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My maternal grandmother died when I was very young so I never knew her well. What I remember most clearly about her, though, is that whenever I saw her she was living in one of my aunts’ homes. For a while she lived with us. My grandfather built the house in which my grandmother gave birth to thirteen children, many of whom died in infancy, and in which she raised the survivors once she became a young widow. Without a husband she raised her children by herself with whatever income she could earn, primarily as a janitor at the local school. When the children had grown and left home and when grandmother became too frail to take care of herself, my parents, my sister and I moved into the old house with her. Four of my aunts lived nearby. Even though they grew up in poverty my mother and three of her sisters managed to attend university and become teachers. They were ahead of their time in terms of modern gender roles since they worked full-time while raising children and taking care of their own homes, but they were traditional in that they combined efforts to care for their mother, even as they continued to work and raise their own families. After several years of living with one or another of her daughters, my grandmother died in her own bed at the age of 87 in the house in which she had raised her children.

Unlike my grandmother, when my mother died at the age 96 it was in a long-term care facility far from the city in which she was born. Since her only daughter had died at 50, she had only one surviving son. Although she was far more financially secure than her own mother, she had no large group of family caregivers who could combine eldercare with work and other family responsibilities. Formal long-term care was the only realistic option. In only one generation, then, my family had changed dramatically in terms of its eldercare capacity. But my family’s story is not unique. Changes in family size, the migration of children away from their place of birth, longer lives, and much more have changed the caregiving capacities of families generally. Today, with clear exceptions, the family is less able to provide all of the care that frail elderly parents need. Other alternatives must be explored. In this chapter I investigate the possibilities for civil society to provide at least some of the day-to-day care that the family can no longer provide. By civil society I refer to the wide range of nongovernmental organizations (NGOs), from faith-based organizations and community groups to formal charitable organizations like Meals on Wheels. In the modern world such organizations are becoming an increasingly important part of the social world and in the future they may assume a greater role in eldercare.

For individuals born at the end of the nineteenth or early in the twentieth centuries the family was the major source of care and support when they became old and frail. With the passage of the Social Security Act in 1936 and the introduction of Medicare in 1965 the State has assumed a large part of the financial and long-term care responsibility for elderly citizens. Income supports and medical care consume a large fraction of the budgets of most developed nations. Yet the State faces limits in what it can provide in terms of instrumental care. Many of the needs of frail elders are routine and personal and require close and frequent contact. This sort of care is most easily and efficiently provided by family members. The state might pay for such services, but there are practical limits as to what the State can afford. In this new context organized voluntary action represents at least a partial solution. The challenge for public policy is to determine how best to combine the efforts of nongovernmental actors and organizations with those of formal governmental programs.

The New Demographic and Social Reality

Today longer life spans, migration, lower fertility, increased female labor force participation and more have contributed to a rapidly changing long-term care reality for the elderly (Haber 2006; Quadagno 1982; Thane 2005). During the nineteenth century fertility declined significantly in the United States, but families remained large by today’s standards even at the turn of the twentieth century when the average female had nearly four children (Coale and Zelnik 1963; Himes 1989; Tolnay et al. 1982). Family members for the most part stayed close to home and older parents could call upon at least some of their children who lived nearby to provide basic care when they became frail. Nobody, or almost nobody, entered a long-term care facility other than perhaps a poorhouse or an insane asylum (Grob 1983; Wagner 2005). That remains true today in most parts of the world, although the situation is changing even in countries like India where the number of long-term care facilities is increasing (Liebig 2003).

The reality of the situation, then, is that given the demographic and social changes that have occurred over the last two generations traditional family caregivers find it increasingly difficult to combine eldercare with the demands of work, child rearing, and other duties. Today in Western Europe fertility rates have reached historic lows (Sobotka 2006). In Italy, Spain, and other European countries where almost everyone married and had large families just a generation ago, fertility rates among the native populations are below replacement. The fertility rate in Italy and Spain is barely 1.3, far below the 2.1 that is necessary to assure a stable population (Central Intelligence Agency 2009). In the absence of immigration these countries would have shrinking populations. In the United States the total fertility rate has remained higher, at about 2.0 since the 1980s. To a large degree this reflects the higher fertility of Hispanics (Hamilton et al. 2009). These differential fertility rates suggest significant ethnic and racial group differences in family eldercare capacity in years to come (Angel and Angel 1997).

Growing older populations and lower fertility even affect the developing world. South American populations are aging rapidly and will continue to age well into the twenty-first century (Chamie 2005; Palloni et al. 2002). This growth in older populations in both developed and developing countries will in all likelihood be accompanied by a continuing fiscal austerity that will strain the ability of governments to provide for all of their citizens’ needs (Pierson 2001). This new demographic reality of aging populations and lower fertility, in combination with other social transformations such as increasing divorce rates and the decline of the traditional family requires novel approaches to the care of older adults. For most of human history tradition has largely determined who would care for the frail elderly, but tradition no longer provides firm answers and we are in a new world that will require new institutional arrangements including a greater role for civil society and NGOs. Understanding how nonfamily and nongovernmental sources of elder support might be employed in eldercare represents a core intellectual and practical question for future research and policy design.

Posttraditional Society and Old Age Support Systems

We might usefully ask what the term “tradition” refers to and how has it changed with reference to the care of the elderly. Tradition lies at the core of human social interaction and defines our major social institutions like marriage and the family. Tradition, often codified in law, provides the rules that determine inheritance and dictate the nature and extent of responsibility among generations. Even today tradition dictates that family members assume primary responsibility for the care of aging parents (Bullock et al. 2003; Chatters et al. 1986; Dilworth-Anderson et al. 1999; Jolicoeur and Madden 2002; Stone 2006). In the absence of informal family care greater public expenditures for formal care would be necessary (Bolin et al. 2007; Hayward et al. 2004; Himes and Reidy 2000). Yet when basic structures change radically traditions cannot remain unchanged. Given limited time and energy budgets, there may be an inevitable tradeoff for potential caregivers between caring for older family members and other commitments, including employment. Some studies find that employed women provide less informal care than unemployed women (Fast et al. 1999; Kotsadam 2009). Caregiving responsibilities can interfere with the ability of caregivers to look for work (Bullock et al. 2003).

Tradition, by its very nature resists change since it is undone by change. But change occurs regardless of tradition’s dictates. Today in the developed world we are living in what Anthony Giddens has described as “posttraditional” society (Giddens 1991, 1994). Giddens and others use this term to emphasize the fact that traditional norms and practices have weakened and that individuals today cannot, or have the option of choosing not to, look to tradition for the basic instructions of life. Traditions clearly still exist and remain powerful. Because of the traditional social value placed in the institution or marriage, as well as other practical advantages, same-sex couples wish to partake of the tradition. The fact that marriage can be construed as a union between same-sex individuals underscores the reality that the rules governing the social institution of marriage are in the process of change. Today individuals choose and reinterpret traditions to reflect changing circumstances and newer social realities. Daughters and daughters-in-law are not constrained by strong community expectations to stay at home to care for their aging parents or in-laws.

Traditions and norms do not exist independent of history, and in the domain of eldercare history has moved on. Structurally, though, there remain a limited number of possibilities in terms of the long-term care of the elderly. Financial, instrumental, and emotional support can be provided by some combination of the family, the State, and civil society. By civil society I refer to the entire range of nongovernmental groups and organizations that provide support and services to older individuals. These include faith-based organizations and congregations, NGOs like On Lok in San Francisco, HelpAge India, and many others, some of which I mention below. Unfortunately, there is little systematic research on the role of NGOs and other civil society organizations in the support of the elderly. In what follows, then, I offer a theoretical framework for understanding the potential role of these organizations in eldercare and review the relatively sparse empirical data available. I conclude by proposing a research agenda focused on the potential role of such organizations in the mix of care providers. The core question relates to the extent to which civil society organizations, including NGOs, can complement the State in providing support without further eroding the role of the family or contributing to the State’s neglect of its basic responsibility for guaranteeing the basic social rights of vulnerable elderly citizens.

Addressing this question requires an examination of the role of civil society organizations in terms of the mix of elderly support services. Despite the changes the family has undergone family members continue to provide much of the care older parents need. One might justifiably conclude that the family is the most desirable source of care given the lifelong emotional bonds that exist between parents and children. As desirable as family care might be, though, in posttraditional society children, and especially those with higher levels of education, move away from their parents for career reasons and cannot assume the daily responsibility for dealing with their parent’s immediate needs (Rogerson et al. 1993). Adult children can, of course, provide financial support, and if they or their parents can afford the cost they may chose to move their aging parents to assisted living arrangements nearer by (Silverstein 1995; Silverstein and Angelelli 1998). For adult children with demanding careers having an older parent move in to their homes, especially once the parent suffers serious functional and cognitive decline, may not be realistic.

In addition to the family, or perhaps in place of the family, today the State assumes a major role in the financial care of the elderly. Public pensions, health care, and other supports for the elderly largely define the welfare state. In the United States Social Security, Medicare, and Medicaid have basically socialized the financial responsibility for the elderly. What remains, then, is to examine the actual and potential roles of the nongovernmental and voluntary sector in eldercare.

The New Focus on Nongovernmental Solutions to Social Problems

In order to begin to develop a better sense of the role of NGOs and similar organizations in eldercare it is necessary to briefly review the growing importance of NGOs in the modern world. Although NGOs have been involved in various social issues since the nineteenth century and even earlier, the period since the Second World War has seen a rapid growth in their number. Today NGOs are involved in health, education, human rights, women’s issues, the environment, sustainable development, and much more (Boli and Thomas 1997, 1999; Carroll 1992; Hudock 1999; Keck and Sikkink 1998; Robinson and Riddell 1995; Salamon 2003; Salamon and Anheir 1996). They have assumed an important and growing role as advisors to the United Nations (Global Policy Forum 2010). Many explanations for this growth have been offered and a large literature focused on NGOs as expressions of new social movements has appeared (Albrow et al. 2008; Boli and Thomas 1999; Keck and Sikkink 1998; Pichardo 1997). Some observers view the rapid growth of NGOs in the post-WWII era as a reflection of the spread of a global culture that is supranational in character and largely Western in values (Boli and Thomas 1997). Others see it as reflecting the global demand by poor countries for greater global social justice and a new collective consciousness (Bendaña 2006; Grzybowski 2000). Whatever the causes of the increase in the number and role of NGOs they are more salient actors internationally and locally and their presence calls for a more complex approach to understanding how society operates at all levels (Fisher 1997; Ruggie 1998).

The domains in which NGOs and other civil society organizations operate differ greatly along many dimensions. NGOs that deal with environmental issues and those dealing with human rights, women’s rights, and the rights of native peoples differ in mission and structure from those that provide medical, educational, and emergency services to specific groups. Understanding the potential utility of such organizations requires not only a focus on their structure and organization, but also an understanding of the needs of the populations they serve. In terms of addressing the needs of the elderly the relevant questions relate to how well such organizations function as advocates and service providers.

NGO activities can be characterized in terms of two broad categories, advocacy and service delivery (Pereira and Angel 2009). Advocacy refers to activities that are aimed at improving the situation of a particular group though legislation, public awareness campaigns, and other activities that draw attention to the structural and system factors that produce and perpetuate disadvantage. Organizations like Amnesty International that focus on human rights or organizations like Greenpeace that oppose the exploitation of animal species engage primarily in advocacy. Other organizations like Habitat for Humanity, Doctors without Borders, Oxfam, and the Red Cross focus more on service delivery and the response to crises. Many, if not most, NGOs engage in both activities to one degree or another, providing services while they engage in advocacy and political action aimed at changing laws and practices to encourage democracy, safeguard civil rights, or develop local capacities to deal with longer-term needs.

One of the reasons for the renewed interest in NGOs as service providers is that they often have certain advantages in dealing with the more routine and manageable needs of specific populations (Pereira and Angel 2009; Pereira et al. 2007). For example, although complex and expensive high-tech medicine can only be paid for or provided by the State, routine and relatively inexpensive services, such as basic primary care, assistance with activities of daily living, and companionship are often more effectively and economically provided by NGOs and other local groups. Ideally in the case of eldercare such groups can complement the State in supporting older individuals in the community and enhancing the quality of their lives. Because of their more detailed knowledge of the legal, transportation, nutritional, and other needs of the elderly they could potentially act as both service providers and advocates.

Relatively little research has been carried out focused on the role of civil society organizations in eldercare. A large body of research documents the importance of social networks and social support in later life and offers indirect evidence that nonfamily support could be important in assuring the well-being of isolated older persons (Krause 2006; Moren-Cross and Lin 2006). It is clear that social engagement and human contact are vital to the well-being of the elderly and the potential of nonfamily and nongovernmental sources to provide such contact may be high. Studies of volunteerism, including a recent study in Mexico, reveal that in situations of high need many individuals provide significant amounts of support and assistance to needy neighbors and others either through formal groups, such as churches or voluntary organizations, or informally as personal assistance (Burcher 2008).

Service to the Elderly

The organizations and affiliative groups that make up civil society not only help individuals in need, but they also provide their members opportunities to engage in pro-social activities ultimately strengthening communities (Etzioni 1993, 1995). Churches and religious groups have historically cared for the poor and infirm and as part of that mission they provide much needed companionship and care to the elderly (Idler 2006). Faith-based international NGOs such as CARITAS, Catholic Charities, and Lutheran Social Services provide assistance to the elderly as part of their general missions. The Red Cross and many of the other major international and local relief agencies identify the elderly as a vulnerable population in need of special attention in their relief and support missions. A quick perusal of NGO directories on the Web yields hundreds of such organizations in every country with some focus on the elderly as a vulnerable population.

In addition to NGOs that offer assistance to elderly persons with special needs or in times of crisis, many other international, national, and local organizations of differing sizes and reach provide care to the elderly. Again their number is too large for even a partial enumeration but some examples are informative. What follows is clearly not a systematic sample of NGOs that deal with the elderly. Rather the cases I present represent very well-known organizations or those that illustrate the point that eldercare and issues related to the elderly are drawing greater attention from civil society organizations. For the elderly, of course, companionship and visitation are important needs that volunteers can readily provide. Companionship and the prevention of isolation are major objectives of these organizations.

The Meals on Wheels Association of America (http://www.mowaa.org) is the oldest and best known nongovernmental nutrition program for the elderly in the country. Founded during World War II the organization has grown in size and mission and today is dedicated to ending hunger among the elderly. In addition to providing nutritious meals, volunteers provide clearly important human contact to older persons. The less well-known Little Brothers – Friends of the Elderly (LBFE) (http://www.littlebrothers.org), an international network of nonprofit, volunteer-based organization with branches in the U.S. provides companionship to elderly people to reduce isolation and loneliness. The organization is a member of a larger international organization, the Fédération Internationale des petits frères des Pauvres (International Federation of Little Brothers of the Poor, http://www.petitsfreres.org). Another international organization is the Fédération Internationale des Associations de Personnes Agées (International Federation of Associations of Older Persons, FIAPA: http://www.fiapa.org) headquartered in Paris. The organization’s mission is also to prevent isolation and improve the quality of life (QOL) for older individuals.

Many other examples of specific NGO activities in various countries are easily found on the internet. Three examples illustrate the potential of NGOs in eldercare in less developed countries. India, like most of the rest of the world, is facing a serious problem related to the care of an older population. Even as developing nations with high fertility rates remain comparatively young, their older populations are growing in absolute and relative size. In India NGOs are important advo­cates for and service providers to the elderly (Sawhney 2003). Dignity Foundation (http://www.dignityfoundation.com), a member of the American Association of Retired Persons (AARP) Global Network, provides housing, companionship, recreation, and other services to elderly individuals in several Indian cities. HelpAge India (http://www.helpageindia.org) has a similar service mission. This NGO provides financial, medical, and emotional support to poor elderly Indians. The organization has introduced new programs and is extending its services to previously underserved areas. One example highlighted on the organization’s website is a Mobile Medicare Unit (MMU) program that provides basic health care and is introducing new initiatives such as disability aids, shelter assistance, yoga, specialized home visits, and psychological therapy.

The cases of Dignity Foundation and HelpAge India are examples of eldercare NGOs moving into resource starved areas in which formal supports are rare. Another example in a nation that is far more developed relates to the eldercare functions of Hogar de Cristo (Christ’s Home: http://www.hogardecristo.cl) in Chile (Pereira et al. 2007). Hogar de Cristo is a Catholic organization in a highly Catholic country, a fact that no doubt has contributed to its success. Begun in 1944 by a Catholic priest named Alberto Hurtado, from its founding the organization has focused on the needs of poor Chileans. Given the specific vulnerabilities of the elderly, especially the seriously curtailed social services that were part of the neoliberal reforms introduced by the Pinochet dictatorship, Hogar’s mission has expanded to provide the full range of services to poor elderly individuals. These services include day care, nutritional programs, and even housing. In the absence of an adequate old-age welfare state Hogar de Cristo fills a void that is created by limited government commitments or capacities to address serious social problems.

In the United States a similar comprehensive care approach named On Lok, a Cantonese term which means “peaceful, happy abode,” was begun in the early 1970s in San Francisco to provide services to frail Asian elderly individuals in certain Bay area communities in order to allow them to remain in their own homes (http://www.onlok.org) (Bodenheimer 1999). This success of the program led to its formal adoption by Congress as a model for the PACE program (Program of All-inclusive Care for the Elderly: http://www.cms.hhs.gov/pace), which provides comprehensive services paid for primarily by Medicare and Medicaid to high-need frail elderly individuals (Gross et al. 2004). The On Lok experience serves as an example of how private nongovernmental initiatives can serve as laboratories in which best practices related to the care of older persons can be tried and eventually inform State initiatives. Currently 70 PACE programs employ interdisciplinary teams of care providers who develop care plans for each individual and monitor their progress with the objective of allowing them to enjoy the highest possible QOL. In addition to primary care the programs offer specialist care, home health aides, transportation, recreation and companionship (Gross et al. 2004).

Hundreds of examples similar to those I have presented can be found in all nations of the world and it would be impossible to summarize the activities of even a few. As the PACE example shows, there is often a blurring of the definition of nongovernmental. PACE programs rely heavily on Medicaid and Medicare for financing their operations. The category of nongovernmental, therefore, includes many different degrees of government/civil society cooperation. As I mentioned before, in addition to organizations focused specifically on the needs of the elderly, many other nongovernmental and faith-based groups include assistance to the elderly as part of their missions. Service delivery, though, is not the only mission of NGOs. Adequate pensions and other legal guarantees require changing laws and that objective requires different approaches and organization than short-term crisis interventions.

Advocacy for the Elderly

As important as services are for vulnerable elderly individuals especially in developing nations, basic assistance does not change the fundamental vulnerabilities that undermine the welfare of older persons. While basic assistance with food, medical care, and housing might alleviate some of the most immediate problems that older individuals face they are no substitutes for more comprehensive and continuous social security programs (HelpAge International 2009; Willimore 2006). In addition to service delivery, then, a major role of NGOs is advocacy for the elderly. In the United States the AARP is undoubtedly the most well-known and effective advocate for its membership (Binstock 2004). Other advocacy organizations include the National Committee to Preserve Social Security and Medicare (NCPSSM: http://www.ncpssm.org/), the Alliance for Retired Americans (ARA: http://www.retiredamericans.org), and the National Hispanic Council on Aging (NHCOA: http://www.nhcoa.org/).

According to its Web page NHCOA’s mission includes advocacy, the support of research, the funding of community-based projects, as well as the creation of support networks, capacity-building in Hispanic communities and the support and strengthening of Hispanic community-based organizations. The organization’s core objective is to “empower Hispanic community organizations and agencies, as well as Hispanic older adults and their families.”

The organization offers educational programs focused on the major health risks to Hispanics, like diabetes and it has developed an e-course on cultural competence that educates health care professionals concerning the culture of their patients (http://edu.nhcoa.org).

Smaller local organizations, such as Family Eldercare of Austin, Texas (http://www.familyeldercare.org), the author’s home town, provide important legal services and perform what are basically case-management services in coordinating a wide range of services that the organization’s poor and largely minority clientele needs in terms of housing, instrumental support, and more. The organization participates in a summer fan drive which collects fans and money to purchase them to provide vital cooling to older people who live in a part of the country in which the heat of summer can be life threatening. These activities are replicated in various forms by any number of NGOs all over the country.

Potential Downsides to Nongovernmental Approaches

It is quite possible, of course, to romanticize civil society and nongovernmental approaches to complex social problems or to overestimate the ability of voluntary collective action to empower the powerless. Local approaches to the care and support of vulnerable individuals are appealing because they appear to be more personal and on more human scale than services provided by large impersonal bureaucracies. The new Neoliberalism that has informed public policy in recent decades reflects a deep distrust of big government and the welfare state, a large part of which consists of old-age supports (Binstock 2004). Although support for public pensions remains high in most countries, fiscal constraints and the recent economic crisis have furthered efforts to control the growth of such public programs (Chap. 20). Thatcherism in Great Britain, the Regan revolution in the United States, and new Third Way philosophies in other developed nations reflect a growing antiwelfare state rhetoric and the adoption of policies intended to cap or even reduce social expenditures and the paternalistic role of the state (Andrews 1999; Faux 1999). Public antiwelfare state sentiment and neoliberal social and economic policies have serious implications for the material and social welfare of the elderly, and especially those with limited resources including the elderly, women, African-Americans, and Hispanics (Angel and Angel 1997, 2009).

There can be little doubt that the elderly benefit from local programs that provide companionship and assistance with activities of daily living. The On Lok model and the PACE program clearly demonstrate the benefits of intensive involvement in providing frail older individuals with limited resources the full range of services and supports they need in order to remain in the community. Yet there are serious dangers in placing too much faith in the ability of local communities and organizations to provide all of the supports that older citizens need. Social Security and Medicare are fundamental and indispensable support programs without which millions of older individuals would fall into poverty and be denied the medical care they need. As we attempt to mobilize family and local resources for the care of the elderly we confront the very real danger that the supposed superiority of nongovernmental approaches will be used to justify excessive and harmful cuts in Social Security, Medicare, and Medicaid. Among the big losers would be single and poor older African-American and Hispanic females and other vulnerable individuals. The life-long labor force disadvantages faced by minority Americans leaves them particularly dependent on publicly funded programs in old age. If an unrealistic belief in the support capacities of local organizations and community groups were to encourage reductions in funding for formal services the results could be devastating.

As appealing and noncontroversial as civil society approaches to dealing with human needs might seem at first glance, then (after all who can argue with generosity and civic engagement), there are serious criticisms of NGOs and the nongovernmental approach generally that potentially apply to civil society solutions to dealing with the elderly. In the area of development and assistance to poor countries NGOs have been criticized for often being too apolitical and unwilling or unable to deal with basic social structural factors that account for the powerlessness and exclusion of particular groups. They are seen as part of the neoliberal agenda of privatizing what are in fact public responsibilities (Clarke 1998; Sangeeta 2004; Srinivas 2009). Development NGOs are criticized for having an excessively narrow focus on specific projects and fostering dependency rather than furthering sustainable development. They are criticized for being too accountable to their funders and less concerned with the perspectives of those they supposedly intend to help.

NGOs and the civil society focus more generally are also criticized for their often narrow and excessive focus on subgroups defined in terms of gender, race, ethnicity, disability status, specific illnesses, and more. An excessively narrow focus on particular subgroups or problem areas undermines efforts to address collective political issues. Supporters of the international labor movement, for example, continue to believe that the major locus of disadvantage and struggle in the world that in principle unifies workers in developed and developing nations is that between labor and capital. From this perspective an excessive focus on gender, race, or other narrow interests undermines the possibility for the sort of collective political action necessary to better the lot of all citizens (Roman 2004). Whatever the merits of the various criticisms of a civil society approach in general it seems clear that the core danger to the interests of the elderly lies in the potential justification of the devolution of federal responsibilities for income support and health care or drastic reductions in funding for such programs on the basis of the supposed superiority of local nongovernmental approaches.

A Research Agenda Focused on Civil Society and Eldercare

NGOs have become major international players in developing and implementing environmental policy, furthering women’s rights, redefining development policy, and much more. They are major players at local levels in dealing with problems of poverty, homelessness, teenage pregnancy among others. In this chapter I have posed the question as to whether civil society organizations, including NGOs might meaningfully supplement the family and the State in addressing the needs of growing older populations. It is clear that solutions to the major social problems that developed and developing societies face are extremely complex and that civil society is at best a complement to the State, which remains as important as ever in guaranteeing basic political and social rights to all citizens. Indeed it is probably not possible for NGOs to operate at all in the absence of an effective and strong State. Unfortunately, there is little published empirical research on the potential effectiveness of civil society activity in providing services to or advocating for elderly groups. This lack of research is accompanied by a lack of theory to assist in understanding the complex interaction of various layers of government, private enterprise, the family, and the nongovernmental sector in addressing the needs of aging populations.

At the most general, level the most theoretically and practically important questions relate to the actual possibilities for civil society action in eldercare and advocacy and the forms that they might take. Specifically it is important to know how the role of civil society organizations in eldercare service provision and advocacy is constrained by state policy and funding sources at multiple levels in different political, economic, and cultural contexts. Addressing these questions requires a comparative approach based on national, state, provincial, municipal, and other differences of significance in policy design and implementation. Such analyses, for example, could examine differences in elder support policies in countries like Argentina, Chile, and Mexico which differ in terms of degree of national federalization, public policies, political structures, and more. Such research could provide useful information on how levels of development interact with state policies and civil society activity to influence policy to affect the comparative welfare of the elderly. It would also answer questions as to the range of possibilities for dealing with generational equity in a time of universal fiscal austerity.

Other theoretically important questions relate to the potential of eldercare and elder advocacy to take on characteristics of a social movement that may even be transnational in character. Other questions entail the complex and difficult assessment of the potential negative aspects of civil society involvement. As I mentioned earlier, to the extent that the devolution of services and supports results in State abandonment of its basic responsibilities and shifting of those responsibilities to levels of government and the nongovernmental sectors with inadequate capacities the results may well be negative. These overarching theoretical questions call for several dissertations and serious focused theorizing and empirical research.

At a more practical level the questions of interest relate to a better understanding of how formal State supports for the elderly can be coordinated with civil society efforts to more efficiently and economically address the needs of the elderly and insure their optimal QOL. The objective of a research agenda with such a focus would be to identify the best organizational forms and best administrative practices for insuring older individuals’ personal autonomy, dignity, social participation, and life satisfaction. Since the potential utility and success of civil society approaches depends on the nature of the social problems they address an assessment of the role of NGO’s in elder support must begin with a detailed understanding of the clientele and its needs, including its diversity in terms of race, ethnicity, social class, gender, religious orientation, immigration status and more. Since NGOs and other civil society organizations, to the extent they are more than just casual associations, have some sort of organizational form it would be useful to ask what organizational forms are associated with the greatest success. Of course, defining success represents an important part of the research agenda in and of itself.

Let me suggest a limited set of general questions that might form part of a larger research agenda focused on NGOs as organizations and their roles as advocates for and service providers to the elderly. There are, of course, many more questions and I invite the reader to criticize these and propose others. The list implies a qualitative approach, which is necessary to understand specific organizations and their cultures and internal workings. It would be useful of course to do larger-scale comparative and quantitative analyses to compare different organizations. The questions I propose include the following:

  • How significant is NGO and other civil society activity in advocacy or service provision to the elderly? How many organizations are there with significant elder agenda and how rapidly has this movement grown?

  • To what extent does the entry of new organizations into the field or the redirection of the missions of older organizations toward elder advocacy and service represent a new social movement? What are the demographic, social, and political forces that might propel such a movement and how might these contribute to the definition of the objectives of specific governmental and nongovernmental actors, including those in the for-profit sector?

  • How is the mission of the movement as a whole and the missions of individual organizations involved in eldercare or advocacy determined and by whom? Are the clients of these organizations passive recipients of services or are they involved in framing the mission statement, monitoring progress, and evaluating effectiveness?

  • How is effectiveness defined and measured, and by whom? Are serious QOL criteria applied in the evaluation of effectiveness?

  • How are individual organization’s missions “framed” for presentation to larger audiences, including funders? Does the framing of issues related to eldercare and support truly reflect the needs of this population or subpopulations?

  • How do the political, legal, and regulatory environments in which various civil society organizations operate affect their operation and effectiveness? This question is particularly relevant in comparative research.

  • How are the target populations of specific organizations defined and identified? What sort of outreach efforts, if any, do various organizations employ? Are issues of access and payment addressed adequately?

  • What are the major funding sources for different organizations? To what extent do specific organizations rely on grants, public fundraising drives, or client fees? How do different sources of funding affect accountability and the targeting of services? What is their mix of service provision and advocacy for the elderly in specific organizations? Is the advocacy role of specific organizations or the movement as a whole effective or is it constrained or co-opted by political and financial factors?

  • To whom do specific organizational leaders feel the organization is accountable? How are funders’ and clients’ differing conceptions of what the clients need reconciled? Does the need to be accountable to funders distort the intended mission of these organizations?

  • How do organizations’ basic structures, in terms of information flows, gender, racial, and ethnic composition of staff and clientele, decision making, the role of board members, etc. influence the ability of organizations to identify and respond to the needs of their clienteles?

  • How professionalized is the organization and the movement as a whole? What is the mix of paid staff to volunteers and how does this mix relate to the operation of the organization? Do volunteers have meaningful input into the definition of the mission and the design of service delivery?

  • Does the organization communicate and coordinate its efforts with other organizations engaged in similar activities?

There are of course many additional questions that we might ask concerning all aspects of the eldercare movement and the social, political, and economic forces that determine its organizational expression. Addressing these questions would provide useful theoretical and practical knowledge concerning the potential role of NGOs and other civil society answers in dealing with aging populations in the U.S. and elsewhere.

Conclusion

For the majority of human history change has occurred relatively slowly and one generation’s life course and the traditions it followed were similar to those of generations that had come before and those that came after. That world of stability and tradition has passed in a relatively short time in historical terms. Baby boomers lives have been governed by a very different set of traditions than those that constrained their grandparent’s lives. Their children’s lives will no doubt be more different in ways that we cannot yet predict. It is in this context of demographic and social change that old age must be reconceptualized and new social arrangements suited to the new posttraditional order developed. Most likely that menu of options will contain many variants of traditional institutional arrangements and some groups, especially those with high fertility or those that reject what they see as the moral decay of the modern world, may continue in ways that look very similar to the past.

There is no doubt, though, that the dramatic decline in fertility and the decline of the traditional family though late marriage and divorce mean that families will simply not have the personnel to take care of aging parents, especially as lifespans increase. Some people in second and third marriages may find themselves having to deal with several aging parents at the same time. As baby boomers age they have already found out from their parent’s experience that early old age can be a very independent time of life if one is in good health and has sufficient income and wealth. Older boomers, though, are already finding out that when physical and cognitive capacities decline the care burden for older parents can become overwhelming. Some arrangement other than caring for those parents oneself often becomes necessary. Assisted living in one form or another is a possibility if a family has sufficient resources. With the high cost of assisted living that option eludes many families. For those families Medicaid will become even more important than it is today and the questions addressed in this chapter become especially salient: How can civil society organizations complement Medicaid-financed community or institutional care to optimize the QOL for frail older individuals with limited resources while not breaking the bank? There are probably several answers to the basic question, but the only way to begin to address it is to develop a more sophisticated and informed understanding of the role of civil society organizations in the mix of help providers and advocates for the elderly.

The question is particularly salient in a period that is likely to be characterized by protracted fiscal austerity, limitations on State budgets in all developing and developed nations, and the continued inroads of neoliberal policy aimed specifically at social security programs.

This new research agenda must be informed by a sophisticated understanding of the fact that the elderly are not a homogeneous population either in terms of social characteristics, needs, or political profiles. The elderly differ in terms of such politically and economically relevant dimensions as gender, race, ethnicity, immigration status, rural/urban residence, and more. Even as we advocate for the rights of the elderly as a group, more targeted civil society approaches allow us to deal with the great heterogeneity that characterizes aging in the world today.