Uncared for caregivers: Lack of regulations leaves home nurses vulnerable in Kerala

For more than two years, Lissy Sunny, a 48-year-old home nurse from Wayanad, has been caring for an elderly woman with dementia.

Lissy stays with a family who hired her to care for an aging woman.

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Every morning, after feeding the lying woman, Lissy rushes to the kitchen to prepare a meal for the family of four with whom she is staying. Her daily work ends late at night, long after family members have gone to bed.

All she gets for her tedious work is ₹22,000 a month, of which she has to pay ₹2,500 as commission to the agent who found her the job.

Geetha Gopi, a domestic nurse from Alakode in Kannur district, earns less than Lissy and receives a monthly salary of ₹18,000. She doesn’t know how much money her agent collects from the family. However, she has to pay a monthly commission of ₹2,500 to the agency that hired her.

With changing social patterns as young people move out of state for greener pastures and leave their parents at home, senior care has become a serious concern for a large number of families. The support of caregivers like Lissy and Geetha has thus become indispensable for most families in caring for their elders. Although they are in high demand, caregivers are often exploited and underpaid and even denied proper rest. Caregivers’ service is often unrewarded and unrecognised, complain those in the sector.

“Apart from our salary, we are not offered any extras or incentives for the tiring work we do. We work for a pittance for more than 20 hours a day and too often without proper rest or compensation. Most of the workers chose this job because of the financial crisis. Despite working hard, we are not left without any savings. Sometimes we have to cover a large part of our income or travel expenses from health insurance,” says Geetha.

Home care agencies that assign work to caregivers collect service fees from both families and home nurses. Agencies often collect the workers’ salary and commission from the affected families in advance. Some agencies even ask families for an amount equivalent to a month’s salary as a deposit, say those in the sector.

“Though the worker would be informed about his monthly salary, he would be kept in the dark about the money collected by the agencies from the employers’ families,” says Sunitha Raja, a domestic nurse who used to work as an agent at a home care agency in Koyilandy, Kozhikode.

Although home nursing agencies are often blamed for the ills plaguing the industry, many people like N. Jose from Wayanad rely on them to take care of his parents.

“I have been depending on these agencies to get carers for over eight years. As I am away from home, it is not easy for me to find a carer in my hometown to take care of my elderly parents,” says Jose, who works in London.

However, he adds that some of his friends who are based abroad have had unpleasant experiences with unprofessional carers and the agencies that recruit them.

No employment contracts

In most cases, there would be no legal employment contracts that set out workers’ working conditions, including working hours, holidays and overtime pay.

K. Layana, a domestic nurse from Wadakkancherry in Thrissur, who has since quit her job, recalls the days when she was forced to do household chores in addition to her caregiving assignment.

“There were times when I was asked to cook and clean in addition to my responsibilities as a carer for an elderly woman,” she says.

“Most of us cannot afford to question the extra responsibilities that are imposed on us because it can end up losing our jobs,” laments Jayasree, a house nurse.

While nurses employed by hospitals and clinics have well-defined working hours, a notified salary structure and well-defined professional responsibilities, home nurses and carers are left at the mercy of the families who employ them.

“A caregiver has to be on the alert all the time because they don’t know when an emergency will happen. You have a responsibility to provide help when needed,” explains Sangeetha Babu, a domestic nurse working in Palakkad.

“For a home nurse, weekly days off and holidays are not natural, but must be negotiated with the family that employed them. Such situations would drain the physical and mental health of the caregivers,” says a trained home nurse who works at a nursing home in Kannur.

The service of carers often goes unrewarded and unrecognised, say workers in the sector. | Photo credit: Getty Images

“Also, it’s not easy to get a replacement for a home nurse who goes on vacation for a few days. In some cases, we have to find replacement caregivers ourselves to go on vacation. This problem becomes especially difficult when the nurse gets sick or has an emergency at home,” she notes.

Carers are usually employed for 28 days and taking a day off or holiday during this period could lead to a loss of wages, complains another home nurse.

The informal nature of the profession also leaves many carers vulnerable to exploitation and denial of basic life support, including health insurance or disability, say representatives of the sector.

“Nurses lack any social security schemes and even a small health problem could put them in financial trouble,” says a 38-year-old home nurse working in Kalpetta, Wayanad.

Many cases of exploitation

A recent workshop organized by Mahatma Gandhi University in collaboration with the International Institute of Social Studies and the Inter-University Center for Research and Extension of Social Sciences identified cases of exploitation, precarious working conditions, lack of labor rights and the informal nature of the employment sector as challenges facing caregivers. The conference called for formalization of the sector, regulation of private agencies, and better wage and training standards.

A policy brief on domestic workers in Kerala by the International Domestic Workers Federation also noted vulnerabilities, including low wages and lack of work-related social security benefits. A publication by the Kerala Institute of Labor and Employment highlighted the issue of leave, health benefits and other protections for domestic and care workers, demanding government intervention, minimum wages and grievance redressal mechanisms.

The absence of a comprehensive regulatory framework, experts say, worries both the workers and the families who employ them.

The head of the labor department says that no targeted study has been carried out on the living conditions and services of domestic nurses. According to him, more than 1,000 private agencies, including registered and unregistered ones, are operating in the state.

In a recent dialogue with stakeholders, the International Labor Organization identified unfair recruitment practices, high recruitment costs, poorly regulated employment conditions, limited access to redressal of grievances and inadequate social protection among the challenges faced by Kerala caregivers.

The Kerala Institute of Labor and Employment suggested mechanisms such as job banks or employment centers through local governments as an alternative to total dependence on private intermediaries.

“There are also concerns about the safety of patients who are left under the care of home nurses as crimes against caregivers are being reported from various parts of the state. The proposal for mandatory police certificates for home nurses, which was considered in 2022, is awaiting approval,” says a former police official.

Regulatory framework

There is also a demand for regulatory mechanisms to be put in place for agencies in the sector.

“Agencies should be put under a management regime where they must register with the relevant authorities and keep records relating to the services they offer. There must be written contracts relating to the pay and other terms of service of carers,” suggests KC George, who works with a registered charity treatment centre.

“Agencies provide a common platform for caregivers and those in need of services. Firms are not opposed to any regulatory framework planned by the government,” says a home care agency owner in Kozhikode.

Healthcare professionals stress the need to provide professional training to caregivers, which they say would improve the quality of services in addition to improving their job prospects.

“Nurses who care for the elderly and bedridden patients need special professional training in safe patient handling, infection control, nutrition, basic emergency response and use of care equipment,” suggests Manoj Augustin, a registered nurse in geriatrics who is currently employed abroad.

Home patient care systems and caregiver engagement leave much to be desired.