“Health infrastructure in India is robust on paper, extending to the smallest populations and communities,” says R V Asokan, honorary secretary general, Indian Medical Association (IMA). He and many public health professionals believe that the biggest impediment to a cohesive nationwide approach to the pandemic is that health is a state subject. “We have seen that the fight against Covid depends on actions taken at district level,” he says. “But state governments have responded to it differently. Many have not shared critical district-wise data related to testing, positivity rate, mortality etc, making a national-level effort difficult.”
To address this, IMA has long advocated for an all-India Indian Medical Service. Mooted by the Health Survey and Planning Committee (also known as Mudaliar Committee) in 1961, this cadre would ensure equitable primary, secondary and tertiary healthcare services across the country.
The pandemic has also exposed the lack of documentation of the state of doctors and paramedics. For instance, when Rajeev Jayadevan, president of IMA in Kochi wanted to compile a list of Covid casualties in the medical fraternity across India, in the absence of official data, he had to rely on newspaper reports. “Proper documentation and assessment of the health of doctors is crucial as it will sharpen focus on policies for their welfare,” he says. The same argument can be made for nurses and ASHA workers.
To replace the Indian Nursing Council Act (INCA), the health ministry has finalised the National Nursing and Midwifery Commission Bill, 2020. Nurse activists had hoped this would address some of the lacunae of the old law and set norms for service and patient care; nurse-to-patient ratio, staffing standards; and salaries. However, the Bill remains silent on these. “During the pandemic, several private hospitals cut nurses’ salaries by as much as 30 per cent, while some government hospitals delayed salaries,” says Siju Thomas, joint secretary, Indian Professional Nurses Association (IPNA). Activists say that nurses feel short changed also because they are often excluded from state nursing commissions. “Most decisions about their welfare are taken by doctors,” says Jibin TC, state president of United Nurses Association in Maharashtra.
Nurses and ASHA workers also continue to be dogged by irregular working conditions. “Nurse salaries across the country, and between government and private hospitals, differ widely,” says Roy George, president of Trained Nurses Association of India (TNAI), one of the country’s largest and oldest nurses’ unions. “Why can’t the government set a common minimum salary to protect their interests?”
ASHA workers operate under even more exploitative conditions. “How can the government expect efficient delivery of health services to the grassroots from a cadre of women who have the status of mere ‘volunteers’ and earn barely Rs 2,000-6,000 per month?” asks Vijay Lakshmi of National Federation of ASHA Workers NFAW. “They must receive the government-mandated minimum wage of Rs 18,000 per month.”
The need of the hour is to not only bring in far-reaching legislative changes but to also resolve the workplace issues the health staff faces. “Sometimes, the pandemic feels like a marathon without a definite end,” says George. “By increasing the number of medical and paramedical staff and improving their working conditions, perhaps we can fight the exhaustion.”