NEW DELHI — Radha Kumari is a nurse in India’s eastern state of Bihar. Two months ago, along with 400 of her colleagues from the All India Institute of Medical Sciences in the state capital of Patna, she went on a strike demanding a salary hike and facilities that match permanent employees’ perks — which have become a necessity during the pandemic, she said.
Speaking to Devex using a pseudonym, as she feared retribution from her employers, Kumari said that contractual workers like her have long been dispensable in the Indian public health system.
“We don’t have permanent contracts or job security. I have been working in the hospital for the last two years, and with COVID-19 we’re all putting our life at risk. Why should we do this if the government does not respect us?” she said in a phone interview.
Nurses are not the only group of health care workers who are demanding better pay and facilities in India — over the past two months, doctors, and community health workers have also held strikes across the country.
“The challenge is, where do you get the human resources to run the new infrastructure that you have? You can’t create human resources overnight.”— Anant Bhan, global health and bioethics researcher
Added to this, India also faces a shortage of health care workers, which is severely affecting the country’s COVID-19 response. To plug the gap, various local and state governments have launched recruitment drives, but with little success. After the strike in Bihar, the state sought to recruit more nurses — but despite having advertised for 9,000 posts, it was only able to fill around 5,000. In Pune, in the western state of Maharashtra, which has emerged as the city with the highest number of cases in the last week, staff shortages have plagued new COVID-19 centers that have been set up to deal with the influx of patients.
With over 5 million cases, India is set to overtake the United States as the country with the highest number of cases in the next few weeks. The initial stringent lockdown did not help improve an underprepared health system, and the country’s health force now finds itself struggling to handle the burden.
Shortage emblematic of India’s health care system
“We are continuing our job under great risk only to give the public some level of comfort. But it is very unfortunate that people do not value our sacrifice,” one sanitation worker in Bangladesh said.
The shortage of health workers is not a new problem in India and has severe repercussions on health access. A 2016 study commissioned by the World Health Organization found that the “lack of trained health professionals was obviously a major constraint on our ability to achieve health delivery.”
This is a health systems issue, said global health and bioethics researcher Anant Bhan. With the much-touted national health mission too, human resources have been ignored. “There’s been a focus on physical infrastructure generation, building hospitals, and buying new equipment but not exactly a commensurate effort on building health professional capacity,” Bhan told Devex.
This has been reflected and reinforced in the country’s response against COVID-19.
“There’s a lot of talk about how many beds we have created, getting ventilators, oxygenated beds we have managed to get. The challenge is, where do you get the human resources to run the new infrastructure that you have? You can’t create human resources overnight,” he said.
The situation will become even direr as the pandemic surges, as many of the new cases are now coming from rural India, Bhan said.
Not only is there a shortage of health professionals, but these workers are also concentrated in urban areas, leaving rural areas with a dearth of quality care. The WHO study, for example, found that the density of doctors in urban areas was four times the rural areas in India, whereas in China it was twice the rural density.
This points to a larger problem of health inequities, said Anjela Taneja, health, education, and inequality lead at Oxfam India. “The place where there is the greatest need for medical professionals is the place where we have a shortage. The lack of focus on needs of rural India is one of the major reasons,” she said.
Echoing Bhan, she said a greater focus has been placed on tertiary care instead of primary and secondary health care centers at the rural level, and on increasing the number of specialized health care professionals when what India really needs is frontline medical professionals.
This has been an issue for years. A 2013 paper in the International Journal of Medicine and Public Health also pointed to the causes behind the lack of resources in rural India. “The scarcity of health manpower in rural areas of India was due to skewed prioritization and distribution of resources. This can be corrected by reversing the urban-centric planning and bringing equity in social development,” it said.
One of the reasons for this lopsided concentration is that rural postings are not incentivized, Taneja said. Doctors trained in urban areas either don’t opt to work in rural areas or don’t stay for long.
In this year’s budget, the government recommended setting up a medical college attached to every district hospital, which would in turn train health professionals. But the challenge is getting them to stay in remote areas, Bhan said.
Some states have created a “bond” system as a solution to the problem, in which doctors are contractually bound to stay in the position for three to five years. Despite this, many positions remain vacant in rural areas.
“We need to encourage and train people locally from within those communities, but instead one ends up having a few doctors that are produced in urban areas who are not tempted to go where the greatest needs lie,” Taneja said.
Investment in health care workers
Experts say there needs to be increased investment in the health force, along with ensuring adequate safety measures. The rising number of COVID-19 cases and resulting deaths among health care workers has been a concern among health advocates.
“There is a volcano-like situation. Doctors are being harassed left, right, and center and they are dealing with increased caseload. Doctors across the country are dissatisfied with the way they’re being treated,” said RV Asokan, general secretary of the Indian Medical Association.
This week, answering a question in the Upper House of the Parliament, Ashwini Kumar Choubey, a central minister, stated that 64 doctors and 91 other health care workers had sought relief under a government insurance scheme, which provides relief in case of death of health care providers. However, he was unable to provide the number of total deaths.
The Indian Medical Association believes the number of health care workers who died in the line of duty is much higher. According to data that the organization submitted to the Parliament, there have been 382 deaths just among doctors.
Asokan said the government must step up and ensure the safety of the “COVID-19 warriors.”
“Now the epidemic has entered the stage where it’s between the doctor and the patient, and now is when all health care workers should be supported the most,” Asokan said.
Searching for solutions
Experts are now stressing the need for both short-term and long-terms solutions.
“We need to re-train existing staff and leverage technology where it’s possible,” Bhan said, Paramedical faculty in medical colleges can be asked to volunteer for COVID-19 duty, and put through proper structured training, he added.
In high-pressure cities like Pune, health department officials have suggested appointing post-graduate students who are awaiting their final results to hospitals serving COVID-19 patients.
“Announcing things is relatively easy. It’s implementation which has always been a challenge irrespective of the sector in a country like India,” Taneja said.
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