The Care Boom 110 Annex field. 210 Consequently, the course of study to become a pre-primary teacher varies between two and five years.211 Childcare assistants • Childcare assistants mostly have a VET degree National Education via public education cen- in European and other OECD countries. ters or accredited private courses. Assistants • In the European Union, childcare workers working with older children in kindergartens (ISCO  5311) provide care and supervision (Bağımsız Ana Okulu and Ana Sınıfları) are for children in residential homes and in be- qualified as early childhood education and fore-school, after-school, vacation, and day- care master trainers (okul öncesi eğitimi ve care centers. bakımı usta öğreticisi) with a four-year voca- • In the US, requirements vary from no formal tional-training qualification at ISCED level 3.214 vocational training requirement to a degree re- The training of childcare assistants may cor- lated to early-childhood education and care.212 respond to childcare nurses, as health-related Another assistant occupation in personal-care and hygiene issues are an important aspect of workers is teachers’ aides, who perform non- any form of early-childhood education and care teaching duties to assist teaching staff and (for example, in Germany and France215). provide care and supervision for children in • In Germany childcare nurses and social as- schools and preschools.213 sistants must take a two-year VET course. 216 • In France, the minimum qualification to work These professions support the pedagogic, ed- as an assistant with younger children (accueil ucator, and nursing staff. du jeune enfant) is at ISCED level 3. It may be a • In Portugal a two-year course in child support one-year training course (auxiliaire de uericul- is available. In these two years, students learn ture) or a two-year training course (accompag- about childhood development problems, the nant éducatif petite enfance). Portuguese language, education for citizen- • In Turkey, assistants in daycare centers ship, environment and sustainability, cultural (kreş) must take a one-year training course heritage, information technology, occupation of (2,368 hours including a practicum) after three free time and leisure, food safety, hygiene, child years in general upper secondary education. safety, interpersonal relations, a foreign lan- This training is organized by the Ministry of guage, language acquisition and development, methods and techniques of child-support 210 OECD, 2016, Starting strong IV Early Childhood Education and Care Data Country Note Germany. 211 OECD, 2017b. 212 See, for example, in the US , US Bureau of Labor Statistics. Occupational Outlook Handbook. Childcare workers. Retrieved from: https://www.bls.gov/ooh/personal-care-and-service/childcare-workers.htm 213 European Skills, Competences, Qualifications and Occupations (ESCO). Teachers’ aides. Retrieved from: https://esco.ec.europa. eu/en/classification/occupation?uri=http://data.europa.eu/esco/isco/C5312 214 International Standard of Qualification (ISCED) level 3 relates to programs at the upper secondary education level. secondary school (stage two/upper grades), senior secondary. Education Programs can be general or vocational school or (senior) high school. (OECD, 2015). 215 Ministère de la Santé et de la Prévention (France). « Être professionnel de l’accueil du jeune enfant ». Retrieved from : https://sante. gouv.fr/IMG/pdf/j.-marchal-etre-professionnel-de-laccueil-du-jeune-enfant.pdf 216 Weiterbildungsinitiative. Ausbildung zur Kinderpflege- und Sozialassistenzkraft. Retrieved from: https://www.weiterbildungsini- tiative.de/themen/ausbildung-zur-kinderpflege-und-sozialassistenzkraft The Care Boom 111 Annex service, nature-exploration activities, and proj- education and care, requiring  one  year of ect methodology, and they undertake an inte- training, including classroom-based and work- grated project and internships.217 place-based training. This course of study is • In Australia, family daycare educators, kinder- available as an apprenticeship.218 garten assistants, and long daycare educa - tors may earn certificates in early-childhood Home-based early childhood education and care (ECEC) services • Home-based ECEC services are regulated in • In France, to start working, a childminder three-quarters of European education sys- must demonstrate that they have completed tems.219 In twelve education systems, childmin- half of the 120-hour training at the local lev- ders offering this type of provision are required el (département). The other half of the train- to undergo specific training. ing must be completed within two years. The • The duration of this type of training most often potential childminder must also be approved takes between one hundred and three hun - by the département-level authority. For this, dred hours. In some countries a qualification they must successfully pass a module of the in ECEC or education is required. national training requirements for working in • In Germany, childminders must complete a ECEC (CAP Accompagnant Éducatif Petite En- course in family daycare, the content of which fance at ISCED level 3). By completing the oth- varies between Länder (federal states). How- er modules of this training program later on, ever, several states have adopted a curriculum a childminder may become an assistant in a developed by the German Youth Institute on center-based ECEC setting. behalf of the Federal Ministry for Family, Senior • In Portugal, either childminders must have Citizens, Women and Youth. This course cor- dual certification, which combines on-the-job responds to 300 hours of training (160 hours training with some short units of the National in its former version). In 2016, 51 percent of Qualification Catalogue in support services for childminders had completed at least 160 hours children and young people, or they must have of training, 30 percent had a professional back- successfully completed the short-term training ground in ECEC, 15 percent had attended a units of the National Qualification Catalogue in qualification course of less than 160 hours, support services for children and young people. and 3 percent had no qualification. 217 Politecnico de Viseu. Curso de Técnico Superior Profissional (CTeSP) de Apoio à Infância. Retrieved from: esev.ipv.pt/Cursos/ apresentacao.aspx?value=30 218 Australian Government. Your Career. Certificate III in Early Childhood Education and Care. Retrieved from: https://www.yourca- reer.gov.au/learn-and-train/courses/CHC30121 219 European Commission/EACEA/Eurydice, 2019. The Care Boom 112 Annex Other useful definitions Early-childhood care and education (ECCE) “Programs that, in addition to providing children with care, programs are normally designed for children from age 3 offer a structured and purposeful set of learning activities and include organized learning activities that constitute, either in a formal institution (pre-primary or ISCED 0) or on average, the equivalent of at least 2 hours per day and as part of a non-formal child development program. ECCE 100 days per year.” Early Childhood Education (ECE) “Early childhood education provides learning and educa - instruction outside of the family context to develop some tional activities with a holistic approach to support chil- of the skills needed for academic readiness and to prepare dren’s early cognitive, physical, social and emotional de- them for entry into primary education.” velopment and introduce young children to organized Pre-primary education “Programs at the initial stage of organized instruction, pri- kindergarten or early childhood education, such programs marily designed to introduce very young children, aged at are the more formal component of Early Childhood Care and least 3 years, to a school-type environment and provide a Education. Upon completion of these programs, children bridge between home and school. Variously referred to as continue their education at ISCED 1 (primary education).” infant education, nursery education, pre-school education, Difference between ECCE and ECE: Early Childhood Care and Education (ECCE): • Broader Scope: ECCE encompasses all as- • Includes Basic Needs: This can involve ensur- pects of a young child’s well-being, includ - ing children’s basic needs are met, like proper ing physical, emotional, social, and cognitive nutrition, hygiene, and healthcare. development. • Not Strictly Educational: While learning op- • Focuses on Nurturing Environment: It empha- portunities are present, ECCE doesn’t have a sizes providing a safe and secure environment strictly structured curriculum like traditional where children feel cared for and supported. education. Early Childhood Education (ECE): • Focuses on Learning: ECE primarily concen- • Preparation for School: Many ECE programs trates on planned learning experiences for aim to prepare children for entering primary young children. school In essence, all ECE programs are part of • Structured Activities: It may involve activities ECCE, but not all ECCE programs are strictly ECE. like storytelling, singing, arts and crafts, or ba- sic math and literacy skills. Sources: UNESCO (1); UNESCO (2) and UNESCO (3) The Care Boom 113