Psychosocial interventions which are underfunded rely on volunteer women organisations to administer counselling. These measures strengthen gender inequalities, devalue women and the clinical work required for a successful intervention.
Authors Liana E Chase Dristy Gurung Parbati Shrestha Sunita Rumba explore the issue in the Lancet. December 2020.
Recent conversations in The Lancet Psychiatry have highlighted the ways global mental health institutions reflect and reproduce wider social inequalities.1 Gendered practices of employment and remuneration are an understudied dimension of this problem. The past decade has seen a proliferation of psychosocial interventions delivered by lay community workers, a predominantly female workforce.
Under the right conditions, task shifting in this way can address geographical and socioeconomic inequities in access to care and support women’s empowerment. Yet, such interventions also carry the risk of further entrenching gender inequalities when female community workers are viewed instrumentally as a source of more affordable clinical labour.
As a group of women scholars and clinicians involved with psychosocial interventions in Nepal, we write to sound a note of caution amid the burgeoning enthusiasm for task shifting in global mental health.In 2016, psychosocial care in Nepal reached an important milestone: the first government-financed psychosocial support centres were established, with plans for national scale-up (appendix).
Unfortunately, this achievement required a crucial compromise: because hiring salaried counsellors was deemed unsustainable, the programme recruited volunteer counsellors from women’s cooperatives, reasoning that these women were intrinsically motivated to serve their communities. Instead of a salary, the women received an incentive (about half the current minimum wage in Nepal).
The programme’s realisation was thus predicated on a local moral economy in which women are expected to care for others without financial reward.A 14-month ethnographic study of the programme highlighted complex implications for gender equality.2 Initially, there was enthusiasm and even competition within women’s cooperatives for the opportunity to receive counselling training.
After beginning to practise, however, counsellors started to voice concerns over inadequate remuneration. Most were young married women who bore the heaviest burden of domestic labour in their families while occupying the lowest rungs of the social hierarchy. The cash incentive offered was insufficient for them to be recognised as fully fledged professionals or get reprieve from domestic responsibilities, resulting, in many cases, in women bearing a double workload.
Ultimately, remuneration issues led many counsellors to resign within the first 2 years of the programme.The field of global mental health is increasingly concerned with addressing the social determinants of distress and disorder, among which gender inequality figures prominently.3
In employing frontline workers, psychosocial care programmes have a rare opportunity to go beyond palliation to address the root causes of suffering. Offering women in low-income communities a pathway to financial autonomy, meaningful employment, and professional recognition can contribute to lasting social and structural change.
Conversely, engaging women in demanding, skilled work on a volunteer basis not only reinforces the systemic undervaluation of women’s labour, but exploits this undervaluation to make care available more rapidly in the absence of resources. A growing body of global health research documents the preponderance of women in low-paid and unpaid roles and the gendered social, financial, and mental health consequences of health-care volunteering.4, 5, 6, 7, 8, 9, 10
In the context of mental health, this intersection of gender and clinical hierarchies poses an additional risk that psychosocial interventions will continue to be direly underfunded, and thus underused, relative to pharmacological interventions delivered by a predominantly male workforce of medical professionals.
As a decade of global mental health advocacy sees results and governments begin to invest in national programmes, we need to think critically about the risks of depending on low-paid and volunteer labour to fill the treatment gap, particularly when the onus falls mainly on women. One of the most powerful rhetorical manoeuvres of the movement for global mental health has been reframing the treatment gap as a crisis demanding an urgent response.
Although this approach has successfully rallied resources and will for change, we must be cautious not to let the rhetoric of crisis foreshorten our vision, justifying immediate intervention at the expense of more profound, long-term transformation.
The question is this: are community psychosocial workers merely a stopgap for the world’s poorest—stemming a deluge of need without looking upstream to its sources—or are they key players in a forward-looking movement to achieve a more equitable distribution of mental health globally?
If the answer is, as we hope, the latter, we urge governments, donors, universities, and non-governmental organisations to look carefully at the working conditions of the frontline psychosocial care providers they employ.
If members of this emerging cadre do not receive a competitive salary, paid holiday and maternity leave, and opportunities for professional development and advancement, we must pause to question whether our interventions are still in step with the evolving vision and values of global mental health.