A caregiver looking after a spouse puts in 44.6 hours a week.
That figure comes from a US household survey published in 2015. The same survey put the all-caregiver mean at 24.4 hours. Spousal care ran 1.83 times heavier than the average. Then the series stopped printing it.
Everything else about the arrangement has been priced. The hours have a dollar value, published annually. The nursing-home bed has a monthly rate, the agency has a monthly rate, and the facility in Chiang Mai has a rate that scales with the carer’s English. The one configuration nobody prices is the one that actually happens: a wife, in the house, alone with it.
The week that was printed once
The National Alliance for Caregiving and AARP fielded Caregiving in the U.S. 2015 between September and November 2014, with 1,248 caregivers. Its wording is flat: caregivers spend 24.4 hours a week on average, and “caregiving is particularly time-intensive for those caring for a spouse/partner (44.6 hours a week)”. Co-resident caregivers averaged 40.5. Asked how long they had been providing care, caregivers averaged 4.0 years, and 5.3 where they lived with the person cared for. For anyone still caring, that is the episode so far, not its length.
The 2025 edition, fielded across late 2024 with 6,549 caregivers, reports a 27.3-hour mean and 24% of caregivers at 41 or more hours a week. It does not publish the crosstab by relationship, and neither did the 2020 edition, which kept only a cruder signal: nearly three in five spousal caregivers fell in its high-intensity category, against about a third of those caring for a parent. What the 2025 edition does publish is the age gradient: 15% of caregivers overall are looking after a spouse or partner, rising to 27% among caregivers aged 65 to 74 and 48% among those aged 75 and over. The older the carer, the likelier it is that the person being cared for is the person they married.
None of that is Philippine or Thai data. What the destination side establishes is not the size of the week but the identity of the person inside it.
The Longitudinal Study of Ageing and Health in the Philippines went back into the field in early 2023 and interviewed informants for 1,514 respondents who had died. About two thirds of older people, 68%, had a caregiver before death. Among men, the caregiver was predominantly the spouse, at 53%. Across both sexes, daughters accounted for 39% and spouses for 26%. Only about 12% had a non-family caregiver of any kind.
Thailand’s picture is the same shape. Working from the 2014 Survey of Older Persons, Knodel and colleagues found that spouses and children constitute approximately 90% of main caregivers, and that the association between who provides that care and the household’s education or asset value “is quite weak”. A community survey of 867 caregiver dyads in a Chiang Mai subdistrict put spouses at 44.8% of family caregivers, second only to children at 46.8%. Of those caregivers, 62.3% were women, their median monthly income was around 9,000 baht, and 31.1% had no current job at all.
The paper closest to the specific case (Western husband, Thai wife, end of life) is Jaisuekun and Sunanta’s Til death do us part?, published in Gender, Place and Culture in 2023. Its abstract states the finding: ageing in Thailand as non-citizens, many Western husbands fall through the net of social protection and rely on their Thai wives as the only source of care, and the wives are expected to carry it with little support from either the sending or the receiving state. It rests on the biographical narrations of three women, and the authors are careful to say the three did not answer that expectation the same way. It documents a mechanism. It publishes no rate.
What the week does to the person inside it
Two of the most-cited findings in the caregiving literature point in opposite directions, and both are correct.
Schulz and Beach published the Caregiver Health Effects Study in JAMA in 1999. They followed 819 people aged 66 to 96, mean age 79.6, for four years: 392 caregivers and 427 non-caregivers. Participants who were caring for a disabled spouse and reporting physical or emotional strain had mortality risks 63% higher than non-caregiving controls, whose spouse was not disabled. Relative risk 1.63, confidence interval 1.00 to 2.65 — a lower bound sitting exactly on unity, which is worth noticing.
Roth and colleagues went the other way in the American Journal of Epidemiology in 2013. Using the REGARDS cohort, they individually propensity-matched 3,503 family caregivers to 3,503 non-caregivers across fifteen covariates and followed both groups for about six years. Two hundred and sixty-four caregivers died, 7.5%, against 315 of the matched non-caregivers, 9.0%. Hazard ratio 0.823, confidence interval 0.699 to 0.969. On that reading, caregiving is associated with living slightly longer.
Anyone quoting one of those numbers without the other is selling something. The reconciliation is in Roth’s own paper: fewer than 17% of the caregivers in that analysis reported high levels of caregiving strain, and the authors say plainly that their strained spousal subgroup resembled the one Schulz found dying faster. It just did not show an elevated risk in their sample. The same cohort answered the question directly the same year. Perkins and colleagues followed 3,710 REGARDS caregivers for five years and found that those reporting high strain died at a hazard ratio of 1.55 against caregivers reporting no strain, and 1.83 against those reporting some, and that the effect did not vary by the type of caregiving relationship.
So the exposure is strain, not caregiving. That is the one reading all three papers allow, and it is the least comforting version available. Strain was self-reported in every one of them, and nobody has asked her. But the configuration under discussion here (co-resident, spousal, sole carer, no relief, no second income, a language barrier between her and his consulate) is the one the US surveys find carrying the longest week with the least help, and nothing in it points the other way.
The morbidity side is less equivocal. Sallim and colleagues pooled 17 studies and 10,825 caregivers of Alzheimer’s patients for JAMDA in 2015. Aggregate prevalence: depression 34.0%, anxiety 43.6%, psychotropic drug use 27.2%. Three subgroups carried elevated odds of depression. Female caregivers, 1.53. Caregivers of male care-recipients, 1.86. Spousal caregivers, 2.51.
She is all three at once.
Those three odds ratios are separate univariate estimates and cannot be multiplied; there is no published joint figure and none is claimed here. What can be said is narrower and still hard: of the risk markers that meta-analysis was able to identify, the wife of an ageing Western husband carries every single one, simultaneously, with none of the protective factors (respite, relief carers, a second family member in the rotation) that the low-strain half of Roth’s sample had.
Source: Schulz & Beach 1999 (JAMA); Roth et al. 2013 (Am J Epidemiol); Perkins et al. 2013 (J Gerontol B); Sallim et al. 2015 (JAMDA) · checked 2026-10-03
The same seven rows, scored twice
Score the household. Same rows, one column each.
| Exposure | Him | Her |
|---|---|---|
| Hours committed per week | Him Zero. He is the recipient. | Her 44.6 in the one edition of the US survey that published hours by relationship — 1.83× the all-caregiver mean of 24.4. |
| What those hours are worth | Him A care package he did not buy, insure or contract for. | Her AARP values unpaid care at $20.41 an hour. At 44.6 hours a week that is $47,335 a year, unbilled. |
| Mortality effect over the episode | Him Care at home, by a person who knows him, indefinitely. | Her No excess measured for caregiving as such (HR 0.823). Under high strain, HR 1.55 against no-strain carers; RR 1.63 for strained spousal carers. |
| Depression odds | Him Not the population studied. | Her OR 2.51 as a spousal carer, 1.86 caring for a man, 1.53 as a woman. Pooled prevalence 34.0% depression, 43.6% anxiety. |
| Labour-market position | Him Retired. Income arrives regardless of what happens in the house. | Her Thai time-use data across 70,000+ adults: women substitute unpaid elder care for paid work, men do not. 31.1% of Chiang Mai family caregivers had no current job. |
| Whose standing rests on the marriage | Him His. The Philippine 13(a) is granted "on the basis of his valid marriage to a Philippine citizen". | Her Hers is unaffected. She is the citizen. This is the one row that runs against him. |
| What accrues from the work | Him Care delivered at zero marginal cost, with no contract to renew. | Her No wage, no rest entitlement, no thirteenth month, no SSS, no PhilHealth, no Pag-IBIG. The statute covering this exact job does not reach her. |
Every figure is population-level and drawn from the sources named in the sidecar; none is predictive for any individual couple. The dollar values are US replacement prices and are not converted into peso or baht terms anywhere in this table.
The sixth row is the one that surprises. The pitch runs the other way, that the marriage is what she gets out of it, but the Philippine Bureau of Immigration states the 13(a) eligibility in a single line, and the line is about him: “A foreign national on the basis of his valid marriage to a Philippine citizen.” His legal presence in the country runs through her. Hers runs through nothing. She was already home.
What the state already pays a stranger to do it
Here is the part that is difficult to look at directly. The Philippine state has already priced this labour, in detail, with statutory instruments and enforcement machinery. It priced it for the person hired to do it.
Republic Act 10361, the Batas Kasambahay, covers domestic workers. Section 20 gives an aggregate daily rest period of eight hours. Section 21 gives twenty-four consecutive hours of rest a week. Section 25 gives thirteenth-month pay. Section 30 puts a worker with one month’s service into the Social Security System, PhilHealth and Pag-IBIG, and where the wage is below ₱5,000 a month, “premium payments or contributions shall be shouldered by the employer”. Above that line, which the current Metro Manila floor clears, the worker pays a proportionate share. The Act sets a floor under rest. Beyond the sixteen hours a day that floor leaves open, it sets no ceiling on hours.
On top of that sits the wage. Wage Order No. NCR-DW-06 raised the Metro Manila monthly minimum for domestic workers from ₱7,000 to ₱7,800 with effect from 7 February 2026. Set that against the region’s general non-agriculture floor of ₱755 a day, carried since 26 September 2026 by Wage Order NCR-28 while the earlier order setting the same figure sits in litigation: across a six-day week, ₱19,630 a month. The domestic-work floor is 39.7% of it. The wage is not the whole of it, either. Section 6 obliges the employer to provide at least three adequate meals a day and humane sleeping arrangements, and Section 25 requires the wage in cash and bars deducting anything from it without the worker’s written consent. Board and lodging is precisely the arrangement a wife is already in. In the statute it is owed on top of the wage, not offered as one. Wage orders are revised; the order numbers are printed here so the current figure can be checked against them.
Thailand’s version is younger and thinner. Ministerial Regulation No. 15 on Domestic Work, dated 30 April 2024, set a maximum eight-hour working day. Before it, household-hired domestic workers did not benefit from the daily minimum wage at all. They remain excluded from Labour Protection Act provisions on overtime compensation and severance pay, and Thai law does not regulate stand-by or on-call hours, which is the entire content of caring for someone at night. The 2018 Informal Employment Survey found domestic workers working 4.1 hours a week more than other workers. Community care workers are not workers under Thai law and receive around 2,000 baht a month. The ILO, reporting Kulkolkarn and colleagues, notes that Thai workers expected around 27,321 baht a month for household or community care roles against 15,000 baht expected by migrants — 54.9% of the Thai figure, and both are expectations rather than observed pay.
| Entitlement | Hired kasambahay (PH) | Hired domestic worker (TH) | The wife |
|---|---|---|---|
| Entitlement Wage floor | Hired kasambahay (PH) ₱7,800/month (WO NCR-DW-06) | Hired domestic worker (TH) Daily minimum since MR 15, 2024 | The wife None |
| Entitlement Daily rest minimum | Hired kasambahay (PH) 8 hours aggregate (RA 10361 §20) | Hired domestic worker (TH) 8-hour maximum working day (MR 15) | The wife None |
| Entitlement Weekly rest day | Hired kasambahay (PH) 24 consecutive hours (§21) | Hired domestic worker (TH) Provided under MR 15 | The wife None |
| Entitlement Overtime / on-call pay | Hired kasambahay (PH) Left to the written contract (§11) | Hired domestic worker (TH) Excluded from the LPA provisions | The wife None |
| Entitlement Thirteenth-month pay | Hired kasambahay (PH) Yes (§25) | Hired domestic worker (TH) Not provided | The wife None |
| Entitlement Severance on termination | Hired kasambahay (PH) Notice and unpaid-wage rules apply | Hired domestic worker (TH) Excluded from the LPA provisions | The wife None |
| Entitlement Pension / health / housing fund | Hired kasambahay (PH) SSS, PhilHealth, Pag-IBIG (§30); employer pays all below ₱5,000/mo, a share above | Hired domestic worker (TH) Not established for household hires | The wife None |
Read the fourth column as the finding, not as an omission. Nothing in RA 10361 or in Ministerial Regulation No. 15 is drafted to reach a spouse; the exclusion is structural, not an oversight in either statute.
Source: RA 10361; NWPC/DOLE NCR wage orders; ILO, Care at home (Oct 2025) · checked 2026-10-03
Now price the episode. At 44.6 hours a week across 52 weeks, the year runs 2,319 hours. Held for the 5.3 years co-resident caregivers reported (spouses, in the 2020 edition’s words, “almost always live together”), that is 12,292 hours of work.
12,292 hours at AARP's 2024 valuation of $20.41/hour. AARP's Valuing the Invaluable 2026 update put 59 million US family caregivers at 49.5 billion hours in 2024, worth $1.01 trillion — more than total Medicaid spending that year.
Run on the survey’s all-caregiver averages instead, a shorter week held for a shorter time, the same arithmetic still gives $103,585.
Bought instead at the Metro Manila statutory floor for the identical work, the same 63.6 months costs ₱496,080. In Chiang Mai, the untrained live-in carer at the bottom of the local wage stack earns THB 8,000 to 10,000 a month for twenty-four-hour cover with one day off a week. That is the market rate for the work she is doing. It is not what she is paid, because she is not paid.
No notice period
An employee in either statutory arrangement can resign. That is the difference the tables do not carry, and it is the whole structure.
The carers report it themselves. Forty-nine per cent of the 2015 US sample said they felt they had no choice about taking the role on. Among those providing 21 or more hours a week, 59%. Among co-resident caregivers above 20 hours, 64%. The heavier the week, the less it was chosen — which is what you would expect if the sense of obligation and the number of hours are produced by the same thing, namely that no one else is going to do it.
Then the economics. The Thai national time-use data, covering more than 70,000 adults, shows women providing elderly care spending two to two and a half hours a day on it, far more than men, and the authors state the consequence flatly: women swap paid work for elderly caregiving, and men do not. Half the Chiang Mai family caregivers surveyed were their household’s main income supporter. Nearly a third had no job. Knodel’s finding that the identity of the main caregiver in Thailand is only weakly associated with the household’s assets makes the same point from the other side: within this range, more money does not buy a substitute, because the expectation is normative rather than budgetary.
And then the specific case. Jaisuekun and Sunanta’s Western husbands have fallen through the net of social protection, and their wives carry the care with little support from either the state he left or the one he retired into. The wife is not the preferred option in that arrangement. The paper’s phrase for her is “the only source of care”.
She can leave a marriage. She cannot leave a job that was never constituted as one, because there is nothing to leave: no contract, no notice period, no severance, no accrued entitlement to walk away from, and no successor to hand it to. Resignation requires an employer. What she has instead is a husband who needs help getting to the bathroom at three in the morning.
What it is worth to him
Run his side as a balance sheet and the arrangement is exceptional. Care on call at any hour, with no premium, no policy exclusions, no facility contract, no waiting list, no annual repricing, no assessment, delivered by someone who speaks to him in the language he married into and knows how he takes his tea. Against the Chiang Mai facility rate for comprehensive dementia care, or against the $250,880 that AARP’s own hourly rate puts on 12,292 hours, he has acquired for nothing the item the rest of the care market bills by the month.
He has also acquired a care structure with exactly one point of failure and no reinsurance behind it. There is no rotation. There is no relief carer, no second daughter, no agency on retainer, no statutory backstop, no clause that triggers if the provider falls ill — and if what she is nursing is dementia, the provider belongs to the population in which the pooled studies find depression in 34% and anxiety in 43.6%, and she carries whatever the strain figures mean for a woman in exactly her configuration. If she goes down, the arrangement does not degrade. It ends, at once. In the Philippines only about 12% of older people who died had had a non-family caregiver of any kind, and that is the point at which a man discovers whether he is a burden to someone or to no one.
He did not price that risk because it was never presented as a risk. It was presented as a marriage, and it is one. The work inside it is real, measured at 44.6 hours a week and valued at $20.41 an hour by the people who bothered to look, and covered in Metro Manila by a wage order, a rest entitlement and three social-insurance schemes — none of which apply to her, because the statute drafted for this exact labour assumes the person performing it was hired.
The invoice exists. It was itemised by the Philippine legislature in 2013 and repriced by a wage board in February 2026. It is simply addressed to somebody else.