A representative photo of a nurse at work in a hospital in Mumbai, August 2018. Photo: Reuters.
The Centre’s initiative to replace the Indian Nursing Council (INC) Act 1947 with a new act is welcome and much desired. The changes that the country’s health care landscape has undergone in the last seven decades make it imperative. The nursing sector has been neglected for far too long, and needs better backing to thrive and realise its full potential, instead of playing second fiddle to the medical profession.
The National Nursing and Midwifery Commission (NNMC) Bill 2020 – meant to replace the INC Act 1947 – is currently in the public domain for feedback. The NNMC Bill 2020 may fill a long-standing gap of establishing and regulating service standards for the nursing and midwifery professionals. Drafted along the lines of the National Medical Commission Act 2019, the NNMC Bill 2020 provides for the constitution of regulatory bodies at the national and state levels.
The Bill seeks to standardise entry and exit into the profession by conducting common the National Nursing and Midwifery Entrance Test and the National Exit Test. It is directed towards professionalising the nursing services by defining the different nursing cadres and standardising their nomenclature and scope of work according to the International Standard Classification of Occupations (ISCO).
However overall, the Bill does little to promote and strengthen the nursing profession in the country. Six issues in particular warrant more discussion.
1. Centralisation of power at the Centre
The Bill authorises the Centre to nominate most of the members of the regulatory bodies to be constituted under the Bill. Assisted by a seven-member search-cum-selection committee, also nominated by the Centre, it has the power to select the chairperson, secretary and members of the national nursing and midwifery commission, and the president and full-time members of the four autonomous boards. There is no representation of members elected by the nursing fraternity. This oversight negates the role of the nursing and midwifery professionals in the regulation of their own profession.
In contrast, the INC Act 1947 provides mostly for elected members, including the president of the INC. One of the drawbacks of the INC Act 1947 is the lack of an upper limit on the number of terms members that can serve in the council. This has lead to a select few people dominating the council. In that regard, the NMMC Bill does well to restrict the number of terms for which a person may hold office in the different regulatory bodies.
2. Inadequate representation of states
Unlike the INC which has an elected representative from each state council, the newly proposed national nursing and midwifery commission has limited state representation from six zones, as per the zonal distribution of state and UTs. The nursing and midwifery advisory council is the only body under the Bill that is represented from all the states. However, the members of the advisory council are not elected by the nursing and midwifery professionals. Instead, they are nominated by the Centre and state governments. Further, as the name suggests, the council is an advisory body with no decision-making power.
3. Weak in setting standards and scope of nursing and midwifery
The purpose of the Bill is as much to standardise and regulate the nursing and midwifery professions as it is to regulate their education. However, the Bill disappoints by not delving adequately into the practice aspect. Like the INC Act 1947, it focuses more on the education of the profession. The ‘Scope of Practice’ as defined in the Bill is vague, and the Bill does not provide a vision for how nurses and midwives may contribute to strengthening the healthcare system in the country as a professional cadre.
The bill classifies different types of nurses into six professional categories according to the international classification of health workers by WHO based on the ISCO. Such classification could help professionalise the nursing cadre and clarify the roles of different types of nurses. But the Bill does not mention how some of these categories – such as nursing and midwifery executives, nursing and midwifery managers, midwifery professional, associate nurse (Schedule I) – will integrate into the existing healthcare system.
The definition of both a nursing professional and a midwife professional is a person who works “autonomously or in teams with other healthcare providers”. Does this mean they can function independently – with or without the power to prescribe medicines, perform non-invasive interventions, provide emergency care, etc.?
Clause (h) of sub-section (1), section (19) – that states “regulate the limited prescribing authority for nurse practitioners” – seems like a one-off provision, without a comprehensive direction that it envisages the profession to move in.
In the early 2000s, the Government of India made a policy decision to permit auxiliary nurse midwives, lady health visitors and staff nurses to undertake certain interventions as skilled birth attendants. These include administering specific drugs, providing basic obstetric care and managing complications, including essential newborn care and resuscitation services. The case of mid-level healthcare providers being integrated into the Ayushman Bharat initiative and the midwife-led units associated with labour rooms of medical colleges and district hospitals is similar.
So any new Act concerning nursing and midwifery needs to consider such policy decisions, too, and accordingly lay down the scope of practice for the profession. This has implications for other related Acts as well, like the Drugs and Cosmetics Act 1940 and the Clinical Establishments Act 2010, which may need to be amended to maintain consistency between different legal instruments.
4. No regulation on number of educational institutions, nursing professionals
The Bill does not have any provisions to regulate the number of educational institutions that can be established in India, their distribution in different parts and the number of nursing professionals who graduate. The absence of such regulation over the years has led to more than half of the country’s nursing institutions being situated in South India. Such skewed distribution of training institutions is believed to have contributed to the lack of trained nursing staff and teaching faculty in certain parts of the country.
5. Lack of attention to administrative and service aspects
Experts believe one of the reasons for the continued poor status of nursing services in the country to be the lack of nursing professionals in decision-making and policy-level positions – at both the state and national levels. In several states, senior nursing posts are either vacant or are occupied by medical professionals. A directorate of nursing does not exist in most states or at the national level. And in the absence of the post of a director of nursing, the ultimate decision-making power rests with senior state health administrators and medical directors from non-nursing backgrounds.
At the national level as well, the senior-most post is that of a nursing advisor – which does not have any significant decision-making power. The Bill does not provide any direction for this lacuna to be addressed.
The nurse-patient ratio and nurse-staffing norms have not been updated since the Staff Inspection Unit (1991-1992). These need to be revised according to the changing disease burden and the nature of healthcare services. Service conditions of nurses – such as long working hours, exploitative terms and conditions of employment, inadequate pay and benefits, delegation of non-nursing duties and lack of opportunities for professional growth – are some other service issues that have evaded regulation. The new Bill too seems to maintain this status quo.
6. Restrictive nature of grievance redressal system
The Bill provides for a hierarchical grievance redressal system with a provision for escalating grievances to the next higher–level regulatory body. The highest authority is the central government. However, section 49 of the Bill prohibits anyone except an officer authorised by the national commission, the ethics and registration board or a state commission from appealing in a court of law against an offence punishable under the Act. Such a provision severely hampers the right of ordinary citizens, including the nurses to take recourse to legal action in case of any violation. It also shields regulatory bodies from being answerable to the people whose best interest should be their aim.
The measures that the Bill proposes to improve the quality of nursing and bringing in more professionalism are commendable. At the same time, without envisaging how nursing and midwifery could be developed into a full-fledged profession in its own right, the Bill is at best a half-hearted attempt at transforming the sector.
Pallavi Gupta is a specialist, Health Systems Governance at the Health Systems Transformation Platform, New Delhi. The views expressed here are the author’s own.