Overworked and underpaid: why nurses in India need better treatment
Despite being highly skilled and indispensable to healthcare, nurses in India buckle under below minimum wages, workplace exploitation, and devaluation of labour.
Forty-five-year-old Parineeti* earned a diploma in nursing four years ago from a university in Lucknow. She says she has always wanted to serve the ailing.
But last year, she had to leave her job at a private hospital in Telibagh, Lucknow, after a doctor slapped her in front of patients and ward attendants for a mistake she didn’t commit.
“When I went with my resignation letter, the doctor told me he had already terminated my services,” says Parineeti, now working at TS Mishra Medical College and Hospital in Lucknow.
“I am the only earning member in our family of five people. I take home a salary of Rs 10,000, and I don’t get it until the 18th of every month,” she says.
According to a WHO report from 2018, there are 20.5% male nurses and around 80% female nurses in India. Another statistic from the Union Health Ministry says India has a trifling 1.96 nurses per 1,000 population.
Despite an increased demand for healthcare workers, especially after the pandemic, female nurses continue to face several workplace challenges, including pay disparity, sexual harassment, increased workload, and erratic work hours.
The tragic story of nurse Aruna Shanbaug, who was in a coma for 41 years due to sexual assault in her hospital, is a reflection of the vulnerable condition of nurses in the system.
In 2022, the Ministry of Health and Family Welfare issued draft guidelines proposing the setting up of Internal Committees, annual health check-ups, creche facility, and work hours not exceeding 40 hours a week, among other measures, to improve the working conditions of nurses in all healthcare establishments. But these changes are far from being implemented in nursing homes and hospitals.
Occupational segregation
In the book ‘Kolkata in Space, Time and Imagination Vol 2’, which talks about labouring sectors (including feminised ones) that have been marginalised in the city’s history, Panchali Ray, Associate Professor of Anthropology and Gender Studies at Krea University, points out that historically, when it comes to women in medicine, it is always about the trained lady doctor or the hereditary dai who occupies much of its attention.
Due to the expenses involved in hiring trained nurses, the untrained nurse or the retrained dai had always been an easy substitute. Hence, the call for registration and its subsequent enactment in Bengal (1920) had the elimination of the working-class, lower-caste midwife and the untrained nurse as one of its goals.
“However, it just created newer hierarchies based on skills, registration, and training, and could not eliminate the partially-trained/untrained woman from nursing services,” Ray adds.
The occupational segregation that nurses, particularly female nurses, face today is a direct result of a system that was built on such clear division of labour, believes Ray.
But in the modern-day context, there are various categories in nursing. There are formal nurses who have completed the three-year General Nursing Midwifery (GNM) training or the four-year BSc Nursing course, and may secure registered nursing jobs in top institutions such as National Health Service (NHS) in the UK or All India Institutes of Medical Sciences (AIIMS) in India.
Those who cannot afford formal education undergo partial training or a one-year diploma, and are recruited by smaller nursing centres, or as contract workers in private hospitals where they learn on the job. These often turn into environments where rules are flouted, labour is exploited, and wages are below-minimum.
Challenges faced by nurses
The Ministry of Health and Family Welfare received an allocation of Rs 89,155 crore in the Union budget 2023-24, which was a mere 12.6% hike to the revised Budget estimates for 2022-23.
Low budgets in healthcare have an adverse impact on the wages of nurses that are already below minimum - irrespective of the Central government directive that nurses employed in private hospitals and nursing homes must have wages and working conditions on a par with government nurses.
The International Labour Organisation says that globally women in the health workforce earn 24% less than men, and in India, they earn 34% lesser than men. This remains one of the loftiest challenges that the All India Registered Nurses Federation (AIRNF) has been fighting against in Uttar Pradesh, Bihar, Uttarakhand, West Bengal, and Rajasthan.
Nurses of the Tamil Nadu MRB Nurses Association have been repeatedly staging protests for regularisation of services, maternity benefits and wages.
A central government order from 2022 directs that the minimum pay of nurses working in hospitals with less than 50 beds should be Rs 20,000. But with thousands of private hospitals and nursing homes mushrooming across the country, violations take place unabated, says Anurag Verma, UP State President, AIRNF.
“Since many of them are run by local MLAs and politically influential families, nurses don’t have the courage to share the challenges they face with us--in terms of payments, sexual harassment, violations like overtime work or verbal abuse--fearing backlash,” says Verma.
“And even if we take these grievances to the state health ministry, they do not take action unless the nurses themselves give a written complaint, which they almost never dare to do,” he adds.
Shalini Mishra, 36, who works as a staff nurse at a medical college in Gorakhpur, has gone without a salary for as long as four months at a stretch, forcing her to take quick loans to run the house.
Parineeti says, despite putting in hours of work, she gets no benefits or support. She had to pay the full treatment fee for her son’s kidney problem at the hospital she works.
Malathi*, who works at a small nursing home in Madurai, Tamil Nadu, says she sometimes has to put in back-to-back shifts from morning to evening, followed by a night shift (a total of 16 hours) without being compensated for the extra work. She is also conscious of the devaluation she faces from her superiors, and sometimes even patients, who treat her like she is obligated to serve them.
“This mostly happens when another nurse is on leave, and it is almost considered sacrilege to ask for compensation for filling in, because for the nursing home, stretching myself thin and being ready to serve at their beck and call is considered a part of my ‘duty’,” she says.
Malathi is contemplating taking a loan to go to the UK and work, where she believes she will experience dignity of labour and far better monetary compensation.
Malathi’s state of affairs also reflects those of hundreds of Indian healthcare workers who often fall into debt cycles--sometimes with middlemen--who charge exorbitant fees to place Indians in jobs abroad. There are also cases of nurses being stranded without pay for months in other countries due to administrative delays.
The lure of working abroad
As part of her research with women from Jharkhand, Bihar, Manipur, and other states, Ray found that the parents of many tribal girls from small villages gave out their land in mortgage to pay for their nursing courses. The churches sponsored them and the state governments gave them interest-free loans to study nursing.
“The reason primarily was that they could go abroad, work, and pay back loans,” says Ray.
A March 2023 report by the International Council of Nurses says there is a worldwide shortage of nurses and that a deficit such as this should be treated as a global health emergency. Given such a crisis, the demand for nursing--whether it is hospital or residential nursing--has seen a tremendous spike in the last 20 years.
“When we talk about nurse migration and care work migration, we think only of formally trained nurses. But this is a very segmented field,” says Ray.
“The labour force participation of women is at its historical low. The only places employing working class women are domestic work, sex work, and nursing--all considered traditionally feminine labour. And while immigrant nurses do get better salaries abroad than what they do in India, they are subject to a lot of racism, says Ray.
Unionisation
During the Covid-19 pandemic, care workers across the country were working continuous shifts, not getting tested and falling sick. Their leaves were getting cancelled and many took a loss of pay as well.
But women in private nursing face greater challenges in terms of wages, basic rights such as leaves and, maternity benefits, and working hours, all of which can be met only through unionisation, says Ray.
“The problem with unionisation in critical care service is that, unlike factory work, here, the public perception and the media can turn against you if you go on a strike or withdraw work,” she says.
“But I still believe strongly that unionisation is the only way out for all devalued occupations--be it nursing, beauty work, or domestic work. Unionisation is central to workers’ rights and the way to long-term policy change,” adds Ray.
(*Names have been changed to protect identities.)
Edited by Megha Reddy