Hidden backbone of health systems must be recognised

A major international collaboration is calling for governments to recognise unpaid care as one of the most critical - yet invisible - foundations of modern health systems.

Published in Nature Medicine, the paper, Governing the Social Production of Care: The Hidden Foundation of Health Systems, brings together leading researchers from multiple universities and institutions across Australia, Europe and North America. Led by University of Sydney’s Associate Professor Jo-An Occhipinti, the paper argues that families, friends and communities provide an enormous amount of unpaid care that keeps health systems functioning, yet this contribution is rarely measured, planned for or supported.

As populations age and the prevalence of dementia, neurological disorders and other chronic conditions continues to rise, the researchers warn that health systems are becoming increasingly reliant on unpaid carers without recognising the limits of this essential workforce.

The authors propose a new framework that would enable governments to measure unpaid care as a core component of health system capacity, helping policymakers better forecast demand, strengthen community resilience and prevent avoidable pressure on hospitals and formal care services.

Dr Suraj Samtani, co-author of the paper and Postdoctoral Research Fellow at UNSW Sydney's Centre for Healthy Brain Ageing (CHeBA), said recognising unpaid care is essential to building sustainable health systems.

"Every day, millions of family members, friends and neighbours provide care that keeps people healthier, supports independence and reduces pressure on hospitals, yet this contribution remains largely invisible in how health systems are designed and funded," Dr Samtani said.

"As demand for care continues to grow, we can no longer assume unpaid care is an unlimited resource. If we don't measure, value and support it, we'll see increasing strain on carers, poorer health outcomes and greater costs across the entire health system."

The paper highlights that unpaid care supports prevention, chronic disease management, recovery, earlier hospital discharge and independent living. However, when carers experience burnout or can no longer provide support, demand shifts into more expensive hospital and residential care, creating avoidable costs and inequities.

To address this, the authors outline five policy priorities, including establishing national measures of unpaid care, investing in care-enabling infrastructure such as respite and caregiver support, strengthening community-based care networks, embedding unpaid care into health system resilience planning, and introducing safeguards to prevent responsibility being shifted from governments to families.

The researchers argue that recognising the "social production of care" is fundamental to ensuring health systems remain sustainable in the face of demographic change, workforce shortages and increasing demand for care.

Lead author Associate Professor Jo-An Occhipinti, from the University of Sydney, said the paper was already generating interest beyond the health sector.

“The paper is already informing international efforts to measure social production and strengthen the evidence base for policy on demographic change, the sustainability of public systems, and social and economic resilience. This includes the development of a pilot Social Production Satellite Account with the Swiss Federal Statistical Office and forthcoming discussions with European Commission officials.”