Keynote address

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