The BBC recently reported that the Swansea Bay University Health Board in Wales might recruit nearly 900 nurses in the next four years.
One sentence in the 3 April report stood out: “Many of the nurses will be recruited from Kerala, India.”
The British broadcaster also mentioned the reason. “Immediacy of really experienced staff,” it quoted Gareth Howells, director of nursing and patient experience at Swansea Bay Health Board, as saying.
Ironically, India has a shortage of experienced staff.
On Wednesday, 26 April, the Cabinet Committee on Economic Affairs approved the setting up of 157 new nursing colleges “in co-location with the existing medical colleges” across the country.
The move is to add about 15,700 nurses annually to the pool of medical professionals.
Kerala, however, will not get even a single college under the initiative.
Telangana also misses out
The Union government has allotted just 17 colleges to the South Indian states. Besides Kerala, none has been granted to Telangana.
Tamil Nadu will get the most number of nursing colleges allotted to South India — 11, while Karnataka and Andhra Pradesh will have three each.
The “disparity” in allocating nursing schools has sparked widespread criticism. The CPI(M)’s Rajya Sabha MP from Kerala, John Brittas, minced no words while criticising the central government.
“Perform and perish; that’s the new rule in India,” he summed up the Centre’s denial of even one college to Kerala in a tweet.
Perform and perish ; that’s the new rule in India. 157 New Government Nursing Colleges, with 10 cr each,announced by Centre. Not a single one in Kerala because we have many , according to New Delhi !@MoHFW_INDIA @VeenaGeorge03 #healthcare
— John Brittas (@JohnBrittas) April 27, 2023
The Centre’s justification
The Centre, however, justified allotting more nursing colleges to other states.
Minister of Health and Family Welfare Dr Mansukh Mandaviya said there is a “significant imbalance” in the existing distribution of nursing colleges.
“There is a significant imbalance in the distribution of nursing colleges across the country as 40 percent (of them) are in the four southern states. There are 13 states with no nursing colleges,” he told reporters.
Experts, too, pointed out that more than 40 percent of the country’s nursing colleges are in Kerala, Andhra Pradesh, Tamil Nadu and Karnataka.
Dr Mandaviya added that co-locating nursing colleges with medical colleges would allow optimal utilisation of the existing infrastructure, skill labs, clinical facilities, and faculty.
Also read: Six hospitals agree to nurses’ demands; strike to continue
Why government colleges?
“Pursuing nursing in a private institution is a costly affair, and one has to shell out ₹6 lakh to ₹10 lakh for a seat under the management quota,” Annapoorna G Ravi, a staff nurse from Karnataka’s Hubballi, said.
“The government sector is affordable for students from lower-income families. Such institutes will encourage more students to enroll,” the nurse, who would be retiring soon, told South First.
Another advantage is that these nursing colleges will be attached to medical college hospitals, which means the quality of education and training will be better than that of private colleges.
Also, government nursing colleges can address the shortage of nurses by encouraging them to work in areas where there is a need for healthcare professionals.
It also ensures a uniform standard of education, regardless of where they study.
Also read: Kerala nurses observe ‘black day’ over low wages
Call for change
The World Health Organisation (WHO) has recommended three nurses for every 1,000 people. However, India has fewer than two nurses for 1,000 people.
A FICCI-KPMG report released in 2022 stated that the country needs to hire allied healthcare professionals eight times more than the current numbers to meet its demands in the next 25 years.
Speaking to South First, Ramani Rao (name changed on request), a nurse from Telangana, said Karnataka has the highest number of nursing colleges in South India.
As on March 2022, Karnataka has 668 nursing colleges, including 43 in the public sector. Andhra Pradesh has 291 colleges (19 government-run institutes), Kerala has 266 (34 in public sector), Tamil Nadu has 347 (40 government colleges), and Telangana has 159 (13 government colleges).
Still, the number of nurses graduating from these institutions has been falling short of the country’s requirement.
“Even if each state gets a minimum of 12,000-15,000 nursing graduating each year, we should have enough nurses close to the WHO recommendation. But the situation is different. In each state, the number of nurses — both in government and private hospitals — are less,” Ramani stated.
She pointed to a grave issue that should be addressed. The central and state governments should seriously look into the reasons forcing nurses to either quit the profession or fly abroad.
Anitha Thimmaiah, a staff nurse at KIMS Hospital in Karnataka, further elaborated.
“We will earn respect only if governments decide to consider nurses as important and equal to doctors. Nursing has been considered one of the thankless jobs. This perception should change,” she said.
Also read: Uniform healthcare: SC seeks response from Centre, states
Where are the nurses?
A 2022 WHO report said Kerala has the highest number of nurses working in India and abroad. The state has several Church-run nursing and medical institutions.
“The Kerala Nurses and Midwives Council (KNMC) is an autonomous statutory body under the Government of Kerala and is responsible for registering nursing institutions in the state,” the report said.
“According to the KNMC register, there were 124 nursing colleges (seven are government institutions) offering BSc Nursing degrees and 135 nursing schools (20 are government institutions) offering diploma courses in General Nursing and Midwifery (GNM) in the academic year 2019–2020,” the report said.
According to the Kerala Private Hospitals’ Association, most member hospitals are facing a 15 to 20 percent shortage in nursing staff.
The WHO report further suggested that more than 25,000 Keralites (over 10,000 from institutes within Kerala and above 15,000 from outside Kerala) are graduating from nursing colleges annually.
“However, there are only 10,000 nursing jobs available in the state and the career prospects, too, are inadequate and unattractive. Hence, these qualified nurses migrate outside the state or country in search of jobs,” the report added.
Also read: End contracts, say Karnataka healthcare employees
Vipin Krishnan a nurse attached to AIIMS, Delhi, told South First that India has only 1.7 nurses per 1,000 people, much below the WHO recommendation.
He blamed the brain drain, especially to European and Middle East nations for the shortage.
“As a state that gives so much importance to its health sector and the one that produces the highest number of nurses, denying new nursing colleges to Kerala amounts to blatant discrimination,” he opined.
Krishnan also said that considering the migration of nurses and the number of nurses graduating each year, the numbers are grossly inadequate.
He further added that “…establishing more nursing colleges in Kerala not just helps the state but the whole nation”.
“As more and more nurses from Kerala go abroad, the resultant shortage will increase the burden on the ones working in private hospitals. The working hours could increase by two to three hours due to the workload,” Divya ES, the treasurer of the United Nurses Association in Kerala, told South First.
Also read: Southern states see a slight uptick in preventive healthcare, say docs
Better pay, training to check migration
A report by FICCI and KPMG released last year estimated that the country currently has 57.5-58 lakh allied healthcare professions. It is, however, not enough.
The country needs eight times that number to address the shortage.
According to reports, the current capacity of allied healthcare professionals in South India is estimated to be around 10 lakh but it needs to be increased by eight-13 times to meet the shortfall.
The reasons for the shortage of nurses in South India are complex, Rajani Krishna, a nurse in Andhra Pradesh, said.
She held the lack of investment in quality nursing education and training as a major contributing factor.
“Many of our graduates do not even know how to administer an injection. As simple a thing as finding a vein is not taught properly in some private nursing colleges. Many graduates were not attached to any hospital and they have no practical experience,” she said.
Rajani advocated advanced training and education for nurses.
“Even in the government sector, we are learning only the old techniques. There are several innovations. The private sector holds conclaves, conferences, etc, for their staff, where nurses also learn these techniques. The government should also do the same,” she opined.
Rajani felt such a move will persuade nurses to stay in the profession.
Also read: How Telangana keeps an eye on the rural healthcare system
Meanwhile, Rama Gadgil, a Mumbaiite working in Telangana’s Gandhi Hospital, said the migration of nursing professionals to foreign countries is another reason for the shortage.
Though the pay scale in the government sector is better than in the private sector, the salaries and job opportunities in foreign countries, specifically in countries such as Saudi Arabia, the United States, Canada, Germany and the United Kingdom are high. These countries are actively recruiting nurses from India.
Sharan Reddy, a nurse in Telangana, explained: “We are paid a basic salary of ₹36,750 in the government sector, while in private hospitals it is ₹15,000 per month. In mid-level private nursing homes, the nurses are being paid as little as ₹7,000.”
“This is despite a government order mandating that the basic salary of a nurse has to be ₹20,000. Why shouldn’t I go abroad if I am offered ₹3-4 lakh a month,” he asked.
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Another reason for nurses quitting or shifting elsewhere is the working conditions. Private hospitals operate with a lesser number of staff, despite having a heavy workload.
According to the Indian Nursing Council guideline, a general ward should have one nurse for every six patients, in an ICU each patient should have one nurse, and in an emergency or casualty ward, it must be one nurse per two patients.
Sharan opined that government hospitals are not different. He said the Gandhi Hospital in Telangana started functioning in 1980 with 500 beds and 288 staff nurses.
“Now, the hospital has grown into a 1,500-bedded one but the sanctioned strength of nurses is still 288. This is the case in many government hospitals,” he alleged.
Sharan added that while there are always more doctors, nurses are overburdened. Nurses are hired on a contract basis by the government but are not put on par with government nurses.
“Several state government contract employees have been fighting for pay parity. For instance, nurses and other allied workers in Tamil Nadu and Karnataka have been constantly protesting against the disparity,” said Anitha of KIIMS.
Needed: Monitoring mechanism
Several professionals South First spoke to also suggested that the government should monitor the number of nurses sticking on with the profession after registering themselves with the Indian Nursing Council’s registry. The numbers in the registry will be high, they opined.
The Indian Nursing Council’s annual report released on April 28, 2023, said there are four lakh odd nurses registered in Andhra Pradesh, 2.92 lakh nurses in Karnataka, 4.04 lakh in Tamil Nadu, 63,533 in Telangana, and 4.18 lakh in Kerala.
Sharan felt that many of these nurses “might have dropped out of the profession due to family issues, lack of respect in the field, or harassment at workplace”. Many of them might have shifted to other professions such as hospital management, quality control, etc.
“The government need to check this aspect, instead of just claiming that the number of registered nurses is on an uptick,” he said.
In an earlier interview with South First, Dhanya, a private hospital nurse in Kerala’s Kannur, complained of long working hours and pathetic conditions.
“Most private hospitals do not have changing rooms or washrooms exclusively for the hospital staff. We are suffering because a job is required to survive,” she said.
(With inputs from Sreerag PS in Kochi).