WHY SHOULD WE CARE ABOUT CARE? THE ROLE OF CHILDCARE AND ELDERCARE IN KOSOVO September 9, 2015 1 WHY SHOULD WE CARE ABOUT CARE? THE ROLE OF CHILDCARE AND ELDERCARE IN KOSOVO 1 The World Bank September 9, 2015 1 This report is prepared by the Poverty & Equity Global Practice, Europe and Central Asia team: Victoria Levin, Ana Maria Munoz Boudet, Beth Zikronah Rosen, Tami Aritomi, Julianna Flanagan, Lourdes Rodriguez-Chamussy. This work was done as part of the activities under the Trust Fund “Promoting Gender Equality in the Western Balkans”, supported by the Swiss Cooperation Agency via the World Bank’s Umbrella Facility for Gender Equality multi-donor Trust Fund. 2 Contents Executive Summary....................................................................................................................................... 5 I. Motivation: Why should we care about care?...................................................................................... 7 II. A new, independent mixed-methods dataset ...................................................................................... 9 III. Use of Formal and Informal Care .................................................................................................... 12 IV. Childcare Supply.............................................................................................................................. 16 Availability is limited and existing childcare facilities are at over capacity ........................................ 16 Unaffordability is an important barrier to childcare use .................................................................... 22 Main challenges for quality childcare provision are high child-staff ratios and infrastructure .......... 24 V. Demand for childcare.......................................................................................................................... 26 Main determinants of childcare demand: Perception of benefits for children’s development and need of support for working/willing to work mothers ....................................................................... 26 Social norms play a significant role in shaping negative perceptions about childcare use ................ 28 VI. Eldercare Supply ............................................................................................................................. 29 Limited availability of residential eldercare and lack of day-based services characterize supply in Kosovo ................................................................................................................................................. 29 Residential eldercare and at-home private care options are very expensive .................................... 31 Infrastructure and safety are the main challenges for quality provision of eldercare ....................... 32 VII. Demand for eldercare ..................................................................................................................... 33 Filial obligations and social norms are a strong deterrent for residential eldercare use ................... 33 Day-care centers and home-based formal eldercare formats are more compatible with social norms ............................................................................................................................................................ 34 VIII. Conclusions and Policy Recommendations..................................................................................... 37 References .................................................................................................................................................. 40 Annex 1: List of Variables Used in the Construction of the Childcare Quality Sub-Indices ........................ 43 Annex 2: List of Variables Used in the Construction of the Eldercare Quality Sub-Indices ........................ 44 3 Tables Table 1: Summary of data sources.............................................................................................................. 10 Table 2: Childcare and Eldercare definitions .............................................................................................. 11 Table 3: Country-level data collected through independent mixed methods survey ................................ 12 Table 4: Percentage of women in the study with children 0-14 using different child care arrangements 14 Table 5: Percentage of women in the study who care for an elderly and use eldercare arrangements ... 16 Table 6: The supply of childcare providers in urban and rural areas.......................................................... 17 Table 7: Live-in eldercare provision by country .......................................................................................... 30 Figures Figure 1: Typologies of care ........................................................................................................................ 13 Figure 2: Percent of households with at least one child under 7 years who use institutional, paid at home, and unpaid childcare ....................................................................................................................... 14 Figure 3: Percent of child care facilities with different intensities of working mothers ............................ 15 Figure 4: How often is this provider at capacity? ....................................................................................... 18 Figure 5: Is this childcare provider currently accepting new clients? ......................................................... 19 Figure 6: Percent of childcare facilities by age groups service ................................................................... 20 Figure 7: Percentage of childcare providers offering service throughout the year calendar..................... 21 Figure 8: Percent of childcare providers with some price flexibility........................................................... 23 Figure 9: Childcare quality by country and sub-index ................................................................................ 26 Figure 10: Percent of people who agree with the statement: “A pre-school child is likely to suffer if his/her mother works”................................................................................................................................ 29 Figure 11: "Is this eldercare provider currently accepting new clients?" ................................................... 30 Figure 12: Eldercare quality by country and component ........................................................................... 33 Figure 13: Percent of people who agree, disagree, or neither with the following: "When parents are in need, daughters should take more caring responsibility than sons" ......................................................... 34 4 Executive Summary Despite an increase in female labor participation between 2012 and 2013, 79% of women of working age remain out of the labor market in Kosovo. The conflicting demand of women’s time for care and work activities represents a fundamental barrier to economic participation and generates a vicious circle of low labor market attachment and prominence of the care provider role that leads to increased vulnerability and gender-based inequalities. International evidence shows that support for child and elder care impacts women’s labor market participation. This note examines the care needs of families with children and/or elderly household members and the provision of formal care services in Kosovo with an emphasis on the availability, price and quality characteristics. Based on the analysis of an independent mixed methods dataset collected in the Western Balkans region, this note documents perceptions and barriers for use of quality formal care in Kosovo. Five main messages emerge from the assessment of supply and demand of formal childcare and eldercare in Kosovo: 1. Limited availability of affordable services underlies the relatively low utilization of formal childcare services. 2. There is demand of formal childcare services, voiced predominantly by parents perceiving benefits for child’s development and working (or willing to work) mothers. 3. Supply of eldercare is characterized by lack of day-based services and limited and expensive availability of residential care centers. 4. Social norms are a strong deterrent for use of residential eldercare while use of day-care centers and home-based formats –if available- would be more compatible with prevailing standards. 5. Quality is important for potential users of formal care services and the main challenges of the existing supply involve child-staff ratios and infrastructure (for childcare) and infrastructure and safety features (for eldercare). The rising demand for care services in Kosovo provides an opportunity to develop a formal care industry and increase labor force participation and productivity. Moreover, ongoing discussions about a reform to maternity provisions with the aim of strengthening women’s labor market participation call for accompanying actions to address child care needs. Policy options to appropriately address the challenges identified in this note include the expansion of publicly provided childcare centers, implementation of 5 public subsidies to private childcare provision and use, creation of education and accreditation programs to prepare caregivers and care-entrepreneurs, development of a system and plan to increase quality of services with attention to costs, and revising the legal framework to be adaptable to the demands and expectations of care. 6 I. Motivation: Why should we care about care? 1. Within families, the demand for time devoted to informal and at-home care falls disproportionately on women of all ages. In the Western Balkans countries, as well as in most of the world, it is well documented that childcare duties fall disproportionately on women. For the case of eldercare, while filial obligation on the part of the child might rest equally on daughters and sons, those more likely to act upon it are daughters and daughters-in-law (Box 1). In an expanded generational view, as mothers are expected to be the main childcare provider, grandmothers are often expected to provide care for grandchildren when mothers need support. 2. There is a negative circle of low female labor market attachment and prominence of the care provider role for women that leads to increased vulnerability and gender-based inequalities. Lower labor market attachment and earning potential of women -caused in part by the prominence of their childcare role- combined with women’s higher life expectancy, result in a higher propensity to become caregivers at one or another point in the lifecycle. As women spend more time engaging in unpaid, informal care work, they have less opportunity to work in the market. Studies looking at the relationship between caregiving and labor market outcomes show negative impacts both on the extensive and intensive margins and reduced human capital accumulation (Becker 1985, Behrman and Wolfe 1984, Ribar 1995, Jaumotte 2003). There is also evidence that caregivers receive lower wages, further discouraging labor force participation (Correll et al 2007, Carmichael and Charles 1998, 2003, Heitmueller and Inglis 2007). Together, these may contribute to reduced lifetime earnings for caregivers, leading to a disadvantaged position in terms of financial status, lower pension accumulation, and long-term economic vulnerability. 3. Policy interventions that appropriately address care demands would benefit not only women but the whole society as increasing labor force participation and productivity is vital for sustainable development. The rising demand for care services provides an opportunity to develop a formal care industry, which can contribute to long-term active aging objectives by recruiting younger old to care for older old, as well as increase female labor force participation, in particular for women with low skills. In terms of childcare, given that productive and reproductive years overlap for women, support for working mothers (and fathers) is essential to prevent women to drop out of the labor force due to childcare demands. This target cannot be attained without improved care services that not only free women to take part in paid work, but also ensure adequate human capital investment in the young generations. 4. The current demographic situation provides Kosovo with a unique opportunity for economic growth, poverty reduction and increase savings through greater labor participation. The number of dependents (children and elder) per economically active person will be at its minimum during the next 7 few years. Incorporating as many of these potential workers into paid work represents a unique opportunity for growth, poverty reduction and strengthening of public finances. Despite a significant increase in female labor participation and employment between 2012 and 2013, still 472,511 women (79%) aged 15 to 64 remain out of the labor market. 2 5. This note examines the provision of childcare and eldercare in Kosovo with an emphasis on the availability, price, and quality of care, and suggests policy priorities that address the identified challenges. The analysis in this note is based on a study aimed at exploring childcare and eldercare in the Western Balkans region, drawing primarily from a new mixed-methods dataset, described in the following section, and building on relevant quantitative surveys and data sources specific to Western Balkans countries. The note is structured as follows: Section II introduces the new, independent mixed methods data set that is the basis for the analysis and findings presented. Section III describes the use of formal care arrangements in Kosovo. Next, based on the analysis of perspectives both from families with care needs and from care providers and discussing the role of norms and perceptions of childcare and eldercare use, the following sections are dedicated to the description of supply and demand of childcare and eldercare, respectively. Sections IV and V focus on the supply and demand of childcare, and Sections VI and VII describe supply and demand of eldercare. Section VIII concludes by examining what we know in terms of policies that can support families in informal care provision in a sustainable and incentive- compatible manner. Box 1: Summary of literature review on care and female labor participation The impact of rising care duties on the time women devote to paid work can take the form of lower labor force participation or lower work intensity. The effect of rising care duties on female labor supply can take on numerous forms. Women can decide not to enter the labor force to attend to care demands or they can enter and at a later stage withdraw from the labor force altogether, thereby being affected on the extensive margin, or they can reduce working hours (for example, by starting to work part time or by requesting flexible work arrangements) or switch to jobs that are less time intensive and oftentimes more precarious, implying an intensive margin effect. In Central European countries, caregiving has an impact on the number of hours women work but not on their labor force attachment (Bolin et al. 2008). Spiess and Schneider (2003) demonstrate that a negative effect on work hours for women who start or increase caregiving does not reverse when caregiving is reduced. There is rich evidence that increased availability of formal childcare options results in improved labor force participation of women in many different contexts—in Brazil (Deutsch 1998; Paes de Barros et al. 2011); in rural Colombia (Attanasio and Vera-Hernandez, 2004); in urban Argentina (Berlinski and Galiani, 2007); in Japan (Asai et al. 2015); and in Canada (Lefebvre and Merrigan, 2008). Closer to the region, Del Boca and Locatelli (2006) used data from the European Community Household Panel to show that female labor force participation is affected by the availability, and even more importantly, affordability of childcare. Fong and Lokshin (2000) examined the 2 See “Results of the Kosovo 2013 Labour Force Survey”, Kosovo Agency of Statistics, Social Statistics Department, July 2014. 8 relationship between female labor supply and the cost of paid childcare in Romania between 1989 and 1995 and found that both female labor force participation and the decision to use paid childcare were sensitive to the price of childcare. In the Russian Federation, Lokshin (2000) used policy simulations based on panel household survey data to show that providing subsidies for paid childcare increased maternal employment by almost twice as much as comparable wage subsidies. In Turkey, a recent World Bank study (World Bank, 2015) also finds that mothers with low education have a limited willingness to pay, and will prefer a more basic provision of childcare –but of good quality- than a costlier system providing an expanded range of services within the childcare centers. Besides this extensive margin effect, childcare subsidies increased the amount of time working mothers spent at work and were more effective in raising the overall family income than any other policy intervention examined in the study. It is important to note that access to childcare can affect male labor market outcomes as well as female labor supply. Calderon (2014) examined the impacts of a Mexican government-provided childcare program and found that it not only increased female labor employment rates and earnings but also enabled men to spend time searching for better paid jobs. As with childcare, intensive eldercare duties can reduce female labor supply during the most productive years. There is a substantial body of evidence, from a variety of contexts, that intensive, time-demanding care, such as that requiring more than 20 hours per week, has significant negative effect on the likelihood of staying in the labor force (Jacobs et al. 2014a; Gabriele et al. 2011; OECD 2011; Lilly et al. 2010; Bolin et al. 2008; Heitmueller and Inglis, 2007; Henz. 2006; Johnson and Lo Sasso, 2000; Sarasa, 2006; Carmichael and Charles, 1998). Greater availability of formal eldercare options can be expected to affect female labor force participation, although evidence on this topic is so far limited. Heger (2014) uses SHARE data to look at caregivers’ employment and finds caregiving decreases employment rates in countries with low supply of formal care (or ‘family care countries’) by 34 to 60 percentage points depending on the frequency of care but has no impact on caregivers’ employment probability in countries with more established care systems. Earlier, Viitanen (2007), using the European Community Household Panel to simulate the effect of greater public expenditure on formal residential care and home-help services for the elderly, found a positive effect on the employment rate of 45–59-year-old women by 9–13 percentage points across Europe. Loken et al. (2014) examine a 1998 expansion of local, home-based care for the elderly in Norway, which resulted in a significant reduction of extended absences from work for adult daughters of single elderly. Geyer and Korfhage (2014) examine long-term care support in Germany and conclude that cash benefits discourage care providers from engaging in paid work, while benefits given in kind (and as such better substituting for the specific time commitment of the informal caregiver) provide incentives to already caring household members to increase labor supply. These findings confirm analysis by Todd (2013) showing that there are still few acceptable market-based options for eldercare in developing countries compared with childcare. II. A new, independent mixed-methods dataset 6. The World Bank collected a new, independent mixed methods dataset in order to investigate the changing care arrangements—specifically, childcare and eldercare—and its interaction with female labor force participation and productivity. This contribution sought to bridge a knowledge gap in terms 9 of the interaction between female labor force outcomes and care services in the ECA region, especially in the Western Balkans. In particular, on the demand side, it sought to collect new evidence and document the care needs of families with children and/or elderly household members, and the barriers they face in accessing care services. On the supply side, it investigated the quality, cost, and quality of care in the region. The study also builds up on relevant quantitative surveys including the Generations and Gender Survey (GGS), the Survey of Health, Ageing, and Retirement in Europe (SHARE), and data sources specific to Western Balkans countries, including the European Social Survey (ESS) and National Time Use Surveys (see Table 1 for a summary of data sources by Western Balkans countries). Table 1: Summary of data sources Western Balkans Independent ESS National TUS countries Data Albania X Bosnia and Herzegovina X Kosovo X X FYR Macedonia X X Montenegro Serbia X X 7. The field work, which was conducted between February and May 2014, was divided broadly into two components: (i) A supply assessment of available care services, and (ii) A household and demand assessment, including Focus Group Discussions (FGD) with adults with care needs, and questionnaires completed by participants. The supply assessment was a census-type study, which investigated the types of child and elder care services available to households, both public and private, and explored their accessibility, affordability, and quality. This included site visits, mixed methods interviews, and, when appropriate, quantitative observational checklists. The demand assessment targeted households with children and/or elders and included an investigation of time use, care needs, perceptions, and preferences about care responsibilities, as well as barriers in access to formal child or elder care services. Whenever possible, it followed the dynamics of care demand and supply at the household level, with women and their labor force engagement at the center. This assessment included quantitative individual-level questionnaires, as well as qualitative focus group discussions. Both childcare and eldercare providers were clearly defined (Table 2). 10 Table 2: Childcare and Eldercare definitions Childcare Eldercare Definition Care for children younger than primary Care for aging adults (no set ages school age, or care after-school for specified) older children Providers included Daycare, kindergarten, and preschool, Daycare, long-term care, permanent among others care and living facilities, and social clubs which are run by an administrator Providers excluded Live-in centers (such as orphanages) & Those primarily focused on medical those which are primarily focused on needs, such as hospitals education Results focus on Children younger than 6 years of age Live-in facilities 7. Both demand and supply assessments were conducted in each of seven countries: Kosovo, Bosnia and Herzegovina, FYR Macedonia, Serbia, Ukraine, Kyrgyz Republic, and Armenia. A total of 9 FGDs were held in Kosovo with working women, non-working women and men. The FGDs were held in 3 sites: in a rural community, in a small city, and in a middle-class neighborhood in the largest urban center of the country. For the supply assessment, 9 childcare facilities and 3 eldercare facilities were visited (Table 3). Participants were between 25 and 65 years of age and were spread across different age groups within the range (both younger and older) and experienced different types and levels of care responsibilities (such as childcare, eldercare, both childcare and eldercare). Employed respondents included those with different levels of work intensity (part-time and full-time) and both those who are self-employed and wage workers. The supply assessment was a census-type study of all childcare and eldercare services available in the sites we targeted for the demand assessment. It included public, private, and community- based care providers. Official documentation and snowball sampling were used, and providers mentioned in focus group discussions were included. 3 3 Snowball sampling, also called chain-referral sampling, refers to the non-probability sampling technique where existing study subjects recruit future subjects from among their acquaintances. 11 Table 3: Country-level data collected through independent mixed methods survey Childcare Eldercare Individuals FGDs Intermediaries Country facilities facilities Interviewed held assessed assessed assessed Kosovo 102 9 9 3 3 Bosnia and Herzegovina 107 12 8 5 0 FYR Macedonia 103 9 20 5 3 Serbia 108 9 18 8 4 Ukraine 99 9 51 2 10 Kyrgyz Republic 94 9 73 7 0 Armenia 121 9 30 3 1 Total 734 66 209 33 21 III. Use of Formal and Informal Care 8. Informal care in this study refers to unpaid and generally unregulated care, usually provided by family members, whereas formal care is defined as care that is paid and is thus regulated by some type of a contractual arrangement (Figure 1). In most countries, formal care tends to emerge as a response to support families in their caregiving role when that role cannot be fulfilled within the family. An interaction between prevailing social norms and institutional environment determines each society’s reliance on particular modalities of formal support for caregiving, such as leave arrangements, financial support, and in-kind services. 12 Figure 1: Typologies of care Formal Care Informal Care Refers to care for which recipients or family Refers to unpaid care. Informal caregivers members pay. It can include institutional (center- are usually family members, friends, or based) care, as well as residential (at home) care relatives of the care recipient. Childcare: mothers are seen as "natural" primary caregivers. Others, such as Institutional Care Residential Care grandparents, fathers, and siblings, can also be informal caregivers. Also referred to as Also referred to as center-based care, this center-based care, Eldercare: Unlike informal childcare, there is is a type of formal care. this is a type of formal no "natural" primary caregiver for It includes paid care care. It includes paid eldercare. This role is often, though not which occurs out of the care which occurs out always, taken by the elder's children, home. of the home. spouse, and/or household members Childcare: Examples Childcare: Examples include kindergartens include a nanny or and daycare facilities. babysitter. Eldercare: Examples Eldercare: Examples i l d i h include an at-home nurse. Source: Author’s based on Krauss et al (2010) 9. Use of formal childcare services in Kosovo, as well as in other countries of the region, is very low. Data from the Gender and Generations Survey depicts the prominent care arrangements for children 7 years and younger in Europe by groups of countries (Figure 2). Interestingly, the split between unpaid care and formal institutional childcare is most even in EU-13 countries as well as Eastern Partnership countries, suggesting that the two forms of care might be used as complements in these sub-regions. Individual interviews show that most childcare needs are met by informal care or a combination of formal and informal care. (Table 4). The analysis of supply and demand in the following sections will show that a combination of service availability and intra-household decision-making processes underlies the relatively low utilization of formal childcare services. 13 Figure 2: Percent of households with at least one child under 7 years who use institutional, paid at home, and unpaid childcare 100 % of households with a child under 7 80 65% 63% 57% 60 37% 41% 35 % 32 % 40 28 % 30 % 24 % years 20 0 EFTA, EU15 EU13 Western Balkans Eastern Young Countries Parternship in ECA Paid childcare inside the home (nanny/babysitter) Institutional/paid childcare outside the home Unpaid childcare Source: Authors’ calculations based on GGS data (most recent wave for Bulgaria, Russian Federation, Georgia, Romania, Lithuania, Poland, Czech Republic, Germany, France, the Netherlands, Norway, Austria, and Belgium) and fieldwork data (2014 data for Armenia, Bosnia and Herzegovina, Kosovo, Kyrgyz Republic, FYR Macedonia, Serbia, and Ukraine). Table 4: Percentage of women in the study with children 0-14 using different child care arrangements Only maternal Both Informal and care; no use of Formal Care Only Informal Care Only Formal Care either formal or informal care Armenia 4.2% 34.7% 61.1% 0% Bosnia and 13.4% 28.4% 13.4% 38.2% Herzegovina Kosovo 0% 0% 0% 98.4% Kyrgyz 14.6% 51.2% 13.4% 19.5% Macedonia, FYR 0% 69.2% 21.5% 6.2% Serbia 6.4% 41% 34.6% 14.1% Ukraine 9.3% 50.7% 26.7% 9.3% Total 7% 39.8% 26.5% 24% Source: Quantitative individual-level questionnaires, Independent field data (2014). Note: Users of formal care are those reporting to receive regular help from a day care center, a nursery or preschool, and after- school care center, a school, a self-organized group, a babysitter or from some other institutional or paid arrangement. Users of informal care are those reporting to receive regular help with childcare from relatives or friends or other people for whom caring for children is not a job. 14 10. Use of formal childcare strongly correlates with female labor force participation in Kosovo. As can be observed in Figure 3, childcare is mostly used by mothers who are working full-time or part-time, although there is considerable variation across countries. On one side of the spectrum, there is Slovenia, where 75 percent of mothers aged 25–49 years using childcare are working full-time and another 9 percent are working part-time and FYR Macedonia, where slightly more than 40 percent of childcare users are working. From the supply and demand assessment data, we can also see strong differences between Kosovo (where 90 percent of surveyed facilities had at least 80 percent working mother clientele) and Armenia (where very few facilities had a majority of working mothers as clientele). Whereas working women tend to use childcare services, some women who are not working or are working part-time cite childcare-related reasons for their reduced labor supply. Figure 3: Percent of child care facilities with different intensities of working mothers 100 90 80 70 60 81-100% 50 40 61-80% 30 20 41-60% 10 0 21-40% 1-20% 0% Source: Independent field data (2014). Note: The percentages of clients who are working mothers are based on responses from representatives of childcare facilities to the following question, “What percentage of mothers (whose children receive care here) are employed (‘working mothers’)?” 11. Evidence on the use of eldercare options is thinner, but suggests that most of the eldercare needs in the region are met using only informal care. In Kosovo, a small proportion of participants use formal care arrangements and 14% of women who care for and elderly in the qualitative study report receiving regular help from family or friends, however the great majority fulfills their care needs without regular use of other caregivers whether formal or informal (Table 5). Overall, qualitative analysis around supply and demand of formal elderly care suggests that social norms and quality considerations shape negative perceptions that dominate general views and decision-making processes. However, changing 15 needs of women and households, (both due to changing market and demographic conditions), push for a change of norms and programs around elderly care. Hence, new formats other than (or in addition to) residential care by family are necessary to suit these needs. Table 5: Percentage of women in the study who care for an elderly and use eldercare arrangements Only household Both Informal and female caregiver; no Formal Care Only Informal Care Only Formal Care use of either formal or informal care Armenia 0% 75% 1.7% 23.3% Bosnia and Herzegovina 2.1% 34% 4.3% 53.2% Kosovo 4.8% 14.3% 0% 78.6% Kyrgyz 28.3% 15.2% 47.8% 0% Macedonia, FYR 0% 54.8% 0% 40.5% Serbia 0% 63.5% 0% 36.5% Ukraine 0% 38.1% 0% 57.1% Total 4.7% 44.5% 7.3% 39.8% Source: Quantitative individual-level questionnaires, Independent field data (2014). Note: Users of formal care are those reporting to receive regular help from an institutional or paid arrangement. Users of informal care are those reporting to receive regular help with care for the elderly from relatives or friends or other people for whom caring for elder person is not a job. IV. Childcare Supply Availability is limited and existing childcare facilities are at over capacity 12. While participants voice challenges with regards to affordability and quality as well, overall accessibility of formal care, both in terms of location and capacity appears to be the most pressing problem with regards to childcare in Kosovo, with also impact on quality of services. Accessibility of quality and affordable childcare is voiced as a general problem across Western Balkans, where supply of care services does not seem to meet (actual or potential) demand from households. In focus groups discussions held with urban groups, regardless of the country, the two inter-related main problems mentioned by women were lack of sufficient facilities and restricted capacity for children’s enrollment. In other words, although there is some recognition of supply of care services that are theoretically accessible to households by location, this is eroded by problems of insufficient supply and low capacity. In rural groups, the main problem is the absence of childcare services; except for part-time compulsory pre- 16 schooling that were mentioned by some participants, there seems to be no kindergartens or alternate services for childcare in villages where the FGDs were held. 13. In rural areas it is understood that little or no childcare service provision exist (Table 6). Participants explained that, parents who are willing to use these services have to see if childcare is available in neighboring villages or towns and decide accordingly vis-a-via their resources whether or not to use these services. “We didn’t send [the children to kindergarten] because of financial difficulties and we didn’t have a daycare, we didn’t even have a kindergarten. There are people here who can send their children to daycare centers in Prishtina; they can if both husband and wife work (Rural woman, Kosovo).” Table 6: The supply of childcare providers in urban and rural areas Urban Small city Rural Average Average Average Number Total children Number Total children Number Total children of children served of children served of children served providers served per providers served per providers served per provider provider provider Bosnia and Herzegovina 2 440 220 3 180 60 3 270 90 Kosovo 8 1040 130 1 80 80 0 0 0 Macedonia 13 2375 183 2 345 173 1 120 120 Serbia 6 1323 221 5 681 136 2 136 68 Note: Total children served = total of capacity of all providers in the location. Ex: In Pristina, there were 8 providers who could altogether provide care for a total of 1,040 children. 14. In urban areas, insufficient number of affordable/public childcare centers and high demand from families creates a capacity problem and makes childcare inaccessible for many. Regardless of country, FGD participants reported that low capacities of the state-owned kindergarten are overarching problem that confronts urban families across Western Balkans. Most childcare providers in the region (67%) reported that they are "Always" or "Usually" at capacity. Less than 10% reported that they are "Rarely" or "Never" at capacity. In Kosovo, the majority report that they are “Always” or “Usually” at capacity. (Figure 4). 17 Figure 4: How often is this provider at capacity? 80 70 Kosovo 60 % of childcare providers Bosnia and Herzegovina 50 Macedonia, FYR 40 Serbia 30 Overall Western Balkan 20 countries 10 0 Always Usually Sometimes Rarely Never Source: Questionnaires to childcare providers, Independent field data (2014). 15. A problem of under-supply is especially present in Kosovo: only 22% of providers can accept new clients without putting them on a waitlist. Participants across Western Balkan focus groups explained that there are kindergartens, but enrollment is managed by long waiting lists, and often times families’ turn might never arrive. The supply-side data shows that in Kosovo more than a third of providers are not accepting clients at all (Figure 5). In the Western Balkans, the average waitlist already has 47 people on it. In focus group discussions, participants across the region explained that nepotism is perceived to be common and necessary as a way out of this problem –“you need to pull some strings to get in”– which is not an option for the majority of the citizens. 18 Figure 5: Is this childcare provider currently accepting new clients? 100 13 13 8 14 90 80 33 25 % of Childcare Providers 70 34 50 60 No 50 44 92 40 Yes, but there is a waitlist 30 63 52 Yes, and there is no 20 38 waitlist 10 22 0 Kosovo Macedonia Overall BiH Serbia , FYR Western Balkan countries Source: Questionnaire to childcare providers, Independent field data (2014). 16. In Kosovo, coverage of younger children is more expanded than elsewhere the region, since most other countries’ service providers are focused on older children. In Bosnia and Herzegovina and Macedonia FRY, for example, fewer than half of providers included in the supply-side data cater to children younger than 2 years old (Figure 6). 19 Figure 6: Percent of childcare facilities by age groups service 5 years 4 years Macedonia, FYR 3 years Bosnia and Herzegovina Serbia 2 years Kosovo Under 2 years 0 20 40 60 80 100 Percent of childcare facilities serving this age group Source: Questionnaire to childcare providers, Independent field data (2014). 17. In urban areas in Kosovo, current provision of child care services does not meet (actual and potential) demand. The gap between supply and demand of care services is manifested by common references in FGDs to overcrowding, particularly in public care centers. It is understood that many childcare centers already function above their capacity in terms of both physical space and utilities, and staff. Furthermore, lack of capacity means that not everyone can be enrolled in kindergartens despite their willingness; indeed, nepotism as a means of access to these services was also mentioned by several participants during discussions. “In a public daycare they’ll accept your child if you have someone there, a known person” (Urban woman, Kosovo). 18. The issue of overcrowding in kindergartens due to insufficient service supply, and consequent high child-staff ratios seems to be a common chronic problem across Western Balkans with various detrimental quality implications. Overcrowding seems to affect public kindergartens the most and the number children that were mentioned across groups by class ranged from 30 to 60 children. The need for having more care staff to match the number of children (teachers) for adequate care was repeatedly voiced across groups. In some groups the number of children mentioned per staff was as high as 50. It was observed that even in cases where pre-schooling is mandatory by the state, and so high enrollment 20 rates are to be expected, such as in Serbia, the capacities of facilities were still not perceived to meet the number of children. 19. There are indications that regulation and/or formal practices also limit accessibility to childcare. In one FGD it was reported that enrollment in public kindergartens is conditional on the employment status of the mother, and that only children of working mothers are accepted, making it very difficult for unemployed women to look for jobs while also bearing the burden of care. In another FGD, a participant reported that enrollment in an urban public care center was dependent on the place of residence as opposed to place of employment. “There is no way that they get accepted in a public daycare if they are from village and come here to Prishtina”. (Urban woman, Kosovo). 20. There are limited options of formal childcare service offered year round. Hours of operation and service offering throughout the year calendar are crucial characteristics for accessibility. In Kosovo, there are few options of services that operate during the summer months: in urban areas, only 25% of facilities are open in July and August (Figure 7). In terms of opening hours during the day, the supply-side data shows similar average opening and closing times across the region. During the weekdays, childcare providers tend to open early (between 6 and 7 am), but very few are open after 6 pm. Fewer than 7% of childcare providers are open on the weekends. Figure 7: Percentage of childcare providers offering service throughout the year calendar 120 % of childcare providers offering service 100 80 60 40 20 0 Armenia Bosnia and Herzegovina Kosovo Kyrgyzstan Source: Questionnaire to childcare providers, Independent field data (2014). 21 Unaffordability is an important barrier to childcare use 21. Problems of affordability of care are frequently referred as a barrier to use childcare services. There is a general perception that kindergartens are very expensive. It was understood that costs of public care was less than private care centers. It was also understood that while public care is more affordable than private care, and although there were many participants who stated that public care was affordable, still there is an overall affordability problem that makes these services inaccessible for some segments of the population. 4 Moreover, for some more disadvantaged segments of the population that work for less pay (or minimum wage), income is not enough to cover costs of care services they want to use. 22. Subsidized or free public provision is almost non-existent among the participating childcare providers. A mere three percent of public childcare providers offer full-day care for free, and none of the private providers do. A monthly deposit is the most common arrangement (97% of public providers and 83% of private providers), though some private providers also require an entry deposit. In the middle- class neighborhood in Pristina where our supply-side assessment was conducted, full-day monthly pricing was offered by all eight providers. The overall average price was €66, with an average of €49 for the five public providers and €93 for the three private providers. 23. Many childcare providers offer discounts to families, especially for bringing multiple children to the provider or when family income falls below a certain level. In Kosovo, 89% of providers interviewed offered some type of discount, making it the leader in our sample of the region (Figure 8). Though the discounts vary by public and private providers, the most common discounts provided in the region overall are for the number of children from a family who go to a given center, the monthly incomes of family, whether the father is a war invalid, and whether the family is using social assistance. 4 There is need for further research in this, as it is not possible to tell from FGDs and qualitative analysis with segments of the population can afford the currently available services, or what the conditions are for affordability. 22 Figure 8: Percent of childcare providers with some price flexibility 100 89 90 85 81 80 73 70 Percent of childcare providers 60 50 47 38 40 29 30 20 10 0 Ukraine Bosnia and Kyrgyzstan Armenia Macedonia, Serbia Kosovo Herzegovina FYR Source: Questionnaire to child care providers, Independent field data (2014). 24. In urban areas costs of public childcare seem to be affordable, and yet suffer from other barriers to use, particularly accessibility by location and capacity, as well as regulative challenges mentioned above. Moreover, discussions suggest that, number of children in the family also affects some parents’ perceptions of affordability: some participants mentioned that they would be able to send only one of their children and not the other(s) although they would like to do so. 25. Private care services in urban areas seem to be inaccessible for the majority of the population due to high costs. Some participants explained that as an alternate to public care, private services do not suffer from the capacity problems that are borne by the former, and sometimes offer higher quality services. However they also seem to be unaffordable for the majority of the population due to high costs. 26. In rural areas where little or no formal childcare exists, costs of transportation to use services in neighboring locations, both in terms of finances and time, was explained to create an affordability problem. There are no kindergartens in rural areas, yet some families might use care centers in the 23 nearing villages or towns if they have such facilities. However some participants explained that the financial and time costs of transportation are high and many cannot afford it. “It’s true that you can’t afford to send and drive your children to daycare in the city everyday” (Rural woman, Kosovo). 27. It was also suggested in discussions that inadequate earnings difference between women’s (potential or actual) and costs of formal childcare also create an affordability problem. Few participants in the urban groups mentioned that state should address this problem and subsidize childcare. “So we don’t have to go and work for 200 Euros and give 150 Euros of this to daycare” (Urban woman, Kosovo). Main challenges for quality childcare provision are high child-staff ratios and infrastructure 28. Quality perceptions and expectations of participants in Western Balkan FGDs were discussed around three main themes: (i) quality of basic care services including infrastructure, (ii) quality of ECD activities, and (iii) quality of caregiving staff. Quality of basic services, by participants’ own accounts, includes sufficient care provision for children’s basic needs such as eating, cleaning, sleeping as well as measures that ensure children’s health, safety and security. Quality of ECD activities relates to the content and/or variety of activities that benefit children’s social, behavioral and cognitive development, such as drawing, playing, singing, doing physical activities, as well as socio-behavioral education provided by caregivers. Quality of caregiving staff is described in FGDs with regards to capabilities of caregivers in adequately meeting both basic and ECD needs of children, and therefore is closely related to both the basic service quality and the quality of ECD. 29. Overcrowding in public centers due to low capacity and inadequate supply seems to be the major problem in most Balkan FGDs with regards to quality, and Kosovo is no exception. Not only overcrowding itself is a problem, but also it negatively impacts other quality attributes of care services, such as teacher attentiveness or epidemics. The primary problems that were voiced in Kosovo FGDs with regards to quality are as follows: a. Overcrowding and very high child-staff ratios. In some groups the number of children per staff (teacher) was mentioned as high as 60. b. Low quality of basic services. For example, low hygiene standards in the facilities and/or inadequate teacher attentiveness to children’s basic care needs, such as hygiene or feeding. 24 c. Healthcare risks for children. Frequent epidemics in particular, and especially flu, seem to be a general problem for public childcare centers. Furthermore, level of staff attentiveness to children’s security as well as staff behavior also seems to be problematic in many cases. d. Unsatisfactory qualifications of teachers and/or staff. For example, observations regarding maltreatment of children by teacher, such as yelling, physical harm, etc. 30. Quality of services is an important determinant of parents’ perceptions of use of these centers and their evaluation of the benefits and/or harms of these centers on children. For example: I heard someone saying that they stopped sending their children to daycare because the kitchen is all mold. Where they prepare children’s food is very dirty; you are not assured with what is fed you child. (Rural woman, Kosovo) 31. In Kosovo FGDs, the distinction between public and private childcare did not seem to be significant with regards to perceptions about quality of basic services & staff. The quality problems seem to be general when they exist and the happiness of parents with the quality of services do not always depend on whether the center is public or private.5 However quality expectations from private care are higher with regards to public due to the fact that latter is a paid service. 32. To complement the focus group discussions, supply-side data used a principal component analysis method to created three equally weighted quality sub-indices. These mirrored the central concerns raised in focus group discussions, and include the following: 1) Infrastructure quality sub-index, 2) Materials, curriculum, and learning quality (MCLQ) sub-index, and 3) HR quality sub-index. All inputs varied between 0 and 1. The sub-indices and the overall scores were standardized to a scale between 0- 100, where a higher score indicates better quality. The first sub-index, infrastructure, includes 17 indicators such as whether the space is in good repair and if there is no malodor in the classrooms. The second sub-index, materials, curriculum, and learning, includes eight indicators, including whether children are served food and if there are any provisions for children with special needs. The final sub- index, HR quality, includes four indicators, including whether the caregivers’ minimum credentials include higher school or university, and if a small group of children is primarily cared for by one designated staff member. Full details of the sub-indices can be found in Annex 1. 33. In Kosovo, overall quality of childcare services ranks just below Western Balkans average with a particularly strong score in materials, curriculum and learning, and the greater challenge in quality of infrastructure. At 93, Kosovo’s MCLQ score is particularly stronger – even higher than the Western Balkans 5In comparison to other Balkan FGDs, relatively less emphasis on the quality of private care centers were made; there were also participants who had a higher view of the quality of public service provision than private services provision. 25 average. Though Kosovo’s human resources score is above the average, it is still below 70. Kosovo’s infrastructure score comes to only 59, making it the worst infrastructure score in the sample. (Figure 9). Figure 9: Childcare quality by country and sub-index 100 90 80 70 Value of index 60 Bosnia and Herzegovina 50 Kosovo 40 Overall Western Balkans 30 Serbia 20 10 Macedonia, FYR 0 Overall Quality Infrastructure Human Materials, Resources Curriculum, and Learning Quality Source: Author’s calculations based on data from visits to child care facilities, Independent field data (2014). V. Demand for childcare Main determinants of childcare demand: Perception of benefits for children’s development and need of support for working/willing to work mothers 34. Regardless of location (urban/rural distinction) the need and demand for and willingness to use childcare services have been voiced primarily by: a. Those parents who believe that children will benefit from the education and social environment, and/or b. Those women with little or no informal childcare support and yet are working or are willing to work. 26 35. Benefits of childcare for children’s social and cognitive development is stated as an important motivation among parents for using formal care services across Kosovar FGDs. 6 The emphasis in children’s development however differs across urban and rural groups. Women in Kosovo urban FGDs emphasized a broad set of benefits related to early childhood education, and explained that enrollment of children in care centers allows children to socialize with own age group, learn basic self-care tasks, become more independent, learn and adopt to a routine, and learning new words, improving their self- expression skills. Rural women on the other hand, emphasized benefits of care center enrollment for future school readiness and success. In both rural and urban groups some mentioned that enrollment in care centers was better for children’s education and development in comparison to being brought up by elders at home. 36. Perceptions regarding benefits of care centers on children are highly related to perceptions regarding the quality of these centers. Several participants pointed that it was the higher child-staff ratios and/or and lack of qualified teachers that curbed benefits of these services for children. Participants believe that having more and more qualified teachers per children will increase both the amount and quality of time spent with children, ensuring that children benefit more from these centers. “Such services is not good, neither for me nor for my daughter. The ideal children daycare should have space, have professional staff, not like now anyone can work on a daycare, I don’t trust these services” (Urban woman, Kosovo) 37. Overall, use of childcare by children of age 5-6 is widely accepted in Kosovo, regardless of location or working status, particularly for purposes of early childhood education and school readiness. However views differ across individuals with regards to younger ages. 7 Discussions suggest that it is seen to be natural for children of younger ages to be enrolled in kindergarten if the mother is working. If the mother is based at home during the day, then the child’s positive or negative attitude towards kindergarten might have a stronger influence on the enrollment decision of families. 6 Among a total of 49 mentions in Kosovo FGDs, 59% were mentions of positive perceptions, and 41% were mentioned of negative perceptions/challenges. 7 The views among participants about enrollment of children of ages 5-6 were very clearly stated and therefore are also mentioned in this report. However views for children younger than 5 varied, were not always clear (both with regards to specific age and rationale) and were not probed systematically during the discussions. Accordingly, further research is needed to understand perceptions about age and enrollment in Kosovo. (Note that the issue of age was not discussed in detail in the overall ECA discussions, in this respect Kosovo is not an exception). 27 38. Discussions also suggest that formal childcare services benefit (actual or potential) working women, enabling them to participate in the labor force, as well as look for jobs. Similarly inaccessibility and unaffordability of formal care seems to inhibit women’s working potential, by forcing them to quit their jobs, or preventing them from resuming work. 8 Discussions point out that this is all the more important for single mothers, such as those who lost their partners in war and who have to assume the role of being head of the family. “I used to work before the War; we had a small shop we managed together with my husband. After he passed away after the war I couldn’t do it all alone with small children. I couldn’t send them to daycare because of financial problems; I couldn’t afford it. So I had to close the shop. (Urban woman, Kosovo) 39. Furthermore, according to discussions, inaccessibility / unaffordability of childcare also has longer term implications for women, as the career breaks due care responsibilities makes it harder for women to get back to the labor force. Participants drew attention to the fact that childcare benefits women not only in the short-term by enabling them to work, but also in the longer term by increasing the likelihood and the quality of their employment. “When you don’t find a solution for your children you stop working, when they grew, we get old, now you can’t get a job. This is what our cost was; now 80% of the village is unemployed” (Rural woman, Kosovo). Social norms play a significant role in shaping negative perceptions about childcare use 40. However, norms on childcare, work, and motherhood may play a role in shaping negative perceptions on use of care centers. Although mentions of norms in shaping negative perceptions were very few, 69% of individuals reported agreement with the following statement: “A pre-school child is likely to suffer if his/her mother works” (Figure 10). 8 Unemployment was also mentioned as a significant problem in Kosovo, and more than other Western Balkan countries, in this respect childcare was not the only problem that inhibited women’s working potential. 28 Figure 10: Percent of people who agree with the statement: “A pre-school child is likely to suffer if his/her mother works” 100% 3% 2% 11% 90% 19% 30% 28% 26% 10% 80% 70% 58% 51% 23% 60% 50% 34% 40% 21% 79% 69% 72% 30% 23% 58% 20% 36% 10% 27% 19% 0% Serbia Macedonia Bosnia and Ukraine Kosovo Kyrgyz Armenia Herzegovina Agree Neither agree nor disagree Disagree Source: Independent field data (2014). VI. Eldercare Supply Limited availability of residential eldercare and lack of day-based services characterize supply in Kosovo 41. FGDs suggest that there is an accessibility problem regarding residential eldercare centers, both in terms of location and capacity. When asked about availability, participants mentioned that residential care centers for elderly in urban centers are generally few, and the existing ones are not geographically accessible by all participants and/or suffer from insufficient capacity and higher elder-staff ratios that make in inaccessible for some citizens are far away and/or suffer from insufficient capacity. Supply side data shows the limited number and capacity of live-in eldercare centers, especially in rural areas (Table 7). In Kosovo, the study found only one live-in eldercare provider in our urban catchment area, one in the small city, and none in the rural area. Furthermore, having no vacancy for newcomers, waiting lists, and insufficient infrastructure and staff capacity were mentioned as a shared social problem across urban FGDs, suggesting that the supply of residential care for elderly was below need and/or (potential) demand. In Kosovo, both (100% of) live-in eldercare facilities have a waitlist (Figure 11). 29 Table 7: Live-in eldercare provision by country Urban Small city Rural Number of Total elders Average Number Total Average Number Total Average providers served elders of elders elders of elders elders served providers served served providers served served per per per provider provider provider Kosovo 1 110 110 1 20 20 0 0 -- Bosnia 2 585 293 1 155 155 2 320 160 and Herzegovi na Macedoni 2 173 87 2 20 10 1 20 20 a Serbia 6 936 156 1 220 110 0 0 -- Armenia 2 42 21 0 0 -- 0 0 -- Kyrgyzstan 2 955 478 2 131 131 1 11 11 Ukraine 0 0 -- 1 250 250 0 0 -- Source: Independent field data (2014). Note: Total elders served = total of capacity of all providers in the location. Figure 11: "Is this eldercare provider currently accepting new clients?" 100 5 90 20 % of eldercare providers 80 43 70 60 53 60 40 50 100 No 40 30 57 Yes, but there is a waitlist 20 40 40 42 Yes, and there is no waitlist 10 0 Kosovo Bosnia and Macedonia Overall Serbia Herzegovina Western Balkan countries Source: Questionnaire to eldercare facilities, Independent field data (2014). 30 42. Regulations / conditions about acceptance might limit access to services. In FGDs it is suggested that availability of services depends on retirement plans and pensions bringing to mind the question of care service availability for those aging citizens who do not have social security, pensions or property. 9 43. Recreational facilities with day-based services that are demanded by the participants exist only to a limited extent. These refer to recreational facilities for socialization of elderly. There is demand for facilities of this type which would also provide basic medical and day-to-day assistance for elderly. “I don’t understand something: we all send our children to daycare to work or do something; when it comes to elderly we all back off. What if there was an elderly daycare from 8 am to 4 pm? Elderly are just like children, maybe they could accept that?" (Rural woman, Kosovo) Residential eldercare and at-home private care options are very expensive 44. Quality urban residential care and at-home private nurses for elderly are generally very expensive and cannot be afforded by the majority. Retirement pensions of elderly affect affordability of residential care or at-home private care options and hence decisions. Pensions are seen to be the ideal potential source for formal care of elderly, however in many occasions they are not sufficient enough to cover the costs of care, leading families to use informal care. “We would pay if it were not very expensive. For example my mother’s pension is 60 Euros and we (meaning siblings) would have to put the rest of the money [to collect the fee]. It all depends on what they offer: food, and do they have doctors to take care of them during that time? No one in Kosovo has money to pay that much for quality elderly care. It should be affordable.” (Urban woman, Kosovo) 45. Among the live-in eldercare providers in the sample, care is never offered free of charge. Of the live-in providers sampled across the Western Balkans, 83% charge a monthly fee, and the remaining providers use a different pricing scheme. In Skopje, for example, of the six live-in eldercare providers (two of which are public and four of which are private), all charge using a monthly fee. The cost of basic services ranges from € 420-500 (50,000-59,500 dinar), with an average of € 446 (53,000 dinar) approximately equivalent to the total amount of an average monthly wage in Kosovo (€ 440) 10. The public providers cost an average of € 467 (55,500 dinar), and the private providers cost an average of € 435 (51,750). Though it may seem surprising for the private providers to cost less on average, both require additional fees for an upgraded room and/or for an elder who has poor health. They also both offer discounts for a simpler room, and one also offers a discount for low-income elders. 9 This was also mentioned in Macedonian FGDs 10 According to the Kosovo Agency of Statistics, the average monthly wage in Kosovo in May 2014 was approximately € 440. 31 46. Unlike childcare providers, only a third of eldercare providers offer price reductions for certain services, individuals, or families. The most common price reductions are based on elders’ monthly income (5 providers) and family situation (3 providers). Other discounts are given based on the type of room, elder’s health condition, and elder’s status as a war invalid (2 providers each). Infrastructure and safety are the main challenges for quality provision of eldercare 47. Regardless of location or gender, there is agreement across the WB FGDs that affordable center- based institutional services that are available for elderly suffer from serious quality impediments, and that the quality of care provision is far below standards that could be considered adequate. Among all FGDs, the perceptions about quality seems to be relatively better in Bosnia and Serbia, however it is understood that some of the major problems associated with these services that are related to capacity, staff and basic service conditions are problematic in all countries. 48. Provision of basic quality services is a particular problem regarding elder-care centers. Particularly public elderly homes are thought to suffer from lack of hygiene, poor infrastructure (such as stuffy rooms), and poor staff qualifications. Poor quality also affects norms regarding use of these services negatively. “I have been once [to an elderly home], for I have a friend that works there, but I didn’t like it at all. The care was not good, employers were rough, I didn’t like it. You know how educators are close with children? [The care givers in elderly homes] should be the same with the elderly and treat them with warmth and care." (Urban woman, Kosovo) 49. As with childcare, supply-side data on quality was collected to complement the focus group discussions. A principal component analysis method to create four equally weighted quality sub-indices (one more than in the childcare analysis). These mirrored the central concerns raised in focus group discussions, and include the following: 1) Infrastructure and safety quality sub-index, 2) Schedule, activities, and materials quality sub-index, 3) HR quality sub-index, and 4) Special needs, healthcare, and support quality sub-index. All inputs varied between 0 and 1. The sub-indices and the overall scores were standardized to a scale between 0-100. The first sub-index, infrastructure, includes 24 indicators such as whether the space is in good repair and if there is no malodor in the classrooms, as in the childcare sub- index, along with a questions relevant specifically to live-in elders, such as whether clinical mattresses or beds are available. The second sub-index, schedule, activities, and materials quality (SAMQ), includes 16 indicators. Again, some indicators are the same or similar to those used in childcare, including whether care recipients are served food, and some that are specific to live-in elder care, such as whether there are 32 visiting hours for family members. The third sub-index, HR quality, includes 8 indicators, such whether elders are organized into groups and whether staff members make an effort to ensure that the elder feels respected. The final indicator, special needs, health, and support quality (SHSQ), is unique to eldercare and includes 14 indicators, such as whether there are special services for elders with dementia and whether routine medical care is available. Full details of the sub-indices can be found in Annex 2. 50. The two strongest components of the quality index for eldercare services in Kosovo are “Special needs, Healthcare and Support”, and “Human Resources”. The main challenges are Infrastructure and safety. Kosovo leads in the region in terms of human resources quality, with a score of 75, though it has below average scores in infrastructure and safety, SAMQ, and SHSQ. (Figure 12). Figure 12: Eldercare quality by country and component 100 90 80 70 Value of index 60 Serbia 50 Bosnia and Herzegovina 40 Western Balkans overall 30 20 Kosovo 10 Macedonia, FYR 0 Overall Human Infrastructure Schedule, Special needs, Quality Resources & Safety Activities, and Healthcare, Materials and Support Quality Quality Source: Author’s calculation based on visits to eldercare facilities, Independent field data (2014). VII. Demand for eldercare Filial obligations and social norms are a strong deterrent for residential eldercare use 51. There is a marked mismatch between available care formats and norms of care in Kosovo. This mismatch is true of all ECA countries including the Western Balkans, and it results especially marked in Kosovo where Qualitative analysis of FGDs show that residential care format which is the elder care format available, stands in contradiction with the social norms and filial obligations of families. Specifically, social norms imply that informal eldercare is mainly a task for women and girls (Figure 13). 33 “I wouldn’t want somebody to put a finger on me pointing on me: ‘she sends her mother-in-law to Elderly Home!’” (Urban woman, Kosovo) Figure 13: Percent of people who agree, disagree, or neither with the following: "When parents are in need, daughters should take more caring responsibility than sons" 100% 90% 25% 28% 80% 43% 70% 55% 61% 64% 67% 60% 32% 34% 50% 40% 32% 17% 30% 22% 17% 20% 20% 43% 38% 25% 29% 10% 17% 19% 13% 0% Macedonia Ukraine Serbia Bosnia and Armenia Kyrgyz Kosovo Herzegovina Agree Neither agree nor disagree Disagree Source: Independent field data (2014). Day-care centers and home-based formal eldercare formats are more compatible with social norms 52. Other formats such as day-care centers or home-based formal eldercare are viewed more positively by Kosovars, both urban and rural, as they are seen to be more compatible with the norms that emphasize the well-being of the elderly. However it is understood that accessibility of such services are at best limited and unsystematic. “I would send my father-in-law if there were elderly daycare, just during the day, but to leave him there forever, no; I would feel bad. I don’t know it’s a pity to leave him there (Urban woman, Kosovo). 34 “There is an elderly home but it would be better if we had daycare for elderly to send them in the morning and pick them up after work. [Then] I would send my parents to elderly daycare. That would be very good because then while you work you would know that somebody takes care of them at the daycare. Otherwise you have to quit” (Urban woman, Kosovo). 53. Generally, the preferred format for care of elderly voiced by the participants, is informal care for elderly at home. Caring for elderly at home by family members is viewed by many participants, as an obligation as well as the most appropriate way of helping their aging loved ones to live out their remaining years in comfort, health, peace and dignity, in the companionship of their loved ones. Focus group discussions suggest that this is both due to social norms that emphasize filial obligations and to the belief that the care needs of the elders (social-emotional needs / companionship, medical assistance needs and basic day-to-day needs such as house chores, self-care and security) can be best met at home by relatives vis-à-vis current provision of services. 54. The current formats and quality of formal care service supply, and particularly residential care, 11 for elderly is seen as by most participants as inadequate in addressing the care needs of the elderly and therefore mostly incompatible with social norms. Poor quality of centers also seems to have a role in shaping the norms against use and therefore for many, residential care centers are seen to be for elderly with no family or care support. Accordingly, it is observed that participants’ perceptions of the need for and benefits of use of formal care services are limited in comparison to formal childcare. 55. Ability to identify needs and imagine benefits of formal care for elders is more developed in the Western Balkan FGDs, including Kosovo. In these countries’ FGDs the ability to define benefits of use of formal eldercare is also related to alternate formats that are more compatible with the norms, and are also conditional on the fact that these services offer adequate quality. “Here in Kosovo, It is the people’s mentality there that we don’t use the Elderly Home, people feel that it is very tragic if someone goes. But if there is no one to take care of you, then you have to go. In Kosovo the conditions [of these centers] aren’t that great, not even at the hospital, but that is what we have” (Urban woman, Kosovo). 56. The benefits of eldercare for the care receiver elderly mentioned in the Kosovo FGDs include the following: 11 Residential care for elderly refers to these centers where the elderly citizens reside / live, as opposed to adult day-care centers which provide care for elders only during day times, much like childcare. The most common format of residential care across ECA countries is the nursing homes. 35 • Elderly care centers benefit the elderly for meeting their needs of companionship. Eldercare centers, and (imagined or actual) day-care centers for elderly in particular, can provide spaces for the socialization of the elderly, and meet their needs for companionship during the day. • Residential care centers benefit those elderly that do not have family to care for them. This becomes an important issue particularly because migration abroad for work is becoming more common among younger generation of Kosovars, according to some participants. • Residential care centers can benefit those elderly in need of medical care. Participants explained that these services can be better than care at home for those elderly who needed constant medical attention and/or physical care labor. 12 • Private home-based care services (such as nurses) benefit the elderly who have demanding care and/or medical needs. This way the elderly stays with his/her family in accordance with the care norms, and the burden of care on the caregiver is also relieved. “I don’t think is that tragic to go [to an elderly canter] Why not? There you have medical care, you have friends, you can accept visitors: son, daughter, sister, brother they can visit. (Urban woman, Kosovo). 57. Day care facilities for elderly were seen by Kosovars as a normatively correct solution for care tasks that can facilitate women’s participation in the labor force. Just like childcare, eldercare might hinder women’s participation in the labor force and/or cause interruptions, due to care tasks that need to be undertaken during the day, and the fact that women are the usual informal caregivers. Free home- based services that are provided by NGOs or social services in regular intervals provide benefit both caregivers and receivers. Such services lighten the burden of care on the informal caregivers and improve the quality of care received by the elders. “Normally we have to let go of some things we want to do… For example if the [elderly] don’t feel good you can’t leave them alone at home. As for me, I didn’t look for a job because I can’t leave them alone” (Urban woman, Kosovo). 58. From the public policy perspective, the reasons for directing public resources to support child and eldercare are not the same; however, the focus on the care recipient remains constant. In terms of policies, there are two sides when it comes to care, those intended at improving the outcomes of the recipient. For children, early childhood development via education and care to reduce inequalities later in life; for the elderly, the main focus is to protect them from increased vulnerability after retirement and to limit the effects of age-related functional limitations on the elderly quality of life, respecting their 12 This view was also mentioned in Bosnia and Serbia. 36 preferences. From the care provider side, the main focus is to support them in their care responsibilities and duties, so these responsibilities do not affect their access to opportunities and do not generate unintended effects such as increasing gender gaps in labor outcomes. 13 “Let’s say that your son and daughter-in-law are working, and then you get sick. What are they going to do? Quit their job? Because of you, to take care of you? …Because they can’t send you anywhere? If there had been be an institution where they could send you during the day, you would not be a burden for your family. … People still thinks that if you send them to Elderly Home, you are sending them there to mislay them [sic]. This mentality needs to change because the Elderly Home is not that harmful. (Rural woman, Kosovo). VIII. Conclusions and Policy Recommendations 59. Kosovo needs to increase labor participation among men and women alike, and capitalize the investments of valuable resources in education of a large group of young women by implementing policies to help balance care and work responsibilities. Policy efforts for adequate job creation need to be accompanied by policies addressing care needs. Women tend to reduce their labor supply on either the extensive or intensive margin when market, normative, and institutional forces push them toward fulfilling their caregiving mandate in the household. Career interruptions or reductions in work hours can have a permanent negative impact on women’s lifetime income, affecting their households’ current living standards and human capital investments as well as future well-being due to reduced pension wealth and damaged health. 60. Given the current demographic situation of Kosovo, implementation of formal care systems is strongly compatible with the short and long term objectives of economic growth and poverty reduction and savings objectives. The expansion of formal care services can present a double benefit for the population: A well-developed childcare sector not only helps generating economic participation opportunities for women but also implies potential improvements in the school readiness for children via better coverage of early childhood education; this, in turn, can translate into higher human capital accumulation, which is vital for sustaining economic growth. Similarly, quality provision of formal eldercare can potentially improve health outcomes of the elderly through prevention, early detection, and consistent maintenance of chronic diseases, which may imply long-term cost savings in the health care sector. 13 For example, for the case of Chile, Prada, Rucci and Urzua (2015) show that a mandated child care policy that introduces differential cost in hiring and employing women has negative impacts on wages. 37 61. Analysis in this report shows evidence of a mismatch in the market for care services in terms of expectations on availability, prices and quality between the supply and demand that is mainly caused by a lack of adequate public provision or financing to cover the latent demand. Current challenges in terms of supply and demand of childcare and eldercare services are summarized below in five salient points: (i) limited availability of affordable services that underlies the relatively low utilization of formal childcare services, (ii) latent demand of formal childcare services that is voiced predominantly by parents perceiving benefits for child’s development and working (or willing to work) mothers, (iii) lack of day- based services and limited and expensive availability of residential care centers, (iv) social norms that act as a strong deterrent for use of residential eldercare while use of day-care centers and home-based formats –if available- would be more compatible with prevailing standards, and v) the main challenges of the existing supply in terms of quality - an important factor for potential users of formal care services- involve child-staff ratios and infrastructure (for childcare) and infrastructure and safety features (for eldercare). 62. The rising demand for care services in Kosovo provides an opportunity to develop a formal care industry and increase labor force participation and productivity. Policy priorities to appropriately address the challenges identified in this note include the expansion of publicly provided childcare centers, implementation of public subsidies to private childcare provision and use, creation of education and accreditation programs to prepare caregivers and care-entrepreneurs, development of a system and plan to increase quality of services with attention to costs, and revising the legal framework to be adaptable to the demands and expectations of care. 63. In terms of childcare, comprehensive policies that target both the supply and availability while making services more affordable particularly for women who have potential to join the labor market, are expected and likely to have a high employment impact. The employment impact of a purely demand side subsidy is likely to be limited in the short term. In order to tackle the real problem of accessing affordable and quality child care, a viable alternative is a neighborhood program –made widely available through public or private subsidized provision and based on the expectations of mothers and fathers- combined with a demand side transfer for households with difficulties to afford the services. 64. In terms of eldercare, evidence suggest prioritization of day-care provision and at-home support policies over institutionalization and long-term care in medical institutions. At-home systems of elderly care and treatment make essential to have efficient, multi-professional workers capable of working with elderly people and their families. Government investment in training programs for staff working in elderly care is essential to ensure high standards. 65. Crucial elements in the design of care systems for successfully achievement of intended impacts are the gender neutrality in financing and service characteristics tailored to address constraints related 38 to labor market participation. In order to avoid unintended effects such as increasing gender gaps in labor outcomes or having low take-up of care facilities, the design and implementation of care programs will require i) avoiding differential costs in hiring and employing women and men –for example, mandated benefits that imply for employers higher costs of employing a women versus a men, and ii) providing flexibility in terms of service characteristics (hours of operation, year round service and so on) to respond to working women and family needs. 66. Care leave and flexible work arrangements complement a supporting framework for the economic participations of women in Kosovo. The design, duration, and replacement rate of parental leave and care leave can affect uptake rates and effectiveness of protection against income shocks associated with caregiving, and prevent sub-optimal coping strategies. In a sense, care leave should be sufficiently long and generous to allow the caregiver the opportunity to fulfill the care obligations that are expected by the prevailing social norm and that are made necessary by the availability of formal care options. However, the duration and generosity of the care leave should not provide the caregiver with a disincentive for returning to the labor market at the earliest opportunity, as lengthy breaks in the work history can lead to human capital depreciation and thus a significant reduction in permanent income. Of course, the precise design of care leave policies has to depend on the state priorities and the local context. In the long run, the ability of caregivers to decrease labor supply on the intensive rather than extensive margin can increase the likelihood of transition back to full-time work after caregiving responsibilities abate. Policies supporting uptake of flexible work can take the form of “right-to-request” regulations, or if necessary, temporary subsidization of such arrangements in certain circumstances, where they can prevent costly labor market detachment of caregivers. 39 References Attanasio, Orazio and Marcos Vera-Hernandez. 2004. “Medium and Long Run Effects of Nutrition and Child Care: Evaluation of a Community Nursery Programme in Rural Colombia.” Centre for the Evaluation of Development Policies, Working Paper 04/06, The Institute for Fiscal Studies, London, UK. Asai, Yukiko, Ryo Kambayashi and Shintaro Yamaguchi. 2015. “Childcare Availability, Household Structure and Maternal Employment”, SSRN Paper available at http://ssrn.com/abstract=2462366 Becker, Gary S. 1985. “Human Capital, Effort and the Sexual Division of Labor”, Journal of Labor Economics, Volume 3, Issue 1, Part 2: trends in Women’s Work, Education and Family Building, January 1985. Behrman, Jere R. and Barbara L. Wolfe. 1984. “Labor force participation and earning determinants of women in the special conditions of developing countries”, Journal of Development Economics, vol. 15 (1-3), 259-288. Berlinski Samuel, and Sebastian Galiani. 2007. “The Effect of a Large Expansion of Pre-Primary School Facilities on Preschool Attendance and Maternal Employment.” Labour Economics 14:665–80 Bolin, K. Lindgren B. and Lundborg, P. 2008. “Your next of kin or your own career? Caring and working among the 50+ of Europe” Journal of Health Economics, 27(3), 718-738. Calderon, Gabriela. 2014. “The Effects of Child Care Provision in Mexico”. Working Papers 2014- 07, Banco de Mexico. Carmichael, F. and Charles, S. 1998. “The Labour Market Costs of Community Care” Journal of Healgh Economics, 17(6), 747-765. Carmichael, F. and Charles, S. 2003. “The Opportunity Costs of Informal Care: Does Gender Matter?” Journal of Health Economics, 22(5), 781-803. Correll, Shelley J., Stephen Benard, and In Paik. 2007. “Getting a Job: Is There a Motherhood Penalty?” American Journal of Sociology 112 (5): 1297-1339. Del Boca, Daniela and Marilena Locatelli. 2006. “The Determinants of Motherhood and Work Status: A Survey”, IZA Discussion Papers 2414, Institute for the Study of Labor (IZA). Deutsch, Ruthanne. 1998. “Does Child Care Pay?: Labor Force Participation and Earnings Effects of Access to Child Care in the Favelas of Rio de Janeiro.” Working paper #384. Inter-American Development Bank. 40 Fong, Monica and Michael M. Lokshin. 2000. “Child Care and Women’s labor Force Participation in Romania.” Policy Research Working Papers: 2400. The World Bank. Gabriele, Stefania, Paola Tanda and Fabrizio Tediosi. 2011. “The Impact of Long-Term Care on Caregivers’ Participation in the Labour Market” ENEPRI Research Report No. 98, November 2011. Geyer, Johannes and Thorben Korfhage. 2014. “Long-term Care Insurance and Carers’ labor Supply: A Structural Model”, Discussion Papers of DIW Berlin 1421, DIW Berlin, German Institute for Economic Research. Heger, Dorte. 2014. “Work and Well-Being of Informal Caregivers in Europe”, Ruhr Economic Paper No. 512, Rhine-Westphalia Institute for Economic Research. Heitmueller, A. and Inglis, K. 2007. “The Earnings of Informal Careers: Wage Differentials and Opportunity Costs” Journal of Health Economics 26(4), 821-841. Henz, U. 2006. “Informal Caregiving at Working Age: Effects of Job Characteristics and Family Configuration”, Journal of Marriage and Family, 68, 411-429. Jacobs, Josephine C., Audrey Laporte, Courtney H. Van Houtven, and Peter C. Coyte. 2014. “Caregiving Intensity and Retirement Status in Canada.” Social Science & Medicine 102 (February): 74- 82. Jaumotte, Florence. 2003. “Labor Force Participation of Women: Empirical Evidence on the Role of Policy and Other Determinants in OECD Countries.” OECD Economic Studies 37 (2): 51-110. Johnson, R. and Lo Sasso, A. 2000. “The Trade-Off between Hours of Paid Employment and Time Assistance to Elderly Parents in Midlife. The Urban Institute Working Papers. Krauss, M., M. Riedel, E. Mot, P. Willeme, G. Rohrling and T. Czpionka. 2010. “A typology of systems of long-term care in Europe”, ANCIEN project, Research Institute for Advanced Studies, Vienna. Kosovo Agency of Statistics. 2015. “Results of the Kosovo 2013 Labour Force Survey”, Kosovo Agency of Statistics, Social Statistics Department, July 2014. Lefebvre, Pierre and Philip Merrigan. 2005. “Low-fee ($5/day/child) Regulated Childcare Policy and the Labor Supply of Mothers with Young Children: A Natural Experiment from Canada”. CIRANO Lilly, M.B., Laporte A. and Coyte, P.C. 2010. “Do They Care Too Much to Work? The Influence of Caregiving Intensity on the Labour Force Participation of Unpaid Caregivers in Canada” Journal of Health Economics, 29(6): 895-903 41 Loken, Katrine Vellesen, Shelly Lundberg and Julie Riise. 2014. “Lifting the Burden: State Care of the Elderly and Labor Supply of Adult Children,” IZA Discussion Papers 8267, Institute for the Study of Labor. Lokshin, Michael. 2000. “Household Childcare Choices and Women’s Work Behavior in Russia.” The Journal of Human Resources, 39(4): 1094-1115. OECD. 2011. Doing Better for Families. Paris, April 2011. Paes de Barros, Ricardo, Pedro Olinto, Trine Lunde, and Mirela Carvalho. 2011. “The Impact of Access to Free Childcare on Women’s Labor Market Outcomes: Evidence from a Randomized Trial in Low-Income Neighborhoods in Rio de Janeiro.” Paper Prepared for the 2011 World Bank Economists’ Prada, Maria F., Graciana Rucci and Sergio S. Urzua. 2015. “The Effect of Mandated Child Care on Female Wages in Chile”, NBER Working Paper No. 21080, April 2015. Ribar, David. 1995. “A Structural Model of Child Care and the Labor Supply of Married Women”. Journal of Labor Economics, vol. 13, No. 3. Sarasa, Sebastian. 2006. “Do Welfare Benefits Affect Women’s Choices of Adult Care Giving?” European Sociological Review 24 (1): 37-51. Spiess, K. and U. Schneider. 2003. “Interactions between Care-Giving and Paid Work Hours among European Midlife Women, 1994 to 1996” Ageing and Society, 23(1), 41-68. Todd, Petra. 2013. “How to improve Women’s Employability and Quality of Work in Developing and Transition Economies”, A Roadmap for Promoting Women’s Economic Empowerment. Available at www.womeneconroadmap.org, November 2013. Viitanen, Tarja. 2007. “Informal and Formal Care in Europe”, Working Papers 2007010, The University of Sheffield, Department of Economics, revised June 2007. World Bank. 2013. “What Matters Most for Early Childhood Development: A Framework Paper.” Saber Working Paper Series. Number 5, January. World Bank. 2015. “Supply and Demand for Child Care Services in Turkey. A Mixed Methods Study.” Forthcoming. 42 Annex 1: List of Variables Used in the Construction of the Childcare Quality Sub-Indices Materials, Infrastructure curriculum and HR quality sub- Questions included quality sub- learning quality index index sub-index There is sufficient indoor space for children and adults to move freely X There is a dedicated space for naptime X At least one of the following are available for naptime: Beds/cots, cribs, mattresses, X soft mats Space is in good repair, clean and well-maintained. X There is adequate lighting X No malodor in the classrooms X Floors, walls, and other surfaces are made of easy to clean materials X There are sufficient number of clean, appropriately sized toilets for potty-trained X children There is adequate temperature control(central heating) X There is sufficient outdoors space X The outdoors space is generally safe (for example, mats under swings, fenced area, X etc.) Doors and windows are childproof when appropriate (for example, windows can’t X open fully, heavy doors close slowly, etc.) Safety covers are on all electrical outlets X Electrical cords are out of children’s reach X Heavy equipment or furniture that could tip over is anchored X Stairway gates are locked into place when infants or toddlers are nearby X Sharp furniture edges are cushioned X There is a sufficient number of age-appropriate toys X There is organized and convenient storage for toys X Are there any systems in place to give feedback to parents about their children? X Are there any systems in place to receive feedback from parents? X Are there opportunities and provisions for parents to present and discuss additional X needs? Is there a daily routine? X Are children served food? X Are there provisions for children with special needs? X Whether caregivers’ minimum credentials include higher school or university X degree Whether the typical length of time that caregivers stay working at the provider is 5 X or more years Caregiver to pupil ratio X Is a small group of children primarily cared for by one designated staff member? X 43 Annex 2: List of Variables Used in the Construction of the Eldercare Quality Sub-Indices Schedule, Special needs, Infrastructure activities, and healthcare, and safety HR quality Questions included materials and support quality sub- sub-index quality sub- quality sub- index index index There is sufficient indoor space for elders and caregivers to move freely X Space allows for privacy when desired X Is there a dedicated space for naptime? X What is the quality of the bedrooms? Please take into account cleanliness, lighting, ventilation, temperature, absence of unpleasant odors, comfort, quantity and quality of furniture, safety, and privacy. X Space is in good repair, clean and well-maintained. X There is adequate lighting X The facilities do not have unpleasant odors X Floors are smooth and have nonskid surfaces. Rugs are skidproof X There are clean toilets for staff members and elders X There is adequate temperature control X There is outdoors space for elders to use X The outdoors space is generally safe (for example, mats under swings, fenced area, etc.) X Walls and ceilings have no peeling paint, have no cracked or falling plaster, and are free of crumbling asbestos X Cords and electrical elements are in good condition and do not present a hazard to elders X Heavy equipment or furniture that could tip over is anchored X Doorways to unsupervised or unsafe areas are closed and locked unless the doors are used for emergency exits X The facilities feel comfortable, and nurturing X Do elders sleep in individual or shared bedrooms? X Who provides the furniture for the bedrooms? X Are clinical mattress and bed available if needed? X Do elders use individual or shared bathrooms? X What are families required to provide for their elders? X Are there standards and regulations that pertain to safety? X Do your safety policies and procedures meet these standards and regulations? X For each of the following activities, please check whether it is a frequent part of the elders’ activities, happens on a limited basis, or is not allowed X There is a sufficient number of mentally stimulating materials, such as chess sets X There is organized and convenient storage for materials, such as books and games X Are there any systems in place to give feedback to families about their elders? X Are there any systems in place to receive familial feedback? X 44 Are there opportunities and provisions for families to present and discuss additional needs? X Is there a daily schedule? X Are elders served food? X When are elders served food? X Where is the elders’ food prepared? X Does the food follow nutrition and health standards and regulations? X Does the food follow hygiene and cleanliness standards and regulations? X Does the food follow other relevant standards and regulations? X Is there a set procedure around elders’ first time arrival? X Is there a set procedure to prepare for elders’ departure (moving out or death)? X Are there visiting hours for family members? X What are the caregivers’ credentials and qualifications? (include minimum required) X What is the typical length of time that caregivers stay working at [service provider]? X What is the current ratio of caregivers to elders? X Are elders organized into groups? X Do staff members make an effort to ensure that elders feel respected? X Are there opportunities for continued education, training, and professional development for current caregivers? X What is the typical contract type for caregivers? X On what basis are caregivers evaluated? X Space is accessible for persons with disabilities X Protected access to stairs and facilities allow for limited mobility elders to circulate (i.e., those using wheelchairs, walkers, etc.) X Are there provisions for special needs? X Are elders’ dietary needs and food allergies considered? X What are the types of staff members that are employed by [service provider]? X Who does laundry and cares for elders’ personal items? X Does the [service provider] care for physically able elders, mentally able elders, some disabled elders, and/or all disabled elders? X Are elders given help with their personal hygiene, cleanliness, and appearance? X Is routine medical care available to elders? X What provisions are in place for elders who use wheelchairs or have trouble walking? X Are ambulance services available? X Are elders given help with bathing, shaving, and hair washing? X What services are offered to elders with Alzheimer’s Disease or related dementias? X 45