All Work And Poor Pay: Nursing in India

“I was passionate about becoming a nurse… My mother too was a nurse… She had served for around 30 years when she passed away unexpectedly… People still respect her and say that she was a ‘good’ woman. I worked (in a hospital in Bangalore) as a nurse after my diploma in nursing for around seven years before deciding to do further studies and get out of the clinical area… I realised that my mother remained the ‘good woman’ because she made considerable adjustments and compromises for that… I tried my best to comply but at some point the conditions of work in the hospitals and the attitude of the doctors got on my nerves. I could not take it anymore and decided to quit and become a teacher. Of course, I am a nurse basically but I get respect because I am a teacher…”

This statement from a faculty member of a private nursing college affiliated to the Rajiv Gandhi University of Health Sciences, Bangalore, reveals more than just her life story. She is actually providing a picture of the multiple facets of nursing and the injustices that mark the working conditions and status of nurses. In addition, the story also reflects the ambivalence of nurses when they talk about their work. On the one hand is the respect the profession gives them; on the other hand are concerns about their working conditions.

There are two main avenues of employment for these compassionate yet strong professional women: Public sector hospitals or the multitude of private outfits that have mushroomed across cities and small towns. A comparison of the working conditions in these two sectors can easily be made on the twin scales of remuneration and basic work environment.

Take an average government hospital. The implementation of the Sixth Pay Commission recommendations has reportedly brought in some positive changes in the lives of nurses here – they get a fairly good pay packet and, at times, even their working conditions have been described as “better”. Yet, a poor nurse-patient ratio makes the work “back-breaking”.

The private sector, though, is a different story altogether. Exploitation marks the experiences of nurses here. Critical areas of neglect and mismanagement exist and rules are often flouted to make higher profits. It’s the lower level staff and nurses who mainly bear the brunt of this because it is their salaries that get compromised and not that of the specialist physicians, whose power and mobility cannot be controlled by hospital managements. Moreover, the contractual agreement that nurses enter into includes signing a “bond” that requires them to work in the hospital for two to three years and today even confiscating nursing certificates has become an established practice to restrict their professional mobility. Arrangements of this kind prevent nurses from seeking other placements without the knowledge of their current employers. Such injustice is mostly possible because of an unregulated, and largely sick, health sector.

The fact that many of these professionals are migrants is another factor that often goes against them. Migrant nurses – especially from Kerala – form the largest segment of this workforce. These women move to urban centres like Delhi and Mumbai with the support of their friends, other nurses and relatives, and are vulnerable in an unfamiliar setting and city. What makes things worse is the fact that personal circumstances force them to take up the first job that comes their way, never mind the low pay or killing hours. In fact, fresh diploma holders are the ones who are given very low salaries, with their lack of experience being cited as the reason for this. Even the most professional private sector hospitals give Rs 6,600 (US$1=Rs 46), while in the middle-sized hospitals, the pay packet is around Rs 3,000 to Rs 4,000. And this is after much protest and the implementation of the Sixth Pay Commission in the public sector.

Of course, a look at the working life of nurses is incomplete without taking into account aspects like their living arrangements, transportation and the on-duty facilities. While many hospitals do offer accommodation within their premises or in areas close by – easing the pressure on them to find lodging and daily transportation to work – this largely serves their own purpose. Hospitals are able to cut a substantial part of their costs on house rent allowance that they would otherwise have to pay. In any case, the kind of accommodation provided is of minimal standards and offers no privacy.

In addition, the ever innovative entrepreneurial class that dominates the health sector in India even makes the provision of transport – often ambulances – an assertion of their right to control the movement of nurses. It makes it easy for them to impose overtime work at short notice in the event of shortage of staff.

In many hospitals, during duty hours there are no rooms for them to rest or change their clothes. And even paying for overtime is an alien concept. The nurse-patient ratio in India is a poor – 1:30; it’s worse in the general wards, which could be as high as 1:50 – and this shortage often results in their having to put in additional hours. But then there is no set system of extra compensation. Recently, though, after prolonged protests by nurses of the All India Nurses Federation, an organisation formed by the public sector nurses, and sporadic strikes by nurses in the private sector, some hospitals claim they are taking measures to pay overtime.

According to the nurses, the abysmal situation they find themselves in has been largely exacerbated by the fact that as a group they have not been able to unionise and traditional trade unions have been negligent towards their working rights.

The nature of the work – seen as an essential service – further constrains unionisation. In the past, efforts in this direction were confined to specific cases, such as violent physical attacks or sexual harassment, or issues like changes in uniforms. Despite this, there are important stories of struggles and exceptional displays of leadership. For instance, the Delhi Nurses’ Union has emerged as a winner in many of its negotiations with managements and the government in the 1990s.

But the growing hierarchy within the profession has only aggravated the exploitation of nurses by creating divisions that come in the way of collective bargaining. The proliferation of various nursing diplomas and certificates in numerous nursing institutions has increased the divide. While highly specialised nurses are at one end of the spectrum, the employment of nursing auxiliaries and assistants – who are paid much less – makes the average well-trained nurse an easy target.

Unfortunately, policy measures initiated by the government to improve the status of nursing have not really been implemented. These measures, in any case, are invariably seen within the broader objective of widening the institutional healthcare system in India.

In the absence of government intervention, individual nurses have developed their own strategy to get a better deal. This chiefly entails migrating to greener pastures – and that could be anywhere in the world, especially to developed countries that offer better pay and avenues for professional development.

According to a 2010 World Health Organization report, job insecurity for contractual staff, low pay and lack of a conducive work environment, are just some of the key unresolved issues related to nurse retention in India. Given the burgeoning population and the ever-increasing demands on the healthcare infrastructure, it looks like there is no longer any scope for India to lose any more of its nursing professionals to an exploitative work environment. Change is the only way out.

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