A health worker takes a break in front of a fan in New Delhi, August 2020. Photo: Reuters
- Even before COVID-19, protests by health workers in India were on the rise. According to one database, India had the most such protests in 85 countries between March 2019 and 2020.
- Most of them concerned unpaid salaries, poor management, contracts and regularisation, and patient overload, followed by protests around lack of supplies and equipment.
- Health workers have often faced uphill battles in having their demands met – but the underlying problem has been a lack of attention to health workers’ basic needs.
- One of the biggest casualties of the governance problems were medical entrance exams – a sphere in which NEET replaced the erstwhile faulty system with new problems.
By now, many have watched the dramatic footage of junior doctors and police clashing in New Delhi or heard about ongoing demonstrations by resident doctors around India. These events have been taking place against the backdrop of a rising number of COVID-19 cases.
Strikes and demonstrations by health workers have become ubiquitous in India in recent years, but the current protests have a particular significance. They are a culmination of two long-simmering problems in the governance of health policy in India. The first is the lack of accountability mechanisms and policy engagement for the majority of health worker occupational groups (or different cadres of health workers). Second is the problematic governance of medical education.
Both trends point to deep-seated problems in how the health sector in India is governed: fragmentation of decision-making, weak engagement of constituencies in policy processes, and limited avenues for accountability at all levels of the system. These trends are colliding at a particularly challenging moment in the pandemic, on the cusp of a third wave.
Workers’ rights and health workers’ protests
As The Wire Science reported, resident doctors are protesting the nearly 50,000 vacancies created by a delay in postgraduate medical education counselling. This delay is in turn the product of a legal battle over the Centre’s policy to have a 10% quota of all medical seats for individuals from economically weaker sections (EWS).
With these positions remaining vacant, resident doctors have been pushed to their breaking point in terms of workload – an additional layer to the many concerns that residents have raised for two years, including unpaid salaries, harassment and lack of protective equipment.
Their grievances can be traced to an underfunded public health sector, weak regulation of the private health sector and limited avenues for accountability and redressal. These issues have manifested at ‘micro’ scales across the country, resulting in a large number of protests by various occupational groups of health workers.
But even before COVID-19, protests by health workers in India were on the rise. The last several years have seen sustained action from health worker associations and unions: by ASHAs1 across the country demanding fair wages and regularisation of their cadre, by junior doctors against harassment and violence, by the Indian Medical Association and other groups on the National Medical Commission Act, and against state-level adoption/implementation of rules related to the Clinical Establishments Act.
In fact, according to the ACLED database, India had the most number of protests by health workers – 479 – among 85 countries between March 2019 and March 2020. The next highest was Pakistan (281).
The pandemic’s onset fueled these long-standing grievances and also presented new ones, such as higher workloads and lack of safety equipment. Low-wage health workers, such as ASHAs and resident doctors, were asked to bear many responsibilities in already poor working conditions.
From March 2020 to March 2021, there were approximately 431 protests around India – the third-highest in the world among 149 countries, after the US and France. In India, we found that the majority of these protests concerned working conditions and remuneration: unpaid salaries, poor management, contracts and regularisation, and patient overload, followed by protests around lack of supplies and equipment.
Health workers resort to protests for a variety of reasons, and we would be remiss to say that these protests are solely on the grounds of working conditions. (Recall, for example, the protests earlier this year around ‘mixopathy’ and concerns about private sector regulation.) What is clear, however, is most health workers are concerned about their rights as workers and their right to fair remuneration and decent working conditions.
Indian health workers are not alone in this fight. Of the nearly 7,000 health worker protests in 149 countries from March 2020 to March 2021, most were concerned with working conditions and remuneration.
Health workers have often faced uphill battles in having their demands met for myriad reasons, including complex governance structures. But the underlying problem is a lack of political prioritisation for health workers’ basic needs. Numerous constituencies have been demanding improvements to the health sector by the state for decades. A key pillar of this is to ensure a well-supplied health workforce.
However, investment in India’s health system has been routinely criticised as hugely insufficient, the effects of which were apparent during the deadly second COVID-19 wave in 2021. Over decades, systems have not been built up to pay health workers sufficiently and on time, ensure the availability of equipment and supplies, guarantee proper benefits, and provide health workers with safe and respectful working environments.
When there is a breakdown in the system – as there frequently is – many health workers often have few options but to protest.
This is echoed in the resident doctors’ ongoing protests. During the pandemic, resident doctors have borne a significant brunt of patient care in public hospitals, working in many cases under highly stressful circumstances in a hierarchical system sans adequate remuneration. There is little space to redress their concerns within the existing hierarchy.
Playing in the backdrop of these immediate policy issues are major issues in the nature of career progression for young doctors – a problem driven by the complex system of postgraduate medical education in India. Addressing residents’ needs requires urgent policy engagement, something that public shows of support, while well intentioned, will not solve.
In fact, the residents have been actively calling out the ‘warrior’ label in their advocacy, another trend occurring in other contexts where health workers have been called ‘heroes’ but haven’t been given adequate protection or support.
Breakdown in the governance of medical education
These ‘micro’ issues of lack of accountability appear on a larger scale when looking at the governance of medical education in India. The fault lines in the governance of medical education were laid well before independence. The Medical Council of India, the predecessor to today’s National Medical Commission (NMC), was repeatedly accused of corruption and inefficiencies.
There were institutional bottlenecks and weak coordination between the Medical Council of India and the state medical councils, which were in a position to reform medical education and practice. Successive governments have sought to address this lack of coordination but have had little success. Over the years, the Medical Council acquired the power to license private medical colleges and increasingly became a rent-seeking institution. At the state level, the councils were controlled by doctors and local politicians who served sectional interests.
One of the casualties of this governance problem was medical entrance examinations. Before the National Eligibility cum Entrance Test (NEET) was introduced, medical entrance exams were a patchwork of different tests, including those administered by autonomous medical colleges plus state and national examinations. The multiple systems of entrance examinations didn’t guarantee “universal” quality and were allegedly corrupt.
But some states, such as Tamil Nadu, made room for regional requirements and to decide on the recruitment and retention of doctors, particularly in rural areas.
The origin story of NEET – the solution to these entrance problems – is an example of the consequences of limited coordination, stakeholder engagement and transparency. NEET was first proposed in 2010. A working group composed of leading medical education experts was tasked by the Medical Council’s board of governors to provide a roadmap for strengthening medical education in India.
One of their proposals was a single entrance examination – a “fair and simple test” modelled on the SAT and the GRE. The amount of public consultation that followed this idea, with major implications for countless individuals, is not clear.
The Supreme Court became involved in the matter. It initially scrapped the exam in 2013 and then reversed its decision in 2016, setting off over five years of legal challenges on various aspects of the exam. To make matters worse, NEET is now a hot-button political issue.
The fact that the court system is so entrenched in the governance of medical education is a signal that the decision-making processes in medical education need to be reset quickly. The NMC has been an important step in the right direction. At the same time, fundamental coordination issues persist between the ministries of health, of education, the NMC and state governments.
Of greater concern is that conflicts and concerns are being resolved through the courts instead of through structured accountability processes. Courts have played an important role in deciding matters of medical education, but the trend appears to have accelerated in recent years. This has major implications. For example, in addition to the uncertainties over timelines, what does this mean for stakeholder engagement, experience and other types of knowledge in designing and reforming medical education?
Workers or warriors?
The pile-up of governance issues leading up to the resident doctors’ protests is a signal of deeper issues in how the Indian health sector has been run. These problems often appear to impact narrow constituencies such as health workers and aspiring medical students, but eventually, they start impacting society more broadly and become everyone’s concerns. And in many cases, they should have been all along.
What we need now is careful policy-planning that takes stakeholders’ viewpoints into account, and pays renewed attention to health workers as workers and not as warriors: with the right to regular, decent wages and good working environments. As we enter the third year of the pandemic and possibly the start of a third wave, the time to act is now.
The authors thank Kiran Kumbhar and Sorcha Brophy for their helpful suggestions.
Arima Mishra is a professor at Azim Premji University, Bengaluru. She works at the intersections of anthropology and public health. Veena Sriram is an assistant professor at the University of British Columbia. She studies health workforce and health sector governance. Rama Baru is a professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University.
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