For more than two years, Lissy Sunny, a 48-year-old home nurse from Wayanad, has been attending to an elderly woman with dementia.
Lissy stays with the family that hired her to take care of the ageing woman.
Every morning, after feeding the bedridden woman, Lissy rushes to the kitchen to prepare food for the four-member family with whom she is staying. Her everyday chores end late in the night, long after the family members retire to bed.
All that she is paid for the tiring job is ₹22,000 a month, from which she needs to shell out ₹2,500 as commission to the agent who found her the job.
Geetha Gopi, a home nurse from Alakode in Kannur district, earns less than Lissy and is paid a monthly salary of ₹18,000. Shedoes not know how muchmoney her agent collects from the family. But she needs to pay the agency, which has engaged her, a monthly commission of ₹2,500.
With the changing social patterns where youngsters are moving out of the State in search of greener pastures and leaving behind their parents at home, elderly care has become a matter of serious concern for a large number of families. The support of caregivers like Lissy and Geetha has thus become inevitable for most of the families to take care of their elders. Even though in high demand, the caregivers are often exploited and underpaid and even denied proper rest. The service of the caregivers often goes unrewarded and unrecognised, complain those in the sector.
“Other than the salary, we are not offered any allowances or incentives for the tedious work we undertake. We work for meagre wages for more than 20 hours a day and that too often without proper rest or reward. Most of the workers have opted for the job due to the financial crisis. Despite the hard work, we are left with no savings. At times, a major portion of the income has to be set apart for medical or travel expenses as we are not covered by any social security schemes,” says Geetha.
The home care agencies that assign work to the caregivers collect service charges from both the families and the home nurses.The agencies often collect the salary of the workers and their commission in advance from the families concerned. Some agencies even demand an amount equivalent to a month’s salary as a security deposit from the families, say those in the sector.
“Though the worker would be informed about their monthly salary, they would be kept in the dark about the money the agencies collect from the employer families,” says Sunitha Raja, a home nurse who earlier worked as an agent in a home care agency in Koyilandy in Kozhikode.
Though the agencies offering the service of home nurses are often blamed for the ills plaguing the sector, many people like N. Jose of Wayanad are banking on them to take care of his parents.
“I have been depending on these agencies for obtaining the service of caregivers for more than eight years. Being away from home, it’s not easy for me to find a caregiver in my hometown to take care of my aged parents,” says Jose, who works in London.
However, he adds that some of his friends, who are settled abroad, had unpleasant experiences with unprofessional caregivers and agencies that recruit them.
In most of the cases, there would not be any legal employment contracts listing out the service conditions of the workers, including the working hours, leave, and overtime wages.
K. Layana, a home nurse from Wadakkancherry in Thrissur who has since left the job, recalls the days when she was forced to attend to the household chores besides her assignment as a caregiver.
“There were occasions when I was asked to do the cooking and cleaning, besides the responsibility as a caregiver to an elderly woman,” she says.
“Most of us cannot afford to question the additional responsibilities forced on us as it may end up in losing the employment,” laments Jayasree, a home nurse.
While there are definite working hours, notified wage structure and well-defined professional responsibilities for the nurses engaged by hospitals and clinics, home nurses and caregivers are left to the mercy of the families engaging them.
“A caregiver constantly needs to be on alert as one does not know when an emergency develops. You are required to provide help when needed,” explains Sangeetha Babu, a home nurse working in Palakkad.
“For a home nurse, weekly off days and leaves do not come naturally but have to be bargained with the family that has engaged them. Such situations would drain the physical and mental health of the caregivers,” says a trained home nurse who works at a care home in Kannur.
The service of the caregivers often goes unrewarded and unrecognised, says those in the sector. | Photo Credit: Getty Images
“Moreover, it’s not easy to get a replacement for a home nurse who goes on leave for a few days. In some cases, we have to find a substitute caregiver by ourselves to goon leave. The issue becomes particularly difficult when a nurse falls ill or has an emergency at home,” she notes.
Mostly, the caregivers are engaged for 28 days, and availing a day off or leave during the period could lead to loss of wages, complains another home nurse.
The informal nature of the occupation also leaves many caregivers vulnerable to exploitation and denial of basic support in life, including medical insurance or sick leaves, say those in the sector.
“The caregivers lack any social security schemes and even a small health issue could push them to financial distress,” says a 38-year-old home nurse working at Kalpetta in Wayanad.
A recent workshop organised by the Mahatma Gandhi University in collaboration with the International Institute of Social Studies and the Inter University Centre for Social Science Research and Extension had identified instances of exploitation, insecure working conditions, lack of labour rights and the informal nature of the employment sector as the issues faced by care workers. The conference had called for formalisation of the sector, regulation of private agencies and better wage and training standards.
A policy brief on domestic workers in Keralam by the International Domestic Workers Federation has also noted vulnerabilities including low wages and a lack of work-related social-security benefits. A publication by the Kerala Institute of Labour and Employment had highlighted the issue of leave, health benefits and other protections for domestic and care workers, while calling for government intervention, minimum wages and complaint-redressal mechanisms.
According to experts, the absence of a comprehensive regulatory framework is a matter of concern for both the workers and the families engaging them.
A senior Labour department officer says no focussed study has been undertaken on the living and service conditions of home nurses. According to him, more than 1,000 private agencies, including registered and unregistered, are operating in the State.
In a recent dialogue with the stakeholders, the International Labour Organisation had identified recruitment malpractices, high recruitment costs, under-regulated employment conditions, limited access to grievance redressal and inadequate social protection among the challenges confronting care workers from Keralam.
The Kerala Institute of Labour and Employment had suggested mechanisms such as labour banks or employment centres through local governments as alternatives to complete dependence on private intermediaries.
“Concerns are also being raised about the safety of patients who are left in the care of home nurses as crimes involving caregivers are being reported from different parts of the State. A proposal for mandatory police clearance certificates for home nurses, which was mooted in 2022, is awaiting approval,” says a former police official.
There is also demand for introducing regulatory mechanisms for agencies in the sector.
“The agencies should be brought under a management regime where they need to register themselves with the authorities concerned and maintain records related to the services offered by them. There shall be written contracts regarding the salary and other service conditions of caregivers,” suggests K.C. George, who works with a registered charity medical home.
“The agencies provide a common platform for the caregivers and those in need of the services. The firms are not opposed to any regulatory framework planned by the government,” says the proprietor of a home-nursing agency in Kozhikode.
Experts in the health-care sector highlight the need for imparting professional training to the caregivers, which, according to them, would improve the quality of the service besides enhancing their job prospects.
“Caregivers who look after the elderly and bedridden patients need special professional training in safe handling of patients, infection control, nutrition, basic emergency response and the use of care equipment,” suggests Manoj Augustin, a trained nurse in geriatrics, who is currently employed abroad.
The home-based patient care systems and the engagement of caregivers leave much to be desired.
