File photo of ASHA workers on strike in Bihar. Representative image. Photo: Saurav Kumar
Healthcare workers (HCWs) are individuals who deliver care and services to the sick and ailing. This involves team effort from doctors, nurses, laboratory technicians, pharmacists, ambulance drivers, medical waste handlers, Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), anganwadi workers and several others. ASHAs, ANMs and anganwadi workers form an integral part of the grassroots-level health workers under the National Health Mission. They spread awareness about various health issues and encourage utilisation of healthcare services. In several areas, ANMs have transitioned from primarily being midwives to becoming essential primary healthcare providers. Anganwadi workers make an integral part of child welfare and development in rural areas.
Apart from their poor working conditions and minimal compensation, a major deterrent for these HCWs to provide good care to their patients is facing verbal and physical violence. The violence against healthcare workers has been a persistent issue that has only been exacerbated during the COVID-19 pandemic.
According to a report by Safeguarding Health in Conflict Coalition (SHCC), the number of HCWs who experienced threats increased by five times, those injured grew by almost 1.5 times, and those assaulted increased by three times in 2020 in comparison to previous years. During the pandemic, several cadres among these HCWs were tasked with spreading awareness about COVID-19 and safety protocols, identifying and tracking COVID-19-positive cases, and carrying out vaccination drives, often without personal safety gear. For instance, ambulance drivers risked their lives by not only transporting patients or those dead but also performing the last rites for a large number of COVID-19 victims.
However, the violence against HCWs is a ‘silent pandemic’ due to inadequate reporting on the issue. The incidents reported in the media are just the tip of the iceberg. There is an imminent need for better on-ground reporting mechanisms and systemic data collection.
While workplace violence is faced by all healthcare workers, there seems to be a glaring disparity in the attention given those the violence faced by HCWs like grassroots-level workers. For instance, a previous petition focusing on violence against doctors gained support from over 1.5 million people. However, it did not mention much about violence faced by other healthcare workers. Even the research data on violence against other healthcare workers beyond nurses and doctors is limited.
The scarce data points to a severe problem. For instance, a 2016 mixed-method study involving 396 ASHAs from the rural parts of Northern Karnataka noted that 94% of its participants had experienced violent incidents in the last six months. Another Kashmir-based study during the 2010 unrest focusing on 35 ambulance drivers found that 89% of the interviewees faced more than one incident of physical harm, 54% faced physical assault, and 83% faced job-associated psychological harm. India has over 900,000 ASHA workers (as of 2021) and about 61,000 emergency medical workers and aides (as of 2019) with virtually no robust studies investigating violence. The data dearth is stark.
The violence is a result of failures at multiple levels. There is no security for grassroots and mobile workers who work beyond the health facilities and only limited security for those stationed at the health facilities. For instance, the Indian Public Health Standard guidelines mention the presence of a fence for primary and community healthcare centers but nothing beyond that.
Moreover, in the event of violence, there is limited awareness of how to proceed with legal action. Many healthcare workers opt out of registering an FIR due to reasons like lack of awareness, limited support from police officers, mistrust in the legal system, and fear of losing their jobs. RTI petitions filed by the Medicos Legal Action Group found that not a single perpetrator of violence was booked by the police from 2010 to 2015 under the Medicare Act in Punjab and Haryana. Healthcare workers who proceed with an FIR often have to wait a long time to get justice as there are multiple lags from FIR registration to court rulings, leading to poor follow-through that results in cases being dropped. According to the Indian Medical Association, not a single culprit was prosecuted out of approximately 200 cases of violence against healthcare workers in Kerala in 2020. Having a system in place that tracks violent incidents all the way up to the outcome of prosecution is vital.
At the topmost level, legal interventions are essential. India has some laws for protecting healthcare workers such as the Epidemic Diseases Ordinance (2020) passed on April 22, 2020, as an amendment to an old Act by the same name. It recognises any violence against healthcare service personnel as a cognizable and non-bailable offense. However, since the Act can only be in effect during an epidemic, it is a temporary solution to a systemic problem that has proven to be permanent. While several Indian states have the Medicare Persons and Institutions Act, its implementation has been weak. Further, 11 states and union territories have no laws at all.
A recent petition including on all healthcare workers asks for Union and state governments to step up. It acknowledges that violence against healthcare workers is a systemic problem requiring a systemic solution. The first ask is for the Central Government to consider enacting comprehensive and stringent legislation.
The Parliamentary Standing Committee on Home Affairs which examined the proposed new criminal code also asked the Union government to consider introducing legal safeguards for healthcare workers against violence. The suggestion came after various medical associations requested the panel to introduce provisions under Clause 115 of the Bharatiya Nyaya Sanhita (BNS) – which will replace the Code of Criminal Procedure (CrPC) – to penalise violence against healthcare workers.
The Union home ministry said in response that the general penal provisions are applicable to all and no distinction is made for any class. A special provision for healthcare professionals may “give rise to similar demands from other professionals like media persons, advocates, bankers, charted accountants”, the ministry said.
Studies reveal that the likelihood of assaults against HCWs is four times greater than that against professionals in general workplaces, with particular vulnerability among junior doctors and nurses employed in government hospitals. Moreover, there exists special protective legislation specific to professions (police, armed forces, etc.) and employee groups (such as public servants).
Previously, the withdrawal of the Healthcare Service Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill (2019) was based on the rationale that health is a state subject and the enactment of a separate protection law for healthcare personnel may prompt arguments from other professions. They also argued that after thorough discussion, the Epidemics Diseases (Amendment) Act, 2020 was promulgated to address the incidents of violence against healthcare workers during the COVID-19 pandemic in addition to the provisions of the Indian Penal Code (IPC) and the Code of Criminal Procedure (CrPC). This Bill was drafted with the help of healthcare workers and it defines and includes several specific cadres and institutions. The ask from the state governments is to collaborate with the Centre to set up multi-tier Vigilance Committees at the district, state, and Central levels for improving enforcement. Additionally, states should have monitoring cells that maintain a database of violent incidents and their legal follow-up.
Anoushka Arora is a researcher at the non-profit think-and-do tank – Association for Socially Applicable Research (ASAR), India, and a medical student at NHL Municipal Medical College, Ahmedabad, Gujarat, India.
Anukrati Nigam is a researcher at the non-profit think-and-do tank – Association for Socially Applicable Research (ASAR), India, a program assistant at the PEGASUS Institute, Canada, and a doctoral candidate at the Institute of Medical Science, University of Toronto, Canada
Divya Shrinivas is a researcher at the non-profit think-and-do tank – Association for Socially Applicable Research (ASAR), India.
Siddhesh Zadey is a co-founding director of the non-profit think-and-do tank – Association for Socially Applicable Research (ASAR), India, a Global Surgery researcher at the Duke GEMINI Research Center US, and a doctoral student in the Department of Epidemiology, Columbia University. He serves as a Chair of the G4 Alliance SOTA Care in South Asia Working Group and a Lancet Citizens’ Commission Fellow. Twitter: @RantingSid
Uma Gupta is a researcher at the non-profit think-and-do tank – Association for Socially Applicable Research (ASAR), India, and a Junior Resident at G B Pant Hospital, Delhi.