An emergency: A strained paramedical network

Across India’s hospitals, inadequate staffing of nurses and paramedics hinders the delivery of quality healthcare.

New Delhi: Four years before Independence, an expert committee set up by the central government to examine India’s public health system found that nursing as a profession was not attractive to many women because of the tasks a nurse did, such as cleaning and being in close contact with individuals. Most nurses were being trained in missionary institutions and hospitals were largely functioning without an adequate number of trained nurses.

Seven decades later, the profession now attracts people from various social backgrounds, but on the functional side, little has changed. Hospitals still operate largely without an adequate number of trained nurses, because governments simply do not recruit them in large numbers and private hospitals refuse to pay adequately. The story is more or less the same with other allied health professionals or paramedical staff.

An expert panel set up by the Economic Advisory Council (EAC) to the Prime Minister has shown that India requires 77 to 80 health workers per 10,000 population. Of this, about 45 workers constitute core professionals such as doctors and nurses. The rest will be associate professionals and support workers in equal measure.

This figure is based on a World Health Organisation (WHO) norm that recommends 44.5 doctors, nurses and midwives per 10,000 population to achieve about 80% coverage of the population for an essential basket of healthcare services. The WHO made this recommendation in 2016, replacing its earlier estimate of 22.5 per 10,000, which addressed only reproductive health and child healthcare.

In its report, the EAC expert group has estimated that in 2024, India will be short of nearly 15 to 24 lakh nurses.

“Still, governments are reluctant to create new posts for nurses and fill existing ones. Reduction in the number of nurses and paramedics is seen as a cost-cutting device,” T Sundararaman, chairman of the expert group and former executive director of the National Health Systems Resource Centre, Delhi tells DH.

A reliable method of counting the number of nurses and paramedical staff in hospitals and clinics does not exist, with multiple surveys and studies throwing up different figures. Also, there has been a surplus in some states and a deficit in others. Both state policy and labour markets have failed to transfer human resources from regions of excess to regions that are lacking. And to make matters worse, the quality of training in many institutions is not up to the mark.

Pradeep (name changed), a student from a government-run medical college in Karnataka, bemoans the lack of proper classes and training for paramedical courses. “I am an imaging technology student in a class of 70. We are posted to cover hospital shifts and end up missing classes and internal exams several times during our three-year course,” he says. 

“Despite there being so many of us, the workload in an eight-hour shift is so overwhelming that catching up on classes is a challenge after work,” he adds.

Health officials are aware of the problems. A senior official from the Department of Medical Education, Karnataka acknowledged gaps in faculty, especially in government institutes, and the increased workload on existing staff. Additionally, there is a shortage of trained OT technicians as well.

Padmavathi P, a nursing officer at the Karnataka Medical College and Research Institute, Hubballi, says, the shortage is draining the staff physically and mentally. “The majority of female nurses are working overtime. Their shifts, at times, extend up to around 10 to 12 hours, depending upon the emergency cases,” she says, advocating for the government to hire adequate paramedic staff on a permanent basis. 

In neighbouring Telangana, two months ago, a Comptroller and Auditor General report revealed a severe shortage of paramedics and nurses.

For institutions operating under the administrative control of Telangana Vaidya Vidhana Parishad, responsible for providing primary and secondary healthcare services, the audit discovered significant staffing shortages. Particularly, a lack of auxiliary nurse and midwife staff (56%), paramedical staff (46%), nursing staff (21%) and other support staff (25%) was apparent.

Similarly, health institutions under the administrative control of the Director of Public Health face a vacancy rate of 15% for nursing staff, 75% for paramedical staff, 56% for pharmacists and 24% for other support staff in Telangana.

The situation is similar in most states. In Srinagar’s Sher-i-Kashmir Institute of Medical Sciences (SKIMS), 300 posts of nurses are vacant. “The plight of the patients can be imagined when one nurse is tasked to do the work that would ideally be entrusted to four. One can also fathom what load we have at the hospital,” a senior nurse tells DH.

The Union Health Ministry’s latest rural health statistics corroborate the shortage. The report points to a large number of vacancies in nursing staff in primary and community healthcare centres in populous states like Bihar, Uttar Pradesh, Odisha, Madhya Pradesh and Rajasthan.

“Once, while recruiting to fill up 200 permanent nursing positions in Madhya Pradesh, there were over 80,000 applications. Overwhelmed, the government cancelled the entire process,” recalls Dileep Mavalankar, a professor at the Indian Institute of Public Health, Gandhinagar.

Education and training

According to the Indian Nursing Council, the country has over 5,200 nursing colleges as of March 31, 2023, offering various courses. Of them, 715 are in the government and nearly 4,500 are in the private sector. Of all the private colleges, close to 45% are concentrated in four southern states and Maharashtra. Each year, around 3.55 lakh nursing students graduate from these institutions.

Despite these institutions churning out lakhs of professionals each year, governments fail to fill vacancies. Many also turn down the private sector offers due to paltry salaries, says Mavalankar.

The shortage of paramedical staff has an impact on doctors even in metro cities. “This is an issue in ICUs and operation theatres, where doctors cannot effectively monitor many patients without adept nurses, surgery assistants, and technicians,” says a critical care specialist in a government hospital in Bengaluru.

“Nearly 90% of the work in any ICU is done by nurses. Only if more nurses are employed, can constant monitoring and feedback to doctors be possible. Then, they will not be overworked,” the specialist adds. 

The EAC expert group noted that a high degree of unqualified nurses are at work, largely in the private sector.

The Bengaluru doctor also flagged the absence of skilled workers. “Several residency programmes should be in place in order to upskill nurses, but that has not been implemented in Karnataka,” he says, on the condition of anonymity. “Also, the establishment of allied health institutes has not picked up pace.”

The central government policy of converting all General Nursing and Midwifery (GNM) courses to BSc Nursing courses was a setback for nurse-deficit states. Many states struggle with nursing education in the absence of adequate faculty.

“We do not have dedicated sanctioned posts for nursing school teachers. Nurses from hospitals come to work as teachers in shifts, and it is very rare to have all essential teaching positions filled by professors who are not also working as nurses after their classes,” a Karnataka official says.

To ensure a decent salary for nurses, the Union government, in February 2016, formed an expert panel at the behest of the Supreme Court. The panel recommended that in the case of hospitals with more than 200 beds, the salary given to private nurses should be at par with the salary of state government nurses.

In the case of hospitals with more than 100 beds, the salary of private nurses should not have more than a 10% difference compared to the salary of government nurses. For hospitals with 50 to 100 beds hospitals, the difference should not be more than 25%. The panel also suggested that the salary given to nurses in private hospitals should not be less than Rs 20,000 per month, even for hospitals with less than 50 beds.

Moreover, nurses in private hospitals are eligible for working conditions including leaves, medical facilities, transportation and accommodation at par with the benefits granted to state government nurses. The recommendations were shared with the states, but it is not clear how many states have enforced them, and whether the living conditions of nurses have improved in the last six-seven years.

With many big hospitals having their own nursing schools, they employ graduates from these schools on a lower salary, and often on a contractual basis. “They do not recruit to fill the requirement of nurses and paramedics and make do with a few. Those employees have no job security and suffer due to poor work conditions,” Sundararaman says.

Across allied medical services

The shortfall in the number of other paramedical staff is also seen across the board. A recent health ministry report reveals a 40% shortage of radiographers and a 20% shortfall in laboratory technicians at rural community health centres, whereas primary health centres have a 30% deficiency in lab technicians.

Sunjay Hadagali, a laboratory technician at the Ballari Medical College and Research Centre, says that in the absence of enough hands, they often seek the help of patient attendants and relatives to take patients from one block to another for medical tests, resulting in friction between paramedics and attendants.

“In most government hospitals, the patients and their relatives are required to travel up and down to pay bills, give samples and collect results. If the hospitals are designed to minimise movement of patients, we can avoid a lot of conflict,” he notes.

At SKIMS Srinagar, hundreds of staffers have retired over the past 15 years, but these vacant positions have rarely been filled. “The workload has increased due to a rise in patients, along with diversification of services. Shortages in the number of nurses, technicians and paramedical staff have affected patient care and the situation continues to worsen,” says a senior SKIMS staffer.

“At the Department of Pathology, there were 35 staffers some years ago. Now we are left with just seven people, and this results in enormous delays for pathology reports of patients,” the staffer adds. 

In Kerala, paramedical staff find jobs in the private sector, but the remuneration is low compared to roles in the government sector. “Qualified paramedical staff from Kerala search for good jobs in the Middle East, Europe and Canada,” says Ashraf Perilacode, former associate professor at the Department of Medical Lab Technology at the Government Medical College Thiruvananthapuram. Ashraf is also a former nodal officer of the Kerala Paramedical Council. 

The lack of paramedical institutions is also leading to students seeking admission in institutions in Karnataka and Tamil Nadu.

“Salaries are decent in the government sector, but recruitment is low. In the private sector, there is employment, but salaries are low without any job security. The shortage we see in hospitals is nothing but a policy failure,” notes Sundararaman.

(With inputs from Arjun Raghunath in Thiruvananthapuram, Pavan Kumar H in Hubballi, S N V Sudhir in Hyderabad, Udbhavi Balakrishna in Bengaluru and Zulfikar Majid in Srinagar)

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(With inputs from Raghunath in Thiruv thapuram, Pavan Kuma in Hubballi, S N V Sudh in Hyderabad, Udbhavi Balakrishna in Bengaluru and Zulfikar Majid in Srinagar)