Evaluating the Impact of Structural Policies on Health Inequalities – Quality of Employment, Domestic Work, and Health

The Quality of Work in the Belgian Service Voucher System

International Journal of Health Services 2017, Vol. 47(1) 40–60 ! The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0020731416677478 joh.sagepub.com

Sarah Mousaid1, Kelly Huegaerts1, Kim Bosmans1, Mireia Julia`2,3, Joan Benach2,3,4, and Christophe Vanroelen1,2

Abstract Several European countries implemented initiatives to boost the growth of the domestic cleaning sector. Few studies investigated the quality of work in these initiatives, although effects on workers’ health and on social health inequalities can be expected. This study contributes to the scant research on this subject, by investigating the quality of work in the Belgian service voucher system – a subsidized system for domestic work. The applied research methodology includes a qualitative content analysis of parliamentary debates, legislation and previous research about the service voucher system and of 40 in-depth interviews with service voucher workers. The study shows that the legal framework that regulates the system must be further enhanced in order to improve the quality of work in the service voucher system. In addition, the actors involved must be better controlled, and sanctioned in case of non-compliance with legislation. Keywords Belgium, domestic work, immigrants, the service voucher system, the quality of work, the SOPHIE-project

1

Interface Demography, Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium Health Inequalities Research Group, Employment Conditions Knowledge Network (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain 3 Johns Hopkins University – Universitat Pompeu Fabra Public Policy Center, Barcelona, Spain 4 Transdisciplinary Research Group on Socioecological Transitions (GinTRANS2). Universidad Auto´noma de Madrid, Madrid 2

Corresponding Author: Sarah Mousaid, Interface Demography, Vrije Universiteit Brussel, Pleinlaan 5, Brussels 1050, Belgium. Email: [email protected]

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Introduction Contemporary welfare states are implementing initiatives for dealing with ‘‘new’’ social risks.1–3 Originally, welfare states were designed to ‘‘insure’’ their citizens against a selection of well-defined ‘‘old’’ risks, such as (short-term) unemployment and ill health, which create obstacles for participating in the labor market.2 Yet today ‘‘new’’ social risks are challenging welfare states. Examples are the increasing difficulties of dual-earner families for reconciling work and family life, long-term unemployment and skills mismatch of workers due to rapid technological change. In keeping with ‘‘social investment thinking,’’ policy makers are implementing initiatives for boosting the growth of the domestic cleaning sector in order to deal with these ‘‘new’’ risks.1,2 First, boosting the sector is considered to provide a solution for workers with a poor work-family balance, because it improves their access to domestic help. Second, job creation for low skilled women and immigrants who have limited employment opportunities in other sectors is expected to tackle long-term unemployment. As the ‘‘social investment strategy’’ tries to promote an inclusive agenda, the implemented initiatives fitting within this strategy should also aim for improving health among the workers concerned and reducing health inequalities. Yet, this will largely depend on the quality of work attained in the domestic cleaning jobs.4,5 Therefore, it is important to assess the quality of work in these jobs. The service voucher system is an initiative that is created for boosting the service sector in Belgium. It is an interesting case for investigating the quality of work. First, because the legal framework in the service voucher system is more comprehensive compared to similar systems in Europe (e.g., in France, Germany and The Netherlands).6 Second, because the service voucher system is very successful. It involves around 150,000 workers on a yearly basis (4.2% of total employment in Belgium) and serves almost 1,000,000 active users.7 The objective of this study is to assess the quality of work in the service voucher system. Our definition of the quality of work includes four dimensions of work characteristics.8,9 A first dimension, the ‘‘employment conditions,’’ concerns all implicit and contractual arrangements between employers and workers (e.g., contract type, training and wage). Second, the ‘‘employment relations,’’ include the formal (e.g., employee representation) and informal relations between the actors involved (e.g., personal relations with employers or colleagues). Thirdly, the ‘‘working conditions,’’ refer to the physical and psychosocial circumstances at the workplace (e.g., physical and psychosocial demands). Finally, the ‘‘content of work’’ concerns issues of work task organisation (e.g., autonomy, task variation). The latter two dimensions can be seen as shaping the ‘‘intrinsic characteristics’’ of the work task. This paper begins with an outline of the theoretical background whereupon this study is based. It will then go on to the objective of this study and to the methodology used. Hereafter, the main results are presented, focusing on the dimensions of the ‘‘quality of work.’’ In doing so, special attention is paid to

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differences between immigrants and native Belgians, because immigrants appear to be particularly vulnerable for a poor quality of work.4 The paper concludes with a reflection on how the quality of work in the service voucher system relates to health inequalities. Based on this reflection, policy recommendations to improve the quality of work in this employment scheme are made.

Background ‘‘Third Way Thinking’’ on Welfare State Reform and Domestic Service Employment Today, welfare states are challenged by so-called ‘‘new’’ social risks, which stem from important social and economic evolutions. One of these important evolutions is the massive entry of women into the labor market. By consequence, women have become increasingly squeezed between the role of employee and that of caregiver, because they are still taking up the lion’s share of care work.3,10,11 This evolution occurs in a changing neoliberal macro-economic policy context, which has a severe impact on paid employment.12,13 At the higher end of the labor market, a growing intensification of work further increases the problem of reconciling work and family life in dual-earner families.10 At the lower end of the labor market, a gradual shift to more unstable employment leads to more households, that are only partially or temporary connected to the labor market. Additionally, the demand for low-skilled workers becomes scarce due to the rise of the knowledge-based service economy. By consequence, important parts of the low-skilled labor force become difficult to employ. Because of these evolutions at the lower end of the labor market, an increasing number of persons are becoming (structurally) dependent on social benefits.14,15 In order to cope with the ‘‘new’’ social risks, welfare states began to alter their policy approach in the second half of the 1990s.3,10,11 Much of the welfare state reform in Europe was inspired by ‘‘third way thinking,’’ which proposes a third way between the old social-democratic agenda and the ‘‘new right’’ neoliberal agenda. Central in this third way thinking stands the idea of ‘‘social investment,’’ where a focus on equality of opportunity goes along with a greater emphasis on individual responsibility.1,2,16 In keeping with these ideas, welfare states are investing in ‘‘the right stimuli’’ for people to participate in the labor market. They do so by enhancing individuals’ human capital, and simultaneously supporting the combination of paid employment and family care at the household level.1,2,17 In line with ‘‘social investment thinking,’’ several European countries implement initiatives for boosting the growth of the domestic cleaning sector.11 With these initiatives, the countries aim to improve the access to domestic help in the middle and higher strata of the labor market and so provide a solution for problems related to work-family imbalances.11 At the same time

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they aim to create jobs in the domestic cleaning sector, which is one of the few remaining sectors for creating low-skilled employment. By doing so, these countries provide ‘‘stepping-stones’’ into the labor market for low-skilled workers – predominantly women and immigrants – and so they tackle (long-term) unemployment.3

Domestic Cleaning Work, Health and Health Inequalities Initiatives for supporting the creation of jobs in the domestic cleaning sector can have an important impact on health inequalities in the societies involved. These jobs mainly employ social groups that are difficult to employ and that have an on average lower socio-economic position and health status (low-skilled women and immigrants).18,19 On the one hand, job creation in the domestic cleaning sector can improve the health of the workers involved, because it can help them out of unemployment. A recently performed review and a metaanalysis showed causal relations between unemployment and several (mental) health problems.20–22 On the other hand, previous research also demonstrates that the ‘‘quality of work’’ is poor in cleaning jobs and that these jobs include over-average health risks for the workers involved. For instance, previous research shows that the wages in cleaning jobs are generally lower than in most other occupations. Formal employment contracts are often lacking and the job insecurity is high.4,5 Moreover, cleaners generally lack social contacts with their co-workers and often relations with their customers are poor.4,23 With regard to the intrinsic characteristics of work tasks, studies show that cleaning often includes high physical demands (e.g., repetitive and fast upper body motions used in scrubbing, ironing, and mopping; adopting awkward postures to reach windows or doors).5,24 The psychosocial demands are also high for the workers. Cleaners tend to experience high work pressure because they lack control over their working time, work methods and the amount of work given to them.4 Cleaning work is usually also monotonous work with few opportunities for personal development.4,5,25 The poor quality of work in cleaning jobs clearly relates to elevated health risks for the workers involved. A literature review of 35 studies reveals that cleaning jobs relate to dermatologic diseases, respiratory diseases and musculoskeletal disorders, associated to both physical (e.g., awkward postures, prolonged standing) and psychosocial stressors (e.g., monotonous work).26 In summary, initiatives that boost job creation in the domestic cleaning sector mainly employ workers that are on the lower end of the socio-economic and health distribution of the population. If these initiatives are ‘‘real social investment strategies,’’ they must aim to decrease health inequalities. They can do so by improving the quality of work – and thus also the health – of the workers involved. Therefore, it is important to assess the quality of work in these

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initiatives. We selected the Belgian service voucher system as an interesting case with relevance to similar systems in Europe.

The Belgian Service Voucher System The Belgian Federal Government implemented the service voucher system on the 1/1/2004.27 Since the 1/1/2016, the governments of the three Belgian sub regions have been responsible for the system.28 Belgian policy makers implemented the service voucher system to deal with the ‘‘new’’ social risks discussed above. By creating new jobs, the system aims to be a stepping-stone into the labor market, mainly for low skilled women and those entering the labor market (e.g., immigrants). At the same time the system offers low-cost services for helping dual-earner families to balance their work and family life.29,30 The service voucher system is organized through a triangular employment relationship between the service voucher company (the employer), the customer and the worker. In this triangular employment relationship, both the customers and the domestic workers have a contract with the service voucher company. Customers can hire a domestic help from the service voucher company. That company is responsible for, among others, the payment of the wages and the social security contributions of the domestic help and for securing health and safety at the workplace.28 Customers pay the services with vouchers (one voucher/h). They buy these vouchers from a central private administrator. A voucher costs 9 euro, but because of an additional tax credit, the net price of 1 h of work is 6.03 euro. For each voucher, the service voucher company receives an amount of 22.04 euro, (9 euro paid by the customer and 13.04 euro paid by the government). The total amount covers the expenses of the company, such as the workers’ wages (in 2013 the average gross salary was 11 euro/h) and their social security payments.7,28

Objective The effect of the service voucher system on workers’ health and its impact on health inequalities largely depends on the quality of work in the system. The available evidence clearly suggests that the quality of work is generally poor in cleaning work, but specific evaluations of the quality of work in the service voucher system are still scarce. Therefore, the main objective of this study is to assess the quality of work in the Belgian service voucher system, paying special attention to differences between immigrants and native Belgians. In keeping with the main objective this study seeks to examine: 1. how policy makers took the quality of work in the service voucher system into account when they were planning, evaluating and modifying the system;

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2. what previous research teaches us about the quality of work in the service voucher system; 3. how domestic workers in the service voucher system perceive the quality of work themselves.

Methodology For this study we applied the technique of triangulation of data-sources.31 The study includes a qualitative content analysis of parliamentary debates, legislation and previous publications concerning the service voucher system, as well as an analysis of in-depth interviews with service voucher workers. Qualitative content analysis of parliamentary debates and legislation. To assess how policy makers took the quality of work in the service voucher system into account, an analysis of parliamentary questions was performed: 176 written and 179 oral parliamentary questions that were published between 10/2001 and 6/2014 were included. The legislation regulating the service voucher system (Law [BS8/11/ 2001] and Royal Decrees [e.g., BS12/22/2001; BS7/29/2009]), as well as the collective agreements relevant for the sector complemented this material.32,33 The first author of this paper coded the documents deductively according to the different (sub) dimensions of the quality of work,34 using NVIVO 10TM software. The second author of the paper controlled the results of this coding process. Qualitative content analysis of the literature. To investigate the state-of-the-art on the quality of work in the service voucher system, previous studies investigating the quality of work in the service voucher system were reviewed. This material was consulted through different internet search engines (e.g., ‘‘Web of Science’’ and ‘‘Google’’). We assessed both peer-reviewed and ‘‘grey’’ literature. The literature study includes all literature found and published before the 9/8/2014. We used the following terms: ‘‘evaluation service voucher system’’ and ‘‘service voucher system workers’’ in English, French and Dutch. Of all the studies found, only the studies published after the 1/1/2007 that (partly) investigated the quality of work, were kept for the analyses. Additionally, we looked for interesting references in these studies. The 24 studies that were retained for analysis were coded deductively (using our coding tree, based on the concept of the quality of work). NVIVO 10TM software was used. Qualitative study of workers’ perceptions. For this part of the study 40 in-depth interviews with native and immigrant (born in a foreign country) service voucher workers were performed (Table 1). For conducting these interviews, ethical approval was obtained from the medical ethics committee, of the university hospital of the ‘‘Vrije Universiteit Brussel’’ (B.U.N. 143201316163).

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Table 1. Characteristics of the Respondents. Respondent Amina Sandy Lea Meryem Angelika Debby Ellen Laura Alice Cristina Olesia Mirela Nadia Rania Habiba Bahija Gladys Solange Fouzia Saida Zineb Doris Nicia Zoe¨ Astrid Iris Jolien Jill Lynn Leonie Elisabeta Alejandra Audrey Dounia Allison Jenica

Country of Birth

Age

Years in Belgium

Civil Status

Chechenia Belgium Belgium Morocco Poland Belgium Belgium Belgium Belgium Moldavia Poland Romania Morocco Morocco Morocco Morocco Angola Congo Morocco Morocco Morocco Ghana Congo Belgium Belgium Belgium Belgium Belgium Belgium Belgium Romania Belgium The USA Morocco The USA Romania

50–59 20–29 50–59 50–59 40–49 20–29 30–39 30–39 50–59 20–29 40–49 30–39 30–39 30–39 50–59 60–69 30–39 30–39 30–39 30–39 30–39 20–29 30–39 20–29 20–29 40–49 20–29 20–29 20–29 40–49 40–49 20–29 40–49 40–49 30–39 30–39

0–9 N.A. N.A. 30–39 10–19 N.A. N.A. N.A. N.A. 0–9 10–19 0–9 0–9 0–9 0–9 0–9 0–9 10–19 0–9 0–9 0–9 10–19 0–9 N.A. N.A. N.A. N.A. N.A. N.A. N.A. 0–9 N.A. 0–9 10–19 0–9 0–9

Married Cohabiting Married Married Single Cohabiting Married Married Married Married Cohabiting Married Engaged Married Divorced Single Single Cohabiting Married Married Single Cohabiting Cohabiting Cohabiting Married Married Married Cohabiting Cohabiting Married Married Cohabiting Married Single Married Married (continued)

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Table 1. (continued) Respondent

Country of Birth

Age

Years in Belgium

Civil Status

Karima Johanna Anna Elena

Morocco The Netherlands Belgium Ukraine

30–39 50–59 50–59 20–29

0–9 0–9 N.A. 0–9

Married, lives alone Single Single Married

N.A., Not applicable.

Respondents were recruited through different channels in order to guarantee the diversity of our sample. In the first place, organisations active in the service voucher system contributed to the recruitment: a trade union, a number of service voucher companies and an occupational health practitioner working for a large service voucher company. Chain-referral sampling, starting from our own contacts and from participants in the study, completed the recruiting process. A topic list, which the first and third author constructed based on a literature review, structured the interviews. The topics covered the different dimensions of the quality of work (e.g., contract stability, social security rights, the triangular employment relationship, psychosocial demands, autonomy).8,9 For immigrants the list consisted of additional topics about the respondent’s personal migration history and the process of finding a job after migration. In order to make the interviews appear as a natural conversation the interviewer focused on two narratives: (1) the life course perspective, with emphasis on the migration and employment history, and (2) the structure of a typical working day. Additionally, further probing into the stories of the respondents procured more detailed information. The interviews were conducted between 9/2012 and 10/2014 in the interviewee’s home or in another place chosen by the respondent. The duration of the interviews varied between 37 and 112 min. The interviews were conducted in English (3), Dutch (21) and French (17). Therefore, most quotes in this report were translated. Interviews were digitally recorded, transcribed verbatim and subsequently read through several times. For analyzing the data the researchers applied a phenomenological perspective. This perspective pays attention to the perceptions and feelings of people associated with their experience and not only to mere observations of the experience itself.35,36 The researchers aimed to reveal how the service voucher workers perceived their quality of work. Thereto, coding the data through thematic content analyses guided the analytic process.34 The deductive coding process was done by means of a coding tree that was based on the different (sub) dimensions of the quality of work.8,9 The coding process for the case study was done with NVIVO 10TM software. After the coding process, quotes were selected to illustrate the most important results of the study. These quotations are labeled using

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pseudonyms. If a partner or a family member was participating in the conversation this is also mentioned in the labels. We applied the technique of ‘‘triangulation of investigators’’ in this study because the co-authors of this study were intensively involved with followingup the research process.31 They regularly gave feedback on the research protocol, on the coding scheme and on the several versions of this paper. Also the feedback of two ‘‘service voucher experts’’ working for a trade union, was taken into account when writing the final version of this paper.

Results The Employment Conditions The Royal Decree (B.S. 7/29/2009) regulates the employment conditions in the service voucher system. According to this Royal Decree all service voucher workers automatically receive a contract of unlimited duration after three consecutive months of employment with the same employer. Additionally, the Royal Decree obliges companies to respect some minima regarding the amount and the stability of employment. It stipulates a minimal working time of three subsequent hours per assignment and that contracts have to guarantee a minimum of 10 h per week (13 h for some specific types of workers). It also states that the contractual working hours as well as the wage must be stable throughout the duration of the employment contract.37,38 Yet, our study brings forward that in practice the stability of employment is less guaranteed then legislation stipulates. Some employers appear to oblige the worker to sign a new contract with less working hours if customers cancel permanently (e.g., if the customer leaves the company). To deal with occasional cancellations (e.g., if the customer is on holiday) some employers appear to offer an open-ended contract for a (lower) fixed number of working hours and weekly addenda for a variable number of additional hours. My contract is unlimited. It is a bit of a stupid system. It is an unlimited contract but I have to sign that contract every week, because if you work for the service voucher system you have to go to people. For example, this week I work for those people, but maybe next week I won’t. (Angelika)

Few workers are aware of the fact that their employer is not allowed to apply these practices. Other (forbidden) practices that employers apply in case of a cancellation are obliging their domestic workers to take paid leave (14.5% of the service voucher companies), withholding payment (18.6%) or applying the scheme of temporary unemployment (21.7%) (In Belgium, workers that are employed through an employment contract can become temporary unemployed if the demand for

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their work has temporarily decreased or is suspended. This is only possible under certain conditions (for economic reasons, bad weather or technical disturbances (only for blue-collar workers), force majeure, if the company closes during its annual leave or in case of a strike). Companies often apply this practice if customers cancel, but this is not legal. During days of temporary unemployment, workers do not build up social security rights (http://www.werk.belgie.be/)).39 The interviews show that such practices mainly affect the most vulnerable workers. Service voucher workers are entitled to the same social security benefits as other Belgian workers (i.e., they receive benefits in case of unemployment, illness or an accident, they build up pension rights and they can take paid leave), yet the interviews show that employers apply practices that endanger the workers’ social security rights: She has explained that three month contracts are better for taking leave. Yes, I also don’t know how it all works, but it was better because, first she wanted to give me a contract of unlimited duration, but then she told me ‘‘Wouldn’t it be better for you to take contracts of three months. That is better because then you can stay at home during the holidays.’’ Because I take more leave than the others. (Astrid)

Concerning health and safety training, policy makers and social partners implemented several initiatives for increasing the proportion of trained workers, but most of the workers still do not receive training. The most important initiative is the introduction of a ‘‘Federal Training Fund’’ in 2007. This fund partially reimburses training that is directly related to the job (e.g., ergonomics, efficient work planning) (BS 7/11/2007). The proportion of workers that receives training through the resources of the training fund is rather low (less than 30%).7 A possible explanation is that service voucher workers themselves do not recognize the importance of training because they are not aware of the health and safety risks related to their work.40 The interviews also demonstrate that health and safety trainings do not always prove fruitful. Even the trained workers appear to encounter barriers for putting the advice into practice because customers do not always provide appropriate cleaning material: They show all those things, you shouldn’t bend over, you have to put your bucket on a chair and things like that, and they show how you have to work for your back. But it is not self-evident as sometimes we arrive at the customers’ home and they don’t have any suitable material. (Solange)

In addition, the workers in our interviews easily relapse into their old cleaning habits, possibly because training is often not given at the start of employment or because training is not given regularly.41,42

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While the subsidized service voucher system was presented as a ‘‘steppingstone’’ into the labor market, previous research shows a lack of opportunities for broader professional formation and further career progress.43 In part this relates to the fact that the Federal Training Fund only reimburses trainings that are ‘‘directly related to the job.’’ Nonetheless, (mainly the immigrant) respondents hope to use the service voucher system as a stepping-stone to another profession (e.g., childcare or elderly care). Broader professional formation is also important because many respondents perceive this job as physically demanding and emphasize their inability to keep performing this job in the longer run (at least not full time): There are women that do this job for ten years. What will become of them later? I did it for four years and my back is damaged in any case. Also my nose is damaged because I have way more allergies than before. (Solange)

In contrast, some companies provide training practices aimed towards further career progress. A good example from our interviews concerns an employer who provides the possibility to its workers to follow a caregiver-training course. Some of the workers of this company considered to take this opportunity in order to redirect themselves professionally.

The Employment Relations The service voucher system lacks straightforward guidelines regarding the specific content of the intermediary role of the service voucher companies. As a result, companies provide coaching in a very heterogeneous way.40,44 In some cases coaching and support are even inexistent.44 Obviously, a lack of guidance can negatively impact the quality of work. A first problem concerns the provision of information to workers regarding their rights. Furthermore, our interviews show that not all companies look out for another customer when their workers indicate that they prefer to stop working for a certain customer. In such cases of problematic customer relations, where the service voucher company is not willing to negotiate or provide another customer, workers are obligated to accept suboptimal working conditions. Moreover, if the company never visits the work site, it is difficult to judge the feasibility of the customers’ demands and the safety of the working conditions in their home. Because of a lack of control, unsafe situations may remain unnoticed: They sent me to a guy. When I went in there it was terror. He was crazy. [. . .] everything inside was broken and glued back together [. . .] He showed me his bathtub that I had to clean. I found two jerry cans with acid [. . .] His room was full of wine bottles, he got (himself) drunk. I called the agency and I said that he was crazy. No one wanted to listen to me. (Bahija)

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Notwithstanding the issues mentioned above, most service voucher workers are (very) satisfied with their employing company and the helpfulness of the counselors.39 Yet, workers with a non-EU nationality are less satisfied, compared to the Belgians and the EU-citizens,39 possibly because immigrants are more easy targets for fraudulent employers. Also the customers are important actors in the service voucher system. However, also their rights and obligations are loosely defined in legislation. Again, studies show that most service voucher workers are (very) satisfied of the respect and the help they receive from their customers.39 Yet, compared to Belgian service voucher workers, EU and non-EU immigrants are less satisfied with the contacts that they have with their customers.39 Feelings of discrimination may be important factors here: a previous study demonstrates that workers and companies are frequently confronted with discrimination.45 Our informants experience discrimination because of their headscarf or because of their skin color. Moreover, immigrants may be more vulnerable for exploitation by their customers. This is mainly the case for workers whose residence permit depends on a certain minimum of hours in paid employment. Such a situation puts these immigrants in a very vulnerable position vis-a`-vis their customers, because their right to stay in Belgium literally lies in their customers’ hands: There was one customer where my aunt worked informally before she entered the service voucher system. My aunt called her to explain that she needed to work a certain number of hours to obtain a residence permit. The customer paid my aunt E7.5/hours informally but with the service vouchers she needed to pay E8.5/hour (price of a voucher at the moment of the interview). So she said ‘‘I do not want to pay more than E7.5/hour’’. So my aunt told her that if the customer would pay her E8.5/ hour with the service vouchers she would work one hour per week for free. [. . .] She has no choice. If this customer leaves, she will not have sufficient hours (for the residence permit). (Zineb, with her niece acting as translator)

The fact that workers have little contact with colleagues, makes work in the service voucher system very isolated.46 However, also contradictory opinions on this issue emerge from our interviews. Having contact with colleagues appears to be especially important to the immigrant women, certainly if they work for a less supportive employer. Like all workers in Belgium, service voucher workers can organize themselves in trade unions. This appears to be a common practice because in 2014, 57.45% of all service voucher workers were trade-union members. Yet, the scattered work locations hinder the application of the traditional approach, where workers’ representatives maintain frequent contact with workers on the shop floor.47 Therefore, sectorial approaches (negotiating collective agreements) are more important than in-company union activities. However, the fact that the service

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voucher workers are represented in different Joint Committees also hampers this approach (In Belgium, Joint Committees function as a consultative body between workers and employers aimed at social dialogue. In the Joint Committees collective agreements are made, social disputes are prevented or settled, and advice is prepared for the government, the National Labor Council or the Central Economic Council).48

The Intrinsic Characteristics of Work Tasks As is reflected in legislation, policy makers have paid attention to harmful physical working conditions in the service voucher system. The Royal Decree (BS 12/ 22/2001) defines that the service voucher company should be committed to avoid work in an environment with unacceptable risk or danger or in an environment where the worker could be a victim of abuses or discriminatory practices. Nonetheless, as outlined above, not all companies are visiting the customer’s home before sending a worker. In cases were no visit is made, it remains doubtful whether health and safety precautions are really taken. Either way, the physical demands are high for service voucher workers. Evaluation studies show that 31% of them is not satisfied with the physical demands of the job.39 In our interviews mainly full-time working, older workers or those with high seniority emphasize the high physical demands of their job. Angelika, employed in the service voucher system for ten years, testifies: My doctor told me that the problems with my neck and my arms will never truly heal. You know, if you are cleaning you have to do the same movements all the time. You always do the same. (Angelika)

According to our respondents, the physical demands partly depend on the work equipment they are provided with and on the expectations of the customers. Good information and strict guidelines about cleaning products and work tasks may avoid much harm, but earlier studies and our own interviews show that there is still work to do in that regard.48 Not all companies communicate in detail to their workers what tasks they are allowed to do and which products they are allowed to use. The service voucher workers on their turn are sometimes not aware of the health risks related to cleaning products and work tasks. By consequence, they are often handling potentially hazardous cleaning products and performing dangerous tasks. Customers also for a large part determine the psychosocial demands. Service voucher workers perceive it as a source of stress that customers ask them to finish an unrealistic number of tasks or that they come up with additional work almost at the end of the assignment.48 Work tasks that are perceived as ‘‘disrespectful’’ are another source of stress. An example was provided by Ellen,

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who had to clean the inside of the toilet with a scourer. Our interviews indicate that assertive workers experience fewer problems with the content and the quantity of their work because they are better able to discuss their assignments with their customers. Many of our respondents praise the high amount of autonomy they have in their work because it helps them to cope with the poor content of work tasks. On the contrary, some respondents perceive autonomy as a ‘‘lack of direction,’’ because they do not dispose of the skills for organizing their work independently. According to our informants, the degree of autonomy very much depends on the customer. Some customers provide to-do lists; others leave it to the domestic help to organize the work. In general, most of the interviewees perceive their work as important. They acknowledge the fact that they help their customers with their services: I think that a domestic help is mainly someone who helps people out of trouble. I notice that, I mean, I only do replacements in the company where I work. I have one fixed address and for the rest I always go over to different people’s homes, and then it often happens that their cleaning lady has been ill for a while. And then these people are really in trouble because they don’t have anybody to come over to clean . . . So I do think that it is a necessary job. (Lynn)

Yet, the perceived intrinsic value of the job appears to depend on personal characteristics and future career ambitions. In our interviews several female immigrants were directed to the service voucher system because they had no choice. For instance, their educational qualifications were not recognized or they needed full-time employment to secure their residence permit. These respondents are less inclined to stress the meaningfulness of their work, because they see themselves capable for other kinds of work: I work in a job that is physically very hard. You have to clean the whole day and then you come home and you have to manage three kids and you can start cleaning again. All these things I don’t do them for my pleasure. Working as a domestic worker, you do it because you have no choice. [. . .] In the past I worked as a model and I have also worked for television a bit. When I talk, about this I get worked up about it, because these days I have no other opportunities but to clean. Why? Because I have no choice. . . because I wear a headscarf. (Fouzia)

Discussion In line with the ‘‘social investment strategy,’’ several European countries implemented initiatives to encourage the growth of the domestic cleaning sector. By doing so, these countries expected to provide stepping-stones into the labor

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market for low skilled women and immigrants, while providing a solution for problems related to work-family imbalances in the middle and higher strata of the labor market.3,11 If these initiatives strive towards being ‘‘real social investment strategies’’ they should also contribute to decreasing social health inequalities. Whether they succeed in achieving this goal largely depends on the quality of work attained. Therefore the aim of this study was to investigate the quality of work in the service voucher system. The following paragraphs summarize the main results of this study. Thereafter, we discuss the possible implications that this important employment scheme can have on health inequalities. We also formulate policy recommendations. The service voucher system offers a regulated and relatively stable work environment. Nevertheless, our study showed that service voucher workers still experience insecurity in terms of income, social rights and working times, mainly due to practices of their employer or their customers. Yet, unstable employment conditions can constitute risk factors for health.49 Therefore all actors in the sector should tackle remaining problems causing the instability of the employment conditions. In that regard employers need to sensitize customers about the importance of their engagement for guaranteeing stable employment conditions. Employers must also do more efforts for adapting the work planning so that stable working hours are guaranteed. Many service voucher workers encounter financial problems, mainly because they work part-time. Because financial hardship relates negatively to workers’ health and well-being, the wages in the service voucher system should be a concern for policy makers.50 However, increasing wages in the service voucher system may have adverse effects, e.g., decreasing the demand for domestic work, increasing informal employment or increasing the workload during working hours. Therefore, policy makers should be careful with wage increases and consider alternative options. Offering better possibilities for making career progress might offer a way out of the ‘‘wage dilemma.’’ In order to reach this goal, training support should be extended beyond cleaning-related skills. This will render workers real opportunities for upward career mobility in the service voucher system itself (e.g., administration or activities of coaching and instructing), but also in other segments of the labor market (e.g., care for children and the elderly). It could also provide a solution for workers that encounter health problems due to long years of cleaning work. Health and safety must also be further improved. Here lies a responsibility for both policy makers and employers. Measures should ideally consist of a mix of regular training for workers, awareness enhancing campaigns for customers and more controls on the field. Moreover, employers must instruct customers how they can decrease the health risks related to domestic cleaning. In that regard the provisions of the Federal Training Fund can also be extended to activities for instructing the customers.

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In addition, progress can be made regarding the employment relations. Employers bear an important responsibility here. They must rigorously apply the existing regulations: e.g., guaranteeing employment stability in accordance with the agreed working hours and guaranteeing transparent and correct payment of wages. In addition, the feasibility of the workload should ideally be discussed between the customers and the worker, with the employer fully and actively playing the intermediary role of counselor. Formulas of peer-support where fellow cleaners help each other with inspecting working conditions and making agreements with customers could be a useful tool for enhancing the mutual support among cleaners. Employers should also organize collective activities with the workers (e.g., regular meetings) in order to avoid feelings of isolation. Such events could provide an ideal context for (peer-to-peer) training on various cleaning-related and personal skills. The government must oversee whether all the parties concerned comply with the legislation. They must sanction employers that do not respect the requirements, in order to avoid improper competition between service voucher companies. Additionally, the government can differentiate the subsidies to service voucher companies according to quality of work-related criteria. Moreover, unacceptable behavior of customers (e.g., discrimination, delayed payment, unauthorized or excessive demands) should be centrally registered and repeated violation of the rules must lead to sanctions or even suspension from the service voucher system. Finally, trade unions should be stimulated to think about how to safeguard the quality of work. A main goal must be to represent all service voucher workers by one and the same Joint Committee. The current situation makes the system too complicated and effectively fragments workers’ collective voice.47,48 The service voucher system is among the best-regulated domestic cleaning employment schemes in Europe and it has provided employment opportunities for many low-skilled workers in Belgium.7 Nevertheless, from a health (equity) perspective, the above-discussed measures could effectively improve the service voucher system with regard to its health impact. This is highly important, since domestic cleaning implies important numbers of workers with a vulnerable socio-economic position. An equity perspective is also relevant within the system itself. Our study showed that inequalities between service voucher workers persist, with some profiles accumulating more adverse quality of work characteristics than others. This is mainly the case for immigrant women with few social resources. In the worst-case scenario, they are exposed to a potentially long list of factors that negatively affect their work quality. This creates a situation of accumulated vulnerability. Therefore, making companies to converge to the same high level of work quality can effectively decrease inequalities among domestic cleaners. If further progress is not made, the suboptimal quality of work in the service voucher system can actually increase health inequalities. Currently the service voucher system is mainly improving the health of those

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economically better-off by giving them – as customer of household services – the possibility for reducing work-family conflict. At the same time it is pushing low-skilled women and immigrants into unhealthy cleaning jobs. From a health equity perspective therefore, the service voucher system can only be seen as a valuable policy tool if further measures are taken to improve the general quality of work and if the system becomes a stepping-stone for upward social mobility. Unfortunately this study could not provide a complete picture of how the service voucher system affects health inequalities in society at large. Therefore, more research is needed in addition to this study. Future quantitative research should investigate how the quality of work in the service voucher system relates to the mental and the physical health of the workers. Investigating how the implementation of the system affects the customers’ work-life balance and their health, would deliver further valuable insights. Nevertheless, this study contributes to our understanding of the quality of work in the service voucher system. It also provides very useful recommendations concerning how the service voucher system should be adapted for further improving the quality of work for the workers. In that regard this study provides very valuable information for policy makers. Acknowledgments We are grateful to the informants that took part in the interviews. Additionally, we would like to express our sincere gratitude to the organizations that helped with the recruitment of the informants or provided us with comments and additional feedback: the service voucher companies, IDEWE, ABVV Algemene Centrale and Vorm DC.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the SOPHIE-project which has received funding from the European Community’s Seventh Framework Program Health (FP7/2007–2013) [grant number 278173].

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Author Biographies Sarah Mousaid graduated as a Master in Sociology at the Vrije Universiteit Brussel (VUB). She works as a doctoral researcher for the research group ‘Interface Demography’ (VUB), under supervision of Prof. Dr. Christophe Vanroelen. She prepares a PhD on the quality of work and health among immigrants, with a focus on the ‘Service Voucher System’ in Belgium. Kelly Huegaerts studied Sociology at the Vrije Universiteit Brussel (VUB), where she graduated as a Master in Sociology with a qualitative MA dissertation on the precarious employment of service voucher employees. Currently she is a Master Candidate in Quantitative Analysis in the Social Science at the Katholieke Universiteit Leuven (KUL). She is connected to the research group Interface Demography of the VUB where she works as a PhD Candidate under the supervision of Prof. Dr. Christophe Vanroelen (VUB). Her research focuses on the relationship between unemployment and mental health amongst Brussels youth. Kim Bosmans is a post-doctoral researcher at the Department of Sociology of the Vrije Universiteit Brussel. Her PhD dissertation focused on the psychosocial processes linking precarious employment to mental well-being. Her qualitative research provided a deeper understanding of the lived-experiences of temporary agency workers and domestic workers concerning the association between precarious employment and mental well-being. Mireia Julia` is a doctoral candidate at the Health Inequalities Research Group (GREDS-EMCONET) of the Universitat Pompeu Fabra, and the Johns Hopkins-Universitat Pompeu Fabra Public Policy Center. She holds a master’s degree in Occupational Health. Her research is about employment conditions, precarious employment, informal employment and health inequalities, social

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protection policies and occupational health. She has been involved in several projects related to employment conditions and the impact on health inequalities. Joan Benach is Director of the Health Inequalities Research Group – Employment Conditions Network (GREDS-EMCONET), and Professor in the Department of Political and Social Sciences at the Universitat Pompeu Fabra. He is a member of the Executive Board of the Johns HopkinsUniversitat Pompeu Fabra Public Policy Center. His research deals with social determinants of health such as precarious employment and other employment conditions, the health intersections between social class, gender, migration and geography, and the development of health policy analysis and methods. He is a senior researcher with vast research experience, leading research projects in Europe, Latin America and elsewhere. Christophe Vanroelen is professor at Interface Demography, a research centre connected to the Department of Sociology of the Vrije Universiteit Brussel. He holds a PhD in social health sciences and master degrees in sociology and applied social science statistics. He collaborated in several scientific research projects regarding socio-economic health inequalities, inequalities in the accessibility of healthcare and work-related health. His current research focuses on health inequalities, and effects of health determinants related to work and employment, the welfare state and social and health services. He is a member of the research group GREDS-EMCONET (Universitat Pompeu Fabra, Barcelona).