Bogotá Takes Care of People Who Take Care of Others

With their populations aging, many countries around the world face a growing need to find care options for older adults. In the United States, most people age 65 and older rely on family and community members to provide long-term, unpaid care, including help with tasks like household chores, transportation, and administering medical or self-care needs. The over-65 population is projected to increase by almost 50 percent in the next 30 years, signaling that — absent a dramatic shift in policy — millions more Americans will become unpaid caregivers in the coming years.

Most care in the U.S. is paid for out of pocket. Informal caregivers report spending an estimated 26 percent of their income on caregiving costs, like groceries or household supplies. Nearly all take on at least one medical-related task, such as transportation to doctor appointments or managing medications, and at least one support task such as paying bills or preparing meals. Often this work is done on top of their paid employment.

Across the world, women and girls do the bulk of all caregiving, including an estimated 75 percent of unpaid care work. Often female caregivers put their careers and relationships on hold at the expense of their own well-being. They are, for example, less likely to have a paid job outside the home. As the population continues to grow older in the U.S. and elsewhere, women will increasingly shoulder the responsibility of providing long-term care to loved ones.

But care work doesn’t have to cause financial and emotional strain. In 2020, Bogotá, Colombia’s city government unanimously approved a program to support the invaluable and often unpaid work of female caregivers. Called the CARE System, it is the first program of its kind in Latin America, and one U.S. policymakers could take inspiration from.

Bogotá Recognizes the Value of Caregivers

In Bogotá, 30 percent of female adults are full-time unpaid caregivers, of whom 90 percent have low income. If their work were paid, it would represent 13 percent of the city’s gross domestic product (GDP) and 20 percent of the country’s GDP. The CARE System aims to better support caregivers by integrating the services they and those they care for typically need into physical spaces called CARE Blocks, funded through the municipal budget. Services for caregivers include a range of free offerings such as exercise classes, psychosocial support, legal aid, education courses on topics like computer science and entrepreneurship, and cultural and social activities. While caregivers engage in these activities, the people they care for are supported by municipal staff.

CARE System pioneers knew that CARE Blocks had to be accessible to be successful, so they were built within a 15- to 20-minute walk from potential users to reduce transportation barriers. Since a whopping 75 percent of greater Bogotá’s residents live in rural areas, mobile CARE Buses were deployed to access harder-to-reach populations, changing location every five months to cover a wide area. Still, 14 percent of women caregivers in Bogotá are unable to access the CARE Blocks or CARE Buses because of the hurdles they face leaving their homes. To combat this, the city developed the CARE Home Delivery model to provide in-home services for caregivers.

There are now some 20 CARE Blocks, with 24 more expected to be open by 2035. By the end of this year alone, the Bogotá CARE System is expected to reach 1 million beneficiaries.

A Patchwork of Services for U.S. Caregivers

There is no comprehensive federal policy or infrastructure to support caregivers in the U.S., but some states offer reimbursements to reduce costs. In Arizona, the Family Caregiver Reimbursement Program repays caregivers for the cost of home modifications. Medicaid provides some support for family caregivers in nearly all states, with 49 providing respite care and caregiver training. Under authorization from the COVID-19 public health emergency, these same states expanded benefits for caregivers, including, for example, virtual evaluations for home- and community-based service eligibility. Many states have made certain COVID-era caregiving benefits permanent, including increased payment rates, virtual evaluations of eligibility, and paying family to provide care. But some ended or reduced caregiving benefits when the emergency period expired.

This patchwork of programs is not enough. Not all caregivers in the U.S. are eligible for, or have access to, these programs. And the programs themselves may be inadequate to meet the scale of the problem. While the federal government could encourage states to provide increased financial assistance for long-term care, they continue to rely on state-level action, which tends to exacerbate disparities in coverage and outcomes.

Bogotá’s CARE System, though only four years old, has a lot to teach U.S. policymakers:

• Coordinated action is critical. Bogota’s CARE System engages services from six government agencies, making it crucial that these agencies work together to establish, maintain, and improve the program.

• Once the care support infrastructure is created, continual investment and improvement are necessary to ensure it meets people’s needs. Policymakers expanded on CARE Blocks to incorporate mobile clinics and home visits to ensure these resources make sense for the people they’re serving.

• Care infrastructure is the potential starting point for broader societal shifts. To promote a more equitable division of care work across genders, the CARE System includes a “School for Men” where male members of the household can learn to manage household chores and appreciate care work as meaningful and time-consuming.

The author would like to thank Faith Leonard of the Commonwealth Fund and former Bogotá mayor Claudia López, now with the Harvard Advanced Leadership Initiative, for their review of this Insight.