Between October and November 2024, Uruguay held a presidential election. As no candidate won a majority in the first round on October 27, a runoff was held on November 24 between the top two vote-getters, center-left Yamandú Orsi and conservative Álvaro Delgado, and Orsi prevailed. Held in parallel and influencing the presidential race was a referendum on social security reform. The reform included the globally unusual policy of lowering the retirement age from the current 65 to 60. In the referendum, 61% voted against, and the social security reform did not pass.

Uruguay, which has historically placed strong emphasis on social protection, also enacted a law in November 2015 to establish the National Integrated Care System (SNIC). The law defines care as a shared responsibility of families, the state, and communities, and aims to promote the further development of care. The system incorporates a gender perspective, undertaking initiatives related to childrearing—which, like caregiving, places a heavy burden on women—not just care.

This article explores, as we approach ten years since the introduction of the National Integrated Care System, the background to the introduction of social protection in Uruguay, its current state, and its results.

A building decorated by supporters of social security reform (Photo: BiblioJu / Wikimedia Commons [CC BY-SA 4.0])

Uruguay, a pioneer in social security

Uruguay is known in South America as a pioneer in social security. To understand how it came to be called that, let’s look at some background and basic facts about Uruguay. Located in the southeastern part of South America, Uruguay has a population of about 3.49 million. In 2023, its GDP per capita was 1.43 times the world average. The unemployment rate rose to 11.2% in October 2020 due to the impact of COVID-19, but since around 2022 it has hovered between 7% and 9%.

While social security systems were first introduced mainly in Europe, Latin America followed Europe in adopting such systems. Among Latin American countries, Uruguay was among the earliest to pursue the institutionalization of social security and played a pioneering role in the region.

In 1829, Uruguay’s first retirement law was enacted, granting pensions to former soldiers wounded in war and their families, and in 1835, pensions were extended to veterans and officers with more than ten years of service. The early military pension scheme was limited to the upper ranks and did not apply to rank-and-file soldiers, but after the creation of the military pension fund in 1919, all servicemembers gained what was called the right to retirement—an entitlement to pensions and severance benefits.

These rights were also extended beyond the military to civil servants. Under a law enacted in 1838, civil servants with more than ten years of experience were granted retirement rights. As these rights were legally recognized, a system took shape in which people who met certain conditions could receive pensions to support their post-retirement lives.

Furthermore, from 1919 to 1954, the social security system expanded beyond the military and civil servants. Especially in the 1940s, new laws were enacted to protect against risks such as childbirth and unemployment. Although coverage for risks like illness, maternity, and unemployment was limited, by the mid-20th century the guarantees related to the risks of old age, disability, and death had become universal.

However, social security involves not only monetary support such as pensions, but also support for people who need physical care. Such support includes long-term care and childcare, and Uruguay also turned its attention to these aspects of social protection.

Background to the introduction of the National Integrated Care System

Next, we look at the background to the care system established in 2015. As a global trend, the International Labour Organization (ILO) notes that demand is growing for paid care work, including caregiving and childcare. At the same time, the supply of such paid care work is insufficient, and because the burden of unpaid work such as caregiving and childcare remains disproportionately borne by women, this could lead to a “global care crisis.” A study conducted in 2023 by UN Women, which works toward gender equality and the empowerment of women, found that women worldwide spend about three times as much time as men on unpaid care work, including housework, childcare, and caregiving.

It is also clear from surveys that most women around the world wish to engage in paid work. Some women want to work but are forced to do unpaid care and childcare, resulting in lower labor force participation. There are also reports that the burden of unpaid work borne by women varies depending on household income. Wealthier households can send their children to private daycare or kindergarten, reducing women’s childcare burden.

Uruguay is no exception: women’s burden of childcare and caregiving is heavier than men’s. Despite the importance of these services, they tend to be undervalued and are often performed unpaid, restricting women’s participation in the labor market.

Man using a wheelchair (Photo: R. Lemieszek / Shutterstock.com)

Uruguay also has a particularly high aging rate and care dependency ratio (the share of people who need assistance with daily living) within South America. People aged 60 and over account for 20% of the total population, numbering more than 710,000. A nationwide survey on disability conducted for the first time in Uruguay in 2011 found that about 16% of the population has a disability. As definitions of care dependency vary across surveys, multiple estimates exist, but a report in 2014 prior to the care system’s introduction estimated that the share of people needing help with bathing, dressing, eating, using the toilet, and managing money or medications was 16.3% among those aged 65 and over, rising to 23.1% among those aged 75 and over.

What is the National Integrated Care System?

We now delve into the innovative National Integrated Care System (hereafter, the care system) introduced in Uruguay in 2015 and what it actually does. The system was introduced in 2015 under President Tabaré Vázquez’s second administration. It carried forward the push for social equality and expanded welfare championed by former President José Mujica and evolved into the Care Law, a key initiative of President Vázquez.

The care system’s purpose is primarily to support people aged 65 and over in leading active lives and independently managing basic daily needs. To receive support under the system, applicants submit a form to the SNIC secretariat and are assessed based on predetermined criteria, including degree of care dependency, age, and ability to pay. Depending on the assessment, they may receive care at day centers, remote support through teleassistance, an individual in-home care support program, or a combination of these.

Here is a closer look at each type of support. First, day centers for older adults living at home. Day centers provide comprehensive support to people aged 65 and over who live at home, need mild to moderate care, and face certain difficulties in daily life. They offer recreational activities with professionals to help prevent cognitive decline, aiming to prevent isolation and deterioration in health. Users can choose to attend two, three, or five days a week. Thanks to subsidies, they can receive care with zero out-of-pocket cost.

Older adults walking side by side, Montevideo (Photo: Marcelo Sabbatini / Flickr [CC BY-SA 2.0])

Next, teleassistance, which provides remote support. Teleassistance is a 24/7 remote service available to people aged 70 and over who need mild to moderate care. It can notify designated family members, neighbors, and medical institutions in emergencies at home. If necessary—for example, in the event of a fall—staff can also be dispatched.

Finally, the individual care support program. This program is available not only to older adults but also to people with disabilities, targeting those aged 0 to 29 or 80 and over who require high levels of support services. Under this support, users can receive up to 80 hours of care services per month. Users select a care worker registered with the Social Security Bank (BPS) from among five companies; the care workers are paid. Wages paid to care workers are means-tested, with users contributing a portion according to income, but they are basically covered by the BPS social security fund and paid directly by BPS to the care workers. Completion of the official care worker qualification course is mandatory for care workers.

The care system focuses not only on older adults and people with disabilities, but also on expanding childcare services. In Uruguay, compulsory education begins at age 4. The system aimed to universalize educational care for three-year-olds as part of preschool education, and expanded services through schools and daycare centers operated by the National Administration of Public Education (ANEP), the government body overseeing Uruguay’s education system. At the same time, it sought to expand services for children under three by establishing and expanding community-based childcare facilities known as Child and Family Care Centers (CAIF centers). In addition, a private childcare scholarship called BIS was established to help cover the cost of placing children under two in private centers in areas where public facilities are lacking.

Furthermore, in collaboration with INMUJERES (INMUJERES), the national body promoting women’s rights and gender equality, the “Care Seal for Equality” program was implemented to incorporate gender equality into early childhood education and daycare institutions, aiming to achieve gender equality in educational settings for children.

Parent and child living in Uruguay (Photo: Ximenabc / Wikimedia Commons [CC BY-SA 4.0])

Results of the care system

By recognizing care as a legal right, the series of care policies has increased the share of care work performed for pay, revaluing work that had often been unpaid. While care workers registered with BPS must complete an official qualification course, this upskilling has significantly increased their income. It was also shown in 2019 to reduce stress and depressive symptoms among care workers, increase job satisfaction, and lower turnover. Older adults and people with disabilities have found it easier to access care services. Compared with the period before the system’s introduction, financial support to access care services has been expanded for older adults and people with disabilities in economically difficult circumstances.

As for childcare services, there was criticism that extending maternity and parental leave targeted only mothers already employed and did not lead to women’s broader labor market participation, but the creation of NGO-run CAIF centers with government funding greatly increased the number and scope of services available to children under two. Specifically, 56 new CAIF centers were opened and 96 existing centers were expanded. Plans are underway to build more than 80 additional facilities. Thanks to services provided through the new care system, the public coverage rate for children under three rose from 33% in 2014 to 40% in 2017, according to results.

Challenges

As noted, the care system introduced in 2015 was groundbreaking in recognizing care as a right, revaluing care work, and promoting women’s social participation. However, even if it seems to be progressing smoothly, there are several challenges in practice. This section explores those challenges in depth.

Broadly, three challenges remain. First, eligibility restrictions are strict, especially for people with disabilities, and the impact is limited. The system was created to deliver care to those who need it, but for people with disabilities, eligibility is restricted to those aged 29 or younger or 80 or older. Even if eligible, the monthly limit of 80 hours in the individual care support program can mean services are insufficient. In fact, not a few users feel that time limits make it difficult to realize the right to independent living. Furthermore, in cases of specific disabilities such as intellectual or sensory disabilities, and where high levels of support are needed, there are no care workers within the system capable of providing appropriate support, leaving people outside the scope of assistance.

A gathering for users of the National Integrated Care System (Photo: Intendencia Montevideo / WIkimedia Commons [CC BY-SA 4.0])

Second, due to insufficient government funding, access for users is restricted. Although the law stipulates that the care system covers all people aged 65 and over, given fiscal conditions, the individual care support program is limited to those aged 29 or younger or 80 or older, and teleassistance is limited to those aged 70 and over.

Third, there are design flaws. Because the system is designed with little government oversight of service quality and accountability measures, when care hours are not respected, services are poor, or disputes arise between care workers and users, the only option is for users to bring lawsuits in court themselves. People who need support to use the care system often find it difficult to litigate on their own and must bear the cost of hiring legal representation.

In addition to these challenges, the care system provides services on the premise that people with disabilities who cannot conduct an active life on their own are in a state of dependency. Some argue that this reinforces negative images of people with disabilities and contradicts international standards that call for respect for their inherent dignity and a society free of discrimination.

Summary

As seen above, Uruguay’s National Integrated Care System still faces several challenges. However, positioning care as a public, shared responsibility; building state-supported structures; and, alongside expanding care services, aiming to advance women’s participation and status in the labor market are groundbreaking. By addressing issues such as financial sustainability, eliminating disparities caused by age and other restrictions, and training personnel capable of providing advanced care, the system is expected to deliver even greater impact. With a new administration taking office, we will be watching closely to see how the care system develops.

Writer: Okamoto Ayaka

Graphics: MIKI Yuna

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