Dear friends,
It
is a privilege to be invited to speak with you at the International Nurses Day
and I am very happy to see that nurses are uniting to speak up not just or
themselves, but for ‘Health for All’ in India, which is also the slogan of the Peoples’Health
Movement that I am a member of.
As
a doctor, I have been lucky to be able to work in a variety of health
facilities – from large tertiary care institutions in the UK, to large teaching
hospitals in Delhi, to small clinics and nursing homes and charitable centres
also in Delhi. As a health activist for over two decades, I have observed rural
health facilities across the country.
It
is clear to me, that while doctors may often behave like rock stars, it is the
nurses that carry the heart and soul of a medical institution, and are, in
fact, its very backbone, and every good doctor recognises that. Every doctor
should know that patients cannot be cared for without good team work and that
they could never achieve good results without good nursing. I have had the good
fortune to work in systems abroad where nurses were considered equal partners
in the care of patients and had a major say in patient care decisions. Yet,
attitudes and practices towards nurses in the land where Florence Nightingale
practiced and gained her reputation remain a matter of grave concern.
As
we know, the entire system of health care has been doctor-led and doctor
dominated. Nurses are often treated like extensions of doctors and even with
disrespect, rather than health care professionals
in their own right. Yet, many things that nurses do in their daily work, would
be entirely out of the range of competence of doctors. From the patients point
of view, anyone who had been admitted to hospital or had a loved one there
knows that their entire experience is affected by the quality of nursing. A
good nurse is not only professional, she is also compassionate and the closest
thing to family a patient may have on the hospital. Most nurses I have
encountered have gone beyond the call of duty to be caring warm and
helpful. However, it is the arrogance,
politics and power of doctor-dominated systems that exploit nurses without
according them their due rights. Before I am criticised for being too harsh on
doctors, let me clarify – this exploitation is not individual or personal – it
is systemic, with respect to a whole cadre of health care professionals. There
are many doctors who recognise this and treat nurses with the respect they
deserve. However, the proof of this lack of acknowledgement lies in the
differentials between the earnings and working conditions of doctors and nurses
in India and you know about it better than I do.
The
concept note for this meeting also correctly identifies another key factor in
the poor status of nurses in India, and that is gender. Globally, about 70%
nurses are women and this percentage must be close to 90% in India. Since the
whole cadre comprises mostly of women, it suffers the fate of many such
all-women cadres in India – the anganwadi workers, the ASHAs to name a few.
Women are generally expected to carry out functions of ‘çare’ as an honorary
duty rather than a professional service. They may be given onerous duties like
skilled workers, but they are not paid like workers nor do they receive social
security like workers should. This has been the convenient approach of the
country towards health care, child care, care of the elderly, care of mentally
ill, care of disabled people and so on; informal labour is to be done by women
in the name of social duty. The same attitude definitely permeates the
treatment of nurses within the health sector. Though nursing is defined as a
formal employment as compared to the others I mentioned, it currently faces
de-formalisation of labour by making contractual employment the main strategy
and by the lack of regulation upon employers in the private sector.
Thus,
nurses must continue to struggle to establish the dignity and professionalism
of their work and demand better status as workers within the health care
systems of the world and India. This entails a resistance to casualization,
insistence on decent and comparable wages, insistence on social security
(specially maternity leave and pension) and demands for an HR policy that
allows for professional growth. Moreover, every hospital, public or private
must set up sexual harassment committees in line with the Vishakha Judgement
and ensure that Nurses’ Associations are represented in the management.
Now,
coming to the potential role of nurses in the goal of ‘health for all’; from
the point of view of helping the country deliver decent services to all our
people, especially the poor and marginalised.
As
you all must know, even nearly 70 years post Independence, India cannot boast
of a health care system that fulfils even the basic health care needs of its
people. Poor men, women and children are dying and suffering needlessly simply
because of lack of decent health care services that they can afford and this is
very obvious in the disparity between the health of the rich and the health of
the poor. While the country faces many challenges, policy-makers across the
decades have chosen to neglect this sector, and the investments made for health
have been critically low. WHO suggests that 5% of the GDP be allocated to
health, yet we have never gone above approximately 1%, and the recent budget
has announced a slash of 6000 crores over previous years. This is a disaster,
for, as we know, health care services cost money. While the public sector
languishes, the private sector flourishes – at the great cost of the public. So
much so, that over 70 % health care is provided by private providers and
expenses on health care have become the second commonest cause of indebtedness
in rural areas and a common cause of pushing families below the poverty line.
Services
can also not be run without health care providers, and here too, the country is
in the doldrums.
While
we produce a huge number of doctors, only 30% serve rural India where 70% of
the population lives. We continue to have an overall shortfall of 6 lakh
doctors as well as massive shortfalls in the public health system of
specialists, especially in rural and tribal areas. There is a huge dearth of
nurses in the country – about 1 million nurses still needed – yet they are much
more willing to work in rural areas. Much of the RCH services of the NRHM are
delivered through ANMs and nurses, with doctors playing a managerial and
oversight role. In this context, how is he general public expected to get
health care services of decent quality and what would be the role of the
nursing community?
Many
different committees have deliberated upon the challenges of human resources
for health and come up with various recommendations that have implications for
nurses. We also, in the health movement, have had our own deliberations. I
would like to share some ideas and concepts with you in this regard. Clearly,
many more public institutions are required for teaching nursing courses if we
are to produce the numbers that the country needs. All the various committees
have recommended this. However, it is also very important to strategise where
these would be created, and for whom. In our opinion, we must create such
institutions in the most marginalised districts and regions of the country so
that local students may be attracted from such communities. The system would
have a better chance of retaining such human resource for rural areas. Rural service bonds are also required – even
more so for doctors, who have resisted this idea at every step. Currently
nursing education is dominated by private colleges who would only be interested
in opening profit-making institutions to churn out nurses who would service the
private sector in cities and abroad. That does not help our own people.
An
even more revolutionary idea to aspire to, not just in view of the dearth of
doctors, but also in consideration of allowing nurses more agency as professionals,
is the concept of nurse practitioners. This is by no means a new idea even
though we do not speak about it much in India as a remedy. This concept emerged
around mid 1960s, initially (it has to be said!) as a consequence of shortage
of doctors. However, to date, many countries rely upon the nurse-practioner to
deliver a host of services that were traditionally considered the domain of
doctors alone. Thus, NPs may act like doctors – to diagnose and treat
conditions – within a defined scope for which they have been specially trained.
The growing acceptance of protocol-based medicine makes this even more
feasible. Many of us consider this to be an important idea for India. However
it would require changes in our laws and policies. Most importantly, it would
require a change in the mindset of doctors who are not ready to relinquish or
share the power of their knowledge, even if it could alleviate the current
suffering of countless people who do not have access to doctors. I would hope
that this idea will gain ground amongst the nursing community and have the
support of doctors who genuinely care for health for all. We have seen
countless rural hospitals that are essentially nurse-run and I have personally
witnessed a beautiful neonatal intensive care unit that was run almost entirely
by nurses following carefully designed protocols and with great results. There
is no reason for this not to happen, except for vested interests. However this
concept also suffers the danger of being subverted for providing lower cost
lower quality services and increase profit margins for the private sector. As
with all strategies, we must firmly locate our action for ‘health for all’
within the public health system and not allow their co option for profit making
at the cost of peoples’health.
Of
course, as with any other group that is demanding equality in a highly unequal
world, there is a long struggle ahead of all of you. The struggle demands
organisation, and professionalism. Those who are more powerful may get away
with poor practice, but we must work doubly hard to demonstrate high quality,
professionalism, and our concern for our patients, specially the poor. Only
then do we stand a chance of greater justice, for nurses and for people. We
must also withstand the abject commercialism and malpractice that is plaguing
the health sector in India, led by its doctors. We must demonstrate that we are
better.
I
leave you with these thoughts for the future and with my best wishes. We, in
the health movement stand with you and I hope we will continue to work together
towards social justice for all and the common cause of ‘Health for All – Now!’.
Dr.Vandana Prasad, Public Health Expert
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