The pandemic of coronavirus has highlighted to health systems the world over why health systems are important – and emphasised in particular the vital role of nursing on the front line.
It is fitting, therefore, that 2020 marks the International Year of the Nurse and the Midwife. The World Health Organization (WHO) unveiled earlier this week the first State of the world’s nursing report, highlighting the importance of investing in education, jobs, and leadership in the nursing profession.
On the occasion of World Health Day earlier this week, WHO Director-General Dr Tedros Adhanom Ghebreyesus took to Twitter to say that “we’re highlighting the vital role of nurses and midwives”, adding that “every day, nurses are putting themselves at risk to alleviate suffering and save lives” – quantifiable in the context of COVID-19 that, as Tedros pointed out, more than 3,000 health workers “have been infected with COVID-19 and many have paid the ultimate price.”
COVID-19 is highlighting how nurses, midwives, and other health workers are the saviours of the health system, with India being no exception to this reality. Writing in The Asian Age, journalist Sunanda K. Datta Ray emphasised that “India desperately needs its doctors and nurses.” Of nurses, Ray wrote “we can’t do without them.”
Ray pointed to the ratio of nurses to the population, noting that the country has only 1.7 nurses per thousand people, well short of the [WHO]-recommended three-per-thousand.” At the global level, the world is short of the nurses it needs to – as the WHO writes in its report – “deliver on the promise of “leaving no one behind” and the global effort to achieve the Sustainable Development Goals (SDGs).” Nurses, the WHO notes, “make a central contribution to national and global targets related to a range of health priorities, including universal health coverage, mental health and noncommunicable diseases, emergency preparedness and response, patient safety, and the delivery of integrated, people-centred care.”
With this in mind, the WHO’s pronouncement that “no global health agenda can be realised without concerted and sustained efforts to maximise the contributions of the nursing workforce” seems patent. Yet, the world does come up short on a number of factors.
Even as the world is home to a nursing workforce of 27.9 million, this is “not…commensurate with the universal health coverage and SDG targets.” The WHO report identifies a global shortage of nurses posited at an estimated 5.9 million in 2018 – a gap partially plugged since the 2016 shortage of 6.6 million but still one that presents a major obstacle. Low- and lower middle-income countries bear the brunt of nursing shortages worldwide, accounting for 89 percent of the gap – translating to a personnel shortage of 5.3 million approximately.
In India, the nursing shortage is pronounced and a long-standing phenomenon. As a 2011 paper noted, “although nursing services are an integral part of both preventive and curative aspects of India’s health system, the nursing estimates of the country shows that India has been facing a shortage of nurses since independence.”
As the WHO report notes, “the countries accounting for the largest shortages (in numerical terms) in 2018 included Bangladesh, India, Indonesia, Nigeria and Pakistan.” Quantified, in 2018, Captain Usha Banerjee wrote
“Currently, India has only 1.7 nurses available per thousand population against WHO recommendation of 2.5 nurses per thousand population. In other words the country is short of 2.5 million nurses. The situation is complicated by [a] declining number of student enrolments and poor educational facilities. This despite the fact that India churns out the highest number of trained nurses in the world and is also amongst top five exporters of nurses.”
International migration of nurses from India was flagged in the 2011 paper and is an issue at the global level as the WHO report notes: “one nurse out of every eight practises in a country other than the one where they were trained. The international mobility of the nursing workforce is increasing. While the patterns are evolving, equitable distribution and retention of nurses is a near-universal challenge.”
The 2011 paper outlined that “studies show that professional, social, and economic reasons are considered to be behind the nursing shortage in India. Similar reasons induce Indian nurses to look for migration opportunities in other countries.”
A 2018 survey conducted in Tamil Nadu “[implied] that international migration by nurses can be explained in part by the gap between the private sector and the public sector in terms of salary and working environment. Since the impact of social status on the migration decisions of nurses has lessened, economic factors are the crucial determinant of international migration of nurses.
“Policy intervention in this area is the necessary first step to solving this long-standing problem. The priority in any policies formulated should be given to nurses working in the private sector whose salaries are considerably lower than those in the public sector and whose voices are unheard.”
Marginalisation and neglect of India’s nursing population has been acutely manifest against the backdrop of the COVID-19 crisis. News18 reported recently how issues such as defective personal protective equipment (PPE) have sparked protests by nurses in multiple parts of India; how healthcare workers are facing harassment, violence and even rape and/or death threats, including sometimes from the authorities; how healthcare workers staffing the front line against the COVID-19 crisis are facing eviction from their homes because of fears surrounding their exposure to COVID-19.
A United Nations (UN News) piece headlined “COVID-19 highlights nurses’ vulnerability as backbone to health services worldwide” is apposite in the Indian context. Giorgio Cometto, Human Resources for Health Policies and Standards Coordinator in the WHO’s Health Workforce Department, is quoted in the article outlining the adverse working conditions nurses are facing amidst COVID-19.
Not only are we “witnessing an unprecedented global market failure in the provision of PPE” according to Cometto, “we have seen unprecedented levels of overwork by nurses, particularly those specialised in intensive care units, those in management or those most directly involved in the response to the COVID-19 pandemic, oftentimes without adequate time for rest and recuperation, without support and assistance, with limited considerations for their mental health and wellbeing.”
Does India stand as a case in point?
Reports indicate this to be the case. While eviction threats against healthcare workers amidst COVID-19 have been disavowed by Union Health Minister Dr Harsh Vardhan and the Union Government is working towards alleviating PPE shortages, the long-term will see whether India can plug its nursing workforce gap. Ensuring a working environment that is fit and safe for nurses will be a critical component of this. This must be inclusive of support for their physical and mental wellbeing and adequate remuneration. A 2015 Times of India report described the nursing workforce as “underpaid and overworked, but ignored” and went on to note
“Nurses here are hired at laughable pay scales, confined to minimum skill sets, straitjacketed in a profession with no room for growth and lack a conducive work environment and infrastructure facilities…it’s no surprise that the profession has a high attrition rate and acute shortage.”
Providing for the wellbeing, professional attainment, and appropriate compensation for its nursing workforce is a challenge that is incumbent upon India to meet. If the COVID-19 crisis underscores anything, it is how lost India would be without its nurses and midwives. The WHO report contains a number of recommendations for how the state of the world’s nursing in 2020 can be better – especially by 2030, with achieving the SDGs in mind. Attaining them, without investing in nurses, is impossible as the WHO report notes.