POSITION PAPER
Health workers’ rights in the time of COVID-19
by Jan Swasthya Abhiyan (JSA), All India People's Science Network (AIPSN) and
Public Services International India National Coordination Committee (PSI India NCC)
21 April 2020
Introduction
As of 21 April, the COVID-19 pandemic has infected about 2,482,158 people worldwide and
contributed to 170,470 deaths. In India as on 20 April, the number of people infected with COVID-
19 is 17,656 with 559 deaths. The corona virus Sars-CoV-2 that causes COVID-19 is potent for certain
biological reasons―its structure enables it to latch on to hosts easily, it has a long infection
period, it is infectious even in asymptomatic carriers, and human beings have no immunity to it as
yet. Hence it can spread easily and quickly. A large, sudden influx of patients can put extreme stress
on both the healthcare system in India and on its health workers, as we are currently witnessing in
many countries in Europe and the United States. Health workers are generally at high risk. In Italy
for instance, it has been reported a staggeringly high proportion of all those infected are healthcare
workers. India is witnessing an increasing number of cases of infection among health workers.
The situation is made worse by the fact that COVID-19 has hit India against the backdrop of
a neoliberal assault on healthcare. This assault has meant that public health facilities are in disrepair,
neglected, and overburdened. At the same time, private hospitals and nursing homes have proliferated,
without adequate regulation.
The main rationale for the poorly planned 27-day lockdown and its extension upto 3 May by
many states, with disastrous effects on lakhs of informal and migrant workers, is that it will buy
time for the government to prepare for COVID-19’s likely assault. However, governments’ actions
till now have been both late and inadequate. The current situation is dire. Testing is inadequate,
there is severe scarcity of test kits and the much-publicized antibody-based kits have barely begun
trickling in, more ventilators are needed, and the availability of personal protective equipment
(PPE) is poor and uneven across regions and hospitals. Moreover, the high population density in
slum settlements and bastis in all towns of India makes physical distancing, even in a period of
lockdown, impossible and puts the poor and a very large number of workers at risk of infection.
Additionally, health facilities can become sources of the spread of infection, with three concentric
circles of risk: individual health workers in direct contact with patients; other employees including
fellow-nurses, doctors, and other health workers; and three, the public coming to a hospital.
Recent episodes, such as in Delhi, Mumbai, and Hyderabad have shown that this can occur at any
health facility, not just at COVID-19-identified ones, particularly given that the current Indian testing
and patient management protocol has no provision for testing symptomatic patients without a
contact history and isolating those who are positive but asymptomatic. These patients might have
high infectivity and will be coming into close contact with many healthcare providers without either
patient or health providers knowing. There are also asymptomatic carriers in the public, many of
whom will be seeking care due to co-morbidities. Health workers at the community level, such as
ASHAs, who are deployed either for Covid-19 outreach and community awareness or for routine
community level work such as immunisation, are also facing higher risk of exposure to the virus.
Hence, the rights and protection against risk of health workers on the one hand, and the robustness
of the health system on the other, and the policies with regard to testing, all deeply intersect in the
times of COVID-19.
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Because health workers are on the frontlines of our response to COVID-19, they face higher
risks of infection, overwork, and stress. Hence, any strategy to fight the pandemic should consider
the rights and protection of health workers, including through the following:
(a) adequate PPE should be provided;
(b) access to testing and treatment needs to be ensured;
(c) health workers should be covered for COVID-19-related sick leave, quarantine and
provided compensation;
(d) workers should be allowed to opt out of performing their work in conditions that puts
them at risk, without risk of losing their jobs;
(e) proper training needs to be provided regarding procedures before workers are deployed;
(f) representatives of health workers need to be actively involved in setting up safeguard
measures in health facilities;
(g) the organization of work in hospitals (such as patient flow in the outpatient wards)
should be such that their risk of exposure to healthcare workers is minimized;
(h) wages and overtime should be paid as per the law without any mandatory or so-called
voluntary cuts;
(i) adequate facilities should be provided across needs such as adequate accommodation,
transportation, child care, and nutritious meals;
(j) measures are urgently required to protect health workers against stigma, violence, discrimination,
and sexual harassment;
(k) existing vacancies need to be filled with a long-term perspective;
The COVID-19 crisis and the effectiveness of health systems response both in India and
globally, clearly underlines the need for healthcare to be in the public sector. The related, broader issues
of health workers’ employment, equal pay for equal work, and rights to occupational health
and safety and better working conditions is central for countries to be able to cope with COVID-19
now. We welcome the broader support and appreciation for the work that health workers are doing
in the forefront in the fight against COVID-19. However, just appreciation and statements of good
intent are not enough. Nor are simply clapping hands and banging plates. We need this support to be
legalized through notifications and legislation by the appropriate authority at varied levels of government:
centre, state, and local bodies. How robust we make the healthcare system and strengthen
all health workers now is central to coping better not just with the present crisis, but how well we
will be able to cope with any health crises in the future.
A precarious health workforce makes the health system more fragile
The continuous underfunding of public healthcare has meant that in public hospitals, due to
budgetary tightening, vacancies of health professionals―from doctors, to nurses to
paramedics―have not been filled. This imposes a heavy workload on the existing staff that was
already hard for them to manage. In many facilities, especially under local bodies and poorer state
governments, professional staff shortages have been dealt with by hiring on short-term contracts or
deploying field staff in hospital settings, such as with ANMs. Health workers who are ‘non-professionals’,
such as ward attendants and housekeeping staff, cleaning and security staff are most often
hired through contractors, at low wages, pathetic working conditions, and too often in violation of
the labour law.
While the private health sector has thrived and expanded, its workforce is highly underpaid,
except for high profile and specialised doctors. Across the country, nurses in private hospitals are, at
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best, paid around the minimum wage for a skilled worker, and most often below this legal benchmark.
This sets the scale for other staff, who also face the challenge of being hired through a third
party which makes their tenure highly insecure and without social security coverage.
The workforce at the primary level of care provided in health posts and at the community
level are unarguably the most neglected. Field/community health workers, such as the Accredited
Social Health Activists (ASHAs) in rural settings or Community Health Volunteers (CHVs) in
Mumbai, are the largest group of health workers with more than 9 lakh workers in India. They are
denied the status of a worker by the State. ASHAs are told they are ‘volunteer’ activists and not
workers of the health system, thus denied minimum wage and any other rights of a worker under the
law.
As health workers across the health system have been mobilised to respond to the pandemic,
the pre-existing cracks and weaknesses in the system make it all the more fragile. Informal employment
leads to unclear responsibilities towards workers, and has created blind spots in the system.
ASHAs and CHVs have been deployed for case identification without adequate safeguards. Sanitation
and support staff who are contractual are being preferentially deployed as compared to regular
staff, so as to avoid social security obligations in case of their illness. Public hospitals will be at the
centre of the response to the COVID-19 epidemic, but they will have to be reinforced by private facilities,
either through collaboration, or preferably, through requisition by the government. The precariousness
faced by the vast majority of the close to 40 lakh health workers has to be addressed as
a matter of priority as part of health system preparedness that the lockdown is meant to enable.
Previous outbreaks of highly infectious communicable diseases have demonstrated that public
health outcomes are significantly improved when labour rights are respected, and trade unions
are able to effectively represent workers actually exposed and potentially exposed to the disease.
The active involvement of health workers’ representatives in government decision-making is necessary
to safeguard workplace safety and health and ensure the cost of the crisis is not borne by
healthcare personnel.
REQUIRED MEASURES
a) Adequate provisioning of Personal Protective Equipment
Reports coming in from Maharashtra, West Bengal, Tamil Nadu, and Bihar point to uneven availability
of PPE of adequate quality, leading to protests. Workers are worried that raincoats are provided
instead of medical gowns, that eye protection and other equipment has not been provided. Workers
are forced to do risky procedures without proper PPE, or asked to quit if they refuse. This is creating
confusion on stress amongst the health workforce and needs to be urgently addressed.
The guidelines of the government of India - that make recommendations regarding the use of specific
PPE for different categories of workers, including medical masks, gloves, gowns, eye protection,
and footwear and respirators depending on the kinds of patient care - have not been adhered to.
Even the WHO interim guidance of 19 March 2020 on Rational Use of PPE for coronavirus disease
(COVID-19) have not been followed. New guidelines (dated 20 April) acknowledge the risk of
infection by asymptomatic patients who visit a health facility for other health reasons, yet they do
not provide guidance on PPE requirements. We recommend that the Indian government ensures systems
to monitor and enforce strict adherence to adequate guidelines for the use of PPE.
There has been a clear and criminal lack of preparedness and stockpiling, in disregard of WHO
guidelines of 27 February 2020. The Ministry of Health has admitted a shortage of equipment and
supply not meeting rising demand. This is compounded by an inadequate estimate of the size of the
health workforce, which the government estimates at 22 lakh, while it should be closer to 40 lakh1.
1A 2016 estimate suggests that the number of health professionals and para professionals alone (including doctors,
nurses and midwives, dentists, laboratory technicians and paramedics) was close to 25.3 lakh. The latter does not
include health workers such as cleaning staff, ward attendants, ambulance drivers, ASHAs and ANMs, to name a few.
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Given the uneven nature of PPE availability across regions, we recommended that PPE be sourced
in priority from domestic manufacturers with a long-term view of development of domestic industrial
capability, and supplied to deal with clusters of cases as they occur. This implies that PPE procurement
orders have to be increased to ensure adequate access to all health workers, and PPE be
sent to regions where they are most needed.
The shortage of necessary PPE equipment and the traditional structures of social discrimination in
India could lead to certain categories of workers, such as nurses who are at highest risk, but also
ASHAs, non-permanent/contract workers and cleaners, not being provided adequate PPE. We urge
that the government issue a directive that no such discrimination take place against any worker in
any establishment. Health workers should not be forced to work under unsafe conditions without
adequate protective equipment.
b) Free health care for all health workers
The announcement by the Finance Minister of a special life insurance scheme for health workers is
misleading and insufficient. Despite an announcement that all health workers would be covered, the
package covers health workers in the private sector only if they are drafted for COVID-19
responsibilities. The recent case of health workers getting infected at the private facility Delhi State
Cancer Institute shows that this is insufficient. Further, this is subject to the numbers indicated by
MoHFW. The figure of 22 lakh health workers is a gross underestimation of the actual size of the
workforce in the country, as mentioned earlier. The estimate should be modified correspondingly
and increased to at least 40 lakh health workers and the omission of healthcare workers in the
private sectors needs to be corrected immediately to avoid the possibility of denial of compensation.
Most importantly, this scheme is grossly insufficient as it does not provide any support to health
workers and their families unless the worker dies. In case health workers are infected by COVID-19
they should be given treatment, care and support free of cost. Considering that health workers in
informal employment conditions are more vulnerable as employers can hide behind this informality
to deny their responsibility towards them, it is important that they are given special attention in this
regard. The latest testing protocol (31 March) has expanded testing only to symptomatic health care
workers, whereas there is clear evidence of asymptomatic cases. As current testing protocols are
restrictive, health workers might find that they are compelled to go for testing in private labs, and
incur costs. Failure to detect infections early among healthcare workers may result in further
spreading of the infection. Access to comprehensive and free health care, including outpatient,
hospitalisation, and regular free testing need to be ensured, with special attention to informal
health workers. Special provision of regular testing needs to be ensured for health workers
performing high risk tasks, even if asymptomatic.
c) Special COVID-19 related paid leave and compensation
Health workers are at a higher risk of contracting infectious diseases, which is the case with
COVID-19 as well. Reports estimate close to 100 infections already confirmed in India, though
there is no systematic reporting of this data. As facilities are short-staffed, managements of facilities
are extending working hours. They might try to keep health workers on the job even when they are
already showing COVID-19-like symptoms, as we saw in Mumbai and in Bihar. Workers who have
tested positive with COVID-19 should not be asked to continue with their duties if they are showing
symptoms. This is against protocols and puts the workers at more risk of developing more severe
symptoms if they are not able to rest adequately.
Managements of facilities might also deduct leave taken for sickness or quarantine from existing
leave provisions, and when these are used up, take recourse to cutting workers’ wages. Informal
ASHAs alone are estimated to around 8.5 lakh, ANMs to around 2 lakh. While there is no estimate available for
ancillary health staff, it is safe to presume that at least 2 to 4 lakh, bringing the total number close to 40 lakh/4 million.
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workers have a limited amount of paid leave that will run out quickly. Those on daily wages do not
even have paid leave. Special paid leave in case of COVID-19-related sickness and quarantine
should be provided, including to workers on short-term contracts and employed through a third
party. A special compensation should also be announced for health workers who contract COVID-
19 in line with the WHO definition that if exposure to corona virus Sars-CoV-2 happens at the
workplace, contracting COVID-19 should be considered an occupational disease.
d) Mental health support and the right to opt out
Health workers undergo considerable stress during emergencies such as the one we are facing.
Counselling and mental health support should be made available for health workers. Breaks and
time-off should be maintained, as healthcare workers' burnout could contribute to both their
catching the virus and its spread. As per WHO guidelines, health workers should not be required to
return to a work situation where there is continuous or serious danger to their life or health. Health
workers' right to opt out of work when they are not provided with a safe working environment and
adequate protective equipment should be respected, without undue consequences.
Health workers who are pregnant, or have co-morbidities have higher chances to contract the
infection and develop more severe symptoms. They should not be put on duty in the COVID-19
ward and limit exposure to patients with suspected COVID-19. Instead, they should be assigned
appropriate tasks within their profession that does not expose them the virus and be accommodated
if they request so.
e) Training on procedures and infection risk management
Managing the risk of infection in health facilities, both in the public and private sectors, is essential
to ensure that health facilities do not themselves become hubs of infection. Part of the risk
management procedure is to ensure that all health workers understand the measures that are needed
to protect themselves, protect patients, and protect the facility. The government should implement or
direct facilities to implement appropriate training for the diversity of workers categories across
levels of risk.
The government needs to put in place online training programmes on infection control with a focus
on COVID-19 for the entire medical workforce in the country, facility-based training for the entire
workforce in each facility, including ASHA and community-based health workers attached to
different health posts. All health workers should be provided with communication materials in
different languages on the appropriate safeguards, including but not limited to PPEs.
The entire staff in all COVID-19 earmarked hospitals, ICU units, and isolation centres should be
given training and this should include both guidelines and protocols for COVID-19 care, as well as
personal safety, infection risk management and the use of personal protective equipment. The
government should provide guidelines for these procedures to be followed in private facilities. A
helpline should be set up for health workers who face challenges at their workplace, with a defined
procedure to register complaints and interventions to resolve them. In case private facilities fail to
follow the government guidelines and resolve issues with regard to adequate safeguard measures,
the state government should consider requisitioning these private facilities in order to avoid the
spread of the disease due to negligence of private operators.
f) Active involvement of representatives of health workers
The government should engage with trade unions of health workers to ensure that the guidelines effectively
reach all concerned health workers. For instance, there is a need for clear information and
training regarding PPE use, disposal, and care. Health worker unions are well positioned to contrib-
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ute to this process, as they have the organizational ability to reach out to large sections of workers
quickly. Hence, we urge that different state governments involve health worker unions in the process
of information-sharing, training, and workers’ safety. Facility management should facilitate an
active role for health workers' representatives in determining safety measures and safeguards of
their health.
(g) organization of work in hospitals that minimises risk of exposure to healthcare workers
The other part of risk protection is the proper organization of work processes that would limit hospital
infection to patients as well as to (all) health workers. This is a part of most quality accreditation
programmes, such as the national quality assurance standards for public health facilities and
multiple systems for private healthcare facilities. However, only a small proportion of facilities are
registered under these frameworks. One of the reasons why Kerala has reported fewer infections
among workers and less spread of the virus overall is because it has much better level of accreditation
and infection control. The infection control component of the quality accreditation programmes
must be implemented universally across states, including in the private sector, along with a monitoring
mechanism by the government.
h) Wages and extra-time to be remunerated as per the law
As society recognises that health workers are contributing to the common good by standing at the
frontlines of the battle against the COVID-19 outbreak, longstanding violations of legal provisions
with regard to their wages should be acknowledged and addressed. Notifications should be issued
so that wages are provided as per existing government norms, and wage discrimination against
workers in informal employment should be addressed. The current budgets of most municipal
hospitals and state hospitals are too small to provide the legal wages to all workers, which has been
covered up through outsourcing of services such as cleaning and housekeeping.
The central government has formalised the central role of ASHAs in containment and community
outreach, highlighting once again their role as an essential workforce of the state health system. Yet,
the government guideline does not provide an additional budgetary allocation while, of course, all
other tasks are to continue - ante-natal care, vaccination, etc. A paltry Rs 1,000 per month for April
and May is to be paid by states from unspent money. Their contribution in the month of March is
not even acknowledged and, without additional budgetary allocation, most State governments might
not even pay this inadequate incentive. The government pretence that ASHAs are not workers of the
health system amounts to discrimination against an exclusively female workforce that is paid a
fraction of the prevalent minimum wage.
Central and State governments should make the required budgetary allocations to ensure that
ASHAs and other health workers deployed to respond to the emergency situation are provided the
remuneration they deserve, and at least as per the law. Such allocations should be incorporated in
subsequent annual budgets.
As the crisis intensifies, health workers will be asked to provide extra-time on a regular basis. This
extra time needs to be regulated to allow enough time-off to rest and recover. Healthcare workers'
burnout aids the spread of the virus. Breaks and time-off need to be maintained. Extra hours should
also be remunerated as per the law.
It has also been reported that public and private sector hospitals are forcing their staff to contribute
to the government relief fund from their wages, in part of in entirety. Health workers should not be
asked to compulsorily or voluntarily forego their wages in full or partly.
With the exception of specialised doctors, wages in private hospitals and other health facilities in
the private sector are abysmally low. This led to the Supreme Court recommending a wage increase
across the board in the private health sector (2016). The recommendation has largely been un-
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implemented. In some states, such as in Delhi, the High Court directed the state government to
legislate towards the implementation of the Supreme Court recommendation. Yet, no such steps
have been taken. Considering that health workers in private facilities will also be involved in
responding to the COVID-19 epidemic, state governments should ensure compliance with the
Supreme Court recommendations relating to wages in private healthcare facilities.
Due to the financial crisis that preceded the COVID-19 pandemic many health workers such as
ambulance drivers, but also cleaning staff and ward attendants, had not received their payments for
months. The increased budgetary provision should prioritize payment of such arrears. As the
lockdown requires minimising non-essential activities and some workers have been asked to join
duty on alternate days, including for those working in hospital settings, special attention should be
given so that those working fewer hours because of the lockdown are paid their full salaries, even if
they are hired through manpower agencies, or on short-term contracts and other informal
employment conditions. For instance, safai karamcharis might find it difficult to travel to the
hospital they work in because of the shutdown of public transport. They should be considered on
duty for the full period of the lock-down. Finally, private sector hospitals are threatening to cut
wages in the month of April due to fewer patients and reduced “business” in that period. The
government should actively monitor that wages of health workers are paid. A health worker
helpline linked to both the Ministry of Labour and Ministry of Health should be available for
health-workers to notify non-payment of wages and arrears.
I) Adequate facilities across needs
Health workers working in high-risk areas, such as isolation wards, have to be provided the option
of adequate hostel accommodation so that they can avoid going home where there are old relatives
or young children whose health they are concerned about. They should not be asked to vacate the
hostel once their 14-days shift is over, as they risk to expose their families if they go back home.
Separate restrooms for medical personal in direct contact with COVID-19 patients should be
provided. Some states have taken steps to provide accommodation to doctors in hotels near the
hospitals where their work. There is no justification for the same benefits not being provided to
nurses and paramedics in direct contact with patients.
A large proportion of health workers are women who often face the double burden of housework
and care for their families as well as work outside the house. Adequate provisions should be made
to ease the burden of family care, including by providing options for crèche or childcare outside the
hospital setting. This is essential since regular childcare and schools are shut.
Soap and water should be made available in all facilities for workers and the public as a basic
hygiene measure. Hand sanitizers and detergent should be provided to all health workers on a
regular basis to facilitate personal hygiene.
Transport to the place of work, especially for those who do not have private transport, should be
provided, particularly if the lockdown is extended. There are reports of cleaning staff in cities such
as Delhi not able to join work due to the lockdown and decrease in public transport facilities. This
impacts the smooth functioning of hospitals, as well as creates hardship and stress for the workers
who are worried that their salaries will be cut for the days they are not able to attend work. ASHA
workers are facing similar issues as they have to travel from one house to an other.
Lack of nutritious food compromises immunity and puts health workers at risk of coronavirus.
Adequately nutritious food needs to be made available to health workers at the hospital, through the
public distribution system, or through other effective systems.
j) Stigma, social exclusion, violence and sexual harassment
We have seen during previous virus outbreaks that health workers are at risk of stigma and social
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exclusion. Even during the current COVID-19 epidemic there are reports of health workers being
asked to leave their rented accommodation. Other reports have surfaced of health workers being
attacked or harassed during tracing of potential COVID-19 cases or during their routine service
delivery. Particularly distressing are reports of healthcare staff who have become victims of
COVID-19 being refused burial or cremation services because of such stigma, when it is well
known that there is little danger of infection from dead bodies. The government should take
appropriate steps to ensure a safe workplace and work environment, including a strong media
campaign to counter stigma of all forms, and appropriate orders to outlaw stigma and
discrimination. A grievance redressal mechanism should be put in place, including internal
complaints committee in case of sexual harassment.
Health workers, including nurses, bringing lapses in treatment and protocols to the attention of the
public or speaking out about their working conditions are being gagged and harassed. Hospital
management and administrators may be stretched but unethical practices cannot be allowed to
persist and health workers’ role as whistle-blowers should be protected.
Health workers also face violence and harassment from the police while travelling to work, or
crossing inter-state barriers to travel from home to their workplace. The government should order
health facilities to provide letters on the appropriate official letterhead to all health workers, with
an order to the local police and administration to allow their travel, so that they are not harassed
by the police and other officials when travelling to work.
k) Filling of vacancies with a perspective of long-term hiring
Existing gaps in human resources vary between states but are generally substantial. According to
information collected through an RTI in 2017, in the facilities under the Delhi government, 14% of
the sanctioned posts of general duty medical officers (GDMO) were vacant (though another 4%
were filled by contractual staff), and 20% of staff nurse posts were vacant (though the large
majority were actually filled by contractual staff). According to reports, in Uttarakhand, 50% of
sanctioned posts for medical officers and 31% for staff nurses are vacant. These vacancies need to
be filled urgently, with a perspective of prioritising long-term hiring. The waiting list of the Union
Public Services Commission (UPSC) and the Staff Selection Commission (SSC) should be used as a
base to fill vacancies in health facilities under the central government. The waiting list of the
equivalent board or commission under each state should be used to fill vacancies in facilities under
the state governments. Kerala has undertaken this process successfully, using online interviews and
video conferencing. More recently, the Government of Tamil Nadu has appointed 530 doctors,
1,000 nurses, and 1,508 lab technicians through this method.
Considering the lockdown and closure of inter-state boarders, the situation might arise where
candidates on UPSC) or SSC lists are not in the state where the post is available. In such cases, a
temporary adjustment between sanctioned posts under the States and the Centre can be considered.
Considering the need for additional staff, those currently employed on contract should be allowed to
continue with their services. However, hiring on a short-term contractual basis or through
manpower agencies should not be seen as an adequate solution for increasing staffing under the
impression that the time saved in hiring provides a considerable advantage. Those employed on
short-term contracts and contracted through third party agencies are at risk of discrimination with
regard to access to personal protective equipment, leave and other safeguards. This increases the
risk of infection of this vulnerable workforce and weakens the risk management process in the
facility ― putting the larger public at risk.
The public expenditure on health as a percentage of GDP for 2017-18 was a mere 1.28%, while
WHO advises for at least 5% of GDP. Increased budgetary allocation for health will be required to
fill existing vacancies and should be incorporated into subsequent annual budgets.
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In summary, our demands are as follows:
SPECIFIC
1. The Government should provide updated guidelines regarding the rational use of PPE that
also cover non-COVID-19 facilities, facilitate the production and logistics of distribution,
increase PPE procurement orders to ensure adequate access to all health workers, and if
required, intervene in the market to ensure that PPEs are sent to the districts/regions where
they are urgently needed.
2. The government should ensure that guidelines regarding the use of PPE are strictly followed
in both public and private settings, and that there is no discrimination against workers on the
basis of hierarchy, employment status, or other reasons. A monitoring mechanism should be
put in place in order to enforce strict adherence to PPE guidelines in public and private
settings.
3. The government should ensure comprehensive health care free of cost to all health workers,
including outpatient, hospitalisation, and regular testing, with special attention to informal
health workers. Special provision of regular testing needs to be ensured for health workers
performing high risk tasks, even if asymptomatic.
4. The government life insurance scheme should cover all health workers including in private
settings and the estimate of health workers needs to be modified to reflect the real size of the
health workforce in order to avoid denial of compensation in the future.
5. Special paid leave in case of COVID-19-related sickness and quarantine should be provided,
including to workers on short-term contracts and employed through a third party. A special
compensation should also be announced for health workers who contract COVID-19 as an
occupational disease.
6. Health workers who are pregnant, lactating or have co-morbidities should not be put on duty
in the COVID-19 ward. They should be assigned appropriate tasks within their profession
that does not expose them to the risk of COVID-19.
7. Health workers' right to opt out of work when they are not provided with a safe working
environment and adequate protective equipment should be respected.
8. The government should facilitate appropriate training programmes and materials for the
diverse categories of health workers and for the different levels of risk depending on the role
of workers and the role of facilities.
9. Extra hours should be regulated and remunerated as per the law. Breaks and time-off need to
be maintained.
10. Adequate arrangements need to be provided to health workers in high-risk environments,
such as ICUs and isolation wards, including accommodation and separate restrooms.
11. The government should take appropriate steps to ensure a safe workplace and work
environment, protect health workers from harassment by the police and the community,
including a strong media campaign to counter stigma of all forms, and appropriate orders to
outlaw stigma and discrimination. A grievance redressal mechanism should be put in place,
including internal complaints committee in case of sexual harassment.
INSTITUTIONAL
12. Central and State governments should involve health worker unions in the process of
information-sharing, training, and workers’ safety. This will facilitate an effective outreach
to all concerned health workers. Managements should facilitate an active role for health
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workers' representatives in determining safety measures and safeguards of their health.
13. The infection control component of the government's quality accreditation programmes
must be implemented universally across states, including in the private sector, along with a
monitoring mechanism by the government. In case private facilities fail to follow the
government guidelines and resolve issues with regard to infection control and other
safeguard measures, the state government should consider requisitioning the errant private
facilities.
14. Management of health facilities should make adequate arrangements for health workers at
the facility, including but not limited to options for crèche or child care, transport to the
place of work, an official letter and an order to the local police and administration so that
health workers are not harassed by the police when travelling to work, regular provision of
soap and sanitizer, and adequately nutritious food at the hospital or through other effective
systems.
15. Health workers who are not able to work on a regular basis due to the lockdown or due to
precautionary measures should be considered on duty and paid their full wages. All
governments and private facilities should refrain from asking health workers to
compulsorily or voluntarily forego their wages in full or partly. A health worker helpline
linked to both the Ministry of Labour and Employment and the Ministry of Health and
Family Welfare should be available for health workers to notify non-payment of wages and
arrears.
16. State governments should ensure compliance with the Supreme Court recommendations
relating to the long overdue increase of wages in private healthcare facilities. Relevant
directions should be issued in this regard.
17. There should be a health worker helpline that is able to provide online or telephonic support
to health workers in both public and private sector, and protect health workers role as
whistle-blowers without putting their jobs at risk. This helpline should register complaints
and grievances and be linked to competent authorities who would be responsible for taking
timely action on these complaints.
18. The waiting list of the UPSC and the SSC should be used as a base to fill vacancies in health
facilities under the central government. The waiting list of the equivalent board or
commission under each state should be used to fill vacancies in facilities under the state
governments. Health workers hired on a short-term contractual basis are a vulnerable
workforce at increased risk of infection. This weakens the risk management process in the
facility and puts the larger public at risk.
19. Central and state governments should/must increase their budgetary allocations for health in
order to cover health workforce-related costs, such as filling up vacancies, regularization of
informal workers including scheme health workers, payment of wages as per the law and
payment of arrears. This increase should be incorporated into subsequent annual budgets.
This will be of long-term benefit for strengthening the public health system in India, and so
we can cope better when the next health crisis hits us.
10
Health workers’ rights in the time of COVID-19
by Jan Swasthya Abhiyan (JSA), All India People's Science Network (AIPSN) and
Public Services International India National Coordination Committee (PSI India NCC)
21 April 2020
Introduction
As of 21 April, the COVID-19 pandemic has infected about 2,482,158 people worldwide and
contributed to 170,470 deaths. In India as on 20 April, the number of people infected with COVID-
19 is 17,656 with 559 deaths. The corona virus Sars-CoV-2 that causes COVID-19 is potent for certain
biological reasons―its structure enables it to latch on to hosts easily, it has a long infection
period, it is infectious even in asymptomatic carriers, and human beings have no immunity to it as
yet. Hence it can spread easily and quickly. A large, sudden influx of patients can put extreme stress
on both the healthcare system in India and on its health workers, as we are currently witnessing in
many countries in Europe and the United States. Health workers are generally at high risk. In Italy
for instance, it has been reported a staggeringly high proportion of all those infected are healthcare
workers. India is witnessing an increasing number of cases of infection among health workers.
The situation is made worse by the fact that COVID-19 has hit India against the backdrop of
a neoliberal assault on healthcare. This assault has meant that public health facilities are in disrepair,
neglected, and overburdened. At the same time, private hospitals and nursing homes have proliferated,
without adequate regulation.
The main rationale for the poorly planned 27-day lockdown and its extension upto 3 May by
many states, with disastrous effects on lakhs of informal and migrant workers, is that it will buy
time for the government to prepare for COVID-19’s likely assault. However, governments’ actions
till now have been both late and inadequate. The current situation is dire. Testing is inadequate,
there is severe scarcity of test kits and the much-publicized antibody-based kits have barely begun
trickling in, more ventilators are needed, and the availability of personal protective equipment
(PPE) is poor and uneven across regions and hospitals. Moreover, the high population density in
slum settlements and bastis in all towns of India makes physical distancing, even in a period of
lockdown, impossible and puts the poor and a very large number of workers at risk of infection.
Additionally, health facilities can become sources of the spread of infection, with three concentric
circles of risk: individual health workers in direct contact with patients; other employees including
fellow-nurses, doctors, and other health workers; and three, the public coming to a hospital.
Recent episodes, such as in Delhi, Mumbai, and Hyderabad have shown that this can occur at any
health facility, not just at COVID-19-identified ones, particularly given that the current Indian testing
and patient management protocol has no provision for testing symptomatic patients without a
contact history and isolating those who are positive but asymptomatic. These patients might have
high infectivity and will be coming into close contact with many healthcare providers without either
patient or health providers knowing. There are also asymptomatic carriers in the public, many of
whom will be seeking care due to co-morbidities. Health workers at the community level, such as
ASHAs, who are deployed either for Covid-19 outreach and community awareness or for routine
community level work such as immunisation, are also facing higher risk of exposure to the virus.
Hence, the rights and protection against risk of health workers on the one hand, and the robustness
of the health system on the other, and the policies with regard to testing, all deeply intersect in the
times of COVID-19.
1
Because health workers are on the frontlines of our response to COVID-19, they face higher
risks of infection, overwork, and stress. Hence, any strategy to fight the pandemic should consider
the rights and protection of health workers, including through the following:
(a) adequate PPE should be provided;
(b) access to testing and treatment needs to be ensured;
(c) health workers should be covered for COVID-19-related sick leave, quarantine and
provided compensation;
(d) workers should be allowed to opt out of performing their work in conditions that puts
them at risk, without risk of losing their jobs;
(e) proper training needs to be provided regarding procedures before workers are deployed;
(f) representatives of health workers need to be actively involved in setting up safeguard
measures in health facilities;
(g) the organization of work in hospitals (such as patient flow in the outpatient wards)
should be such that their risk of exposure to healthcare workers is minimized;
(h) wages and overtime should be paid as per the law without any mandatory or so-called
voluntary cuts;
(i) adequate facilities should be provided across needs such as adequate accommodation,
transportation, child care, and nutritious meals;
(j) measures are urgently required to protect health workers against stigma, violence, discrimination,
and sexual harassment;
(k) existing vacancies need to be filled with a long-term perspective;
The COVID-19 crisis and the effectiveness of health systems response both in India and
globally, clearly underlines the need for healthcare to be in the public sector. The related, broader issues
of health workers’ employment, equal pay for equal work, and rights to occupational health
and safety and better working conditions is central for countries to be able to cope with COVID-19
now. We welcome the broader support and appreciation for the work that health workers are doing
in the forefront in the fight against COVID-19. However, just appreciation and statements of good
intent are not enough. Nor are simply clapping hands and banging plates. We need this support to be
legalized through notifications and legislation by the appropriate authority at varied levels of government:
centre, state, and local bodies. How robust we make the healthcare system and strengthen
all health workers now is central to coping better not just with the present crisis, but how well we
will be able to cope with any health crises in the future.
A precarious health workforce makes the health system more fragile
The continuous underfunding of public healthcare has meant that in public hospitals, due to
budgetary tightening, vacancies of health professionals―from doctors, to nurses to
paramedics―have not been filled. This imposes a heavy workload on the existing staff that was
already hard for them to manage. In many facilities, especially under local bodies and poorer state
governments, professional staff shortages have been dealt with by hiring on short-term contracts or
deploying field staff in hospital settings, such as with ANMs. Health workers who are ‘non-professionals’,
such as ward attendants and housekeeping staff, cleaning and security staff are most often
hired through contractors, at low wages, pathetic working conditions, and too often in violation of
the labour law.
While the private health sector has thrived and expanded, its workforce is highly underpaid,
except for high profile and specialised doctors. Across the country, nurses in private hospitals are, at
2
best, paid around the minimum wage for a skilled worker, and most often below this legal benchmark.
This sets the scale for other staff, who also face the challenge of being hired through a third
party which makes their tenure highly insecure and without social security coverage.
The workforce at the primary level of care provided in health posts and at the community
level are unarguably the most neglected. Field/community health workers, such as the Accredited
Social Health Activists (ASHAs) in rural settings or Community Health Volunteers (CHVs) in
Mumbai, are the largest group of health workers with more than 9 lakh workers in India. They are
denied the status of a worker by the State. ASHAs are told they are ‘volunteer’ activists and not
workers of the health system, thus denied minimum wage and any other rights of a worker under the
law.
As health workers across the health system have been mobilised to respond to the pandemic,
the pre-existing cracks and weaknesses in the system make it all the more fragile. Informal employment
leads to unclear responsibilities towards workers, and has created blind spots in the system.
ASHAs and CHVs have been deployed for case identification without adequate safeguards. Sanitation
and support staff who are contractual are being preferentially deployed as compared to regular
staff, so as to avoid social security obligations in case of their illness. Public hospitals will be at the
centre of the response to the COVID-19 epidemic, but they will have to be reinforced by private facilities,
either through collaboration, or preferably, through requisition by the government. The precariousness
faced by the vast majority of the close to 40 lakh health workers has to be addressed as
a matter of priority as part of health system preparedness that the lockdown is meant to enable.
Previous outbreaks of highly infectious communicable diseases have demonstrated that public
health outcomes are significantly improved when labour rights are respected, and trade unions
are able to effectively represent workers actually exposed and potentially exposed to the disease.
The active involvement of health workers’ representatives in government decision-making is necessary
to safeguard workplace safety and health and ensure the cost of the crisis is not borne by
healthcare personnel.
REQUIRED MEASURES
a) Adequate provisioning of Personal Protective Equipment
Reports coming in from Maharashtra, West Bengal, Tamil Nadu, and Bihar point to uneven availability
of PPE of adequate quality, leading to protests. Workers are worried that raincoats are provided
instead of medical gowns, that eye protection and other equipment has not been provided. Workers
are forced to do risky procedures without proper PPE, or asked to quit if they refuse. This is creating
confusion on stress amongst the health workforce and needs to be urgently addressed.
The guidelines of the government of India - that make recommendations regarding the use of specific
PPE for different categories of workers, including medical masks, gloves, gowns, eye protection,
and footwear and respirators depending on the kinds of patient care - have not been adhered to.
Even the WHO interim guidance of 19 March 2020 on Rational Use of PPE for coronavirus disease
(COVID-19) have not been followed. New guidelines (dated 20 April) acknowledge the risk of
infection by asymptomatic patients who visit a health facility for other health reasons, yet they do
not provide guidance on PPE requirements. We recommend that the Indian government ensures systems
to monitor and enforce strict adherence to adequate guidelines for the use of PPE.
There has been a clear and criminal lack of preparedness and stockpiling, in disregard of WHO
guidelines of 27 February 2020. The Ministry of Health has admitted a shortage of equipment and
supply not meeting rising demand. This is compounded by an inadequate estimate of the size of the
health workforce, which the government estimates at 22 lakh, while it should be closer to 40 lakh1.
1A 2016 estimate suggests that the number of health professionals and para professionals alone (including doctors,
nurses and midwives, dentists, laboratory technicians and paramedics) was close to 25.3 lakh. The latter does not
include health workers such as cleaning staff, ward attendants, ambulance drivers, ASHAs and ANMs, to name a few.
3
Given the uneven nature of PPE availability across regions, we recommended that PPE be sourced
in priority from domestic manufacturers with a long-term view of development of domestic industrial
capability, and supplied to deal with clusters of cases as they occur. This implies that PPE procurement
orders have to be increased to ensure adequate access to all health workers, and PPE be
sent to regions where they are most needed.
The shortage of necessary PPE equipment and the traditional structures of social discrimination in
India could lead to certain categories of workers, such as nurses who are at highest risk, but also
ASHAs, non-permanent/contract workers and cleaners, not being provided adequate PPE. We urge
that the government issue a directive that no such discrimination take place against any worker in
any establishment. Health workers should not be forced to work under unsafe conditions without
adequate protective equipment.
b) Free health care for all health workers
The announcement by the Finance Minister of a special life insurance scheme for health workers is
misleading and insufficient. Despite an announcement that all health workers would be covered, the
package covers health workers in the private sector only if they are drafted for COVID-19
responsibilities. The recent case of health workers getting infected at the private facility Delhi State
Cancer Institute shows that this is insufficient. Further, this is subject to the numbers indicated by
MoHFW. The figure of 22 lakh health workers is a gross underestimation of the actual size of the
workforce in the country, as mentioned earlier. The estimate should be modified correspondingly
and increased to at least 40 lakh health workers and the omission of healthcare workers in the
private sectors needs to be corrected immediately to avoid the possibility of denial of compensation.
Most importantly, this scheme is grossly insufficient as it does not provide any support to health
workers and their families unless the worker dies. In case health workers are infected by COVID-19
they should be given treatment, care and support free of cost. Considering that health workers in
informal employment conditions are more vulnerable as employers can hide behind this informality
to deny their responsibility towards them, it is important that they are given special attention in this
regard. The latest testing protocol (31 March) has expanded testing only to symptomatic health care
workers, whereas there is clear evidence of asymptomatic cases. As current testing protocols are
restrictive, health workers might find that they are compelled to go for testing in private labs, and
incur costs. Failure to detect infections early among healthcare workers may result in further
spreading of the infection. Access to comprehensive and free health care, including outpatient,
hospitalisation, and regular free testing need to be ensured, with special attention to informal
health workers. Special provision of regular testing needs to be ensured for health workers
performing high risk tasks, even if asymptomatic.
c) Special COVID-19 related paid leave and compensation
Health workers are at a higher risk of contracting infectious diseases, which is the case with
COVID-19 as well. Reports estimate close to 100 infections already confirmed in India, though
there is no systematic reporting of this data. As facilities are short-staffed, managements of facilities
are extending working hours. They might try to keep health workers on the job even when they are
already showing COVID-19-like symptoms, as we saw in Mumbai and in Bihar. Workers who have
tested positive with COVID-19 should not be asked to continue with their duties if they are showing
symptoms. This is against protocols and puts the workers at more risk of developing more severe
symptoms if they are not able to rest adequately.
Managements of facilities might also deduct leave taken for sickness or quarantine from existing
leave provisions, and when these are used up, take recourse to cutting workers’ wages. Informal
ASHAs alone are estimated to around 8.5 lakh, ANMs to around 2 lakh. While there is no estimate available for
ancillary health staff, it is safe to presume that at least 2 to 4 lakh, bringing the total number close to 40 lakh/4 million.
4
workers have a limited amount of paid leave that will run out quickly. Those on daily wages do not
even have paid leave. Special paid leave in case of COVID-19-related sickness and quarantine
should be provided, including to workers on short-term contracts and employed through a third
party. A special compensation should also be announced for health workers who contract COVID-
19 in line with the WHO definition that if exposure to corona virus Sars-CoV-2 happens at the
workplace, contracting COVID-19 should be considered an occupational disease.
d) Mental health support and the right to opt out
Health workers undergo considerable stress during emergencies such as the one we are facing.
Counselling and mental health support should be made available for health workers. Breaks and
time-off should be maintained, as healthcare workers' burnout could contribute to both their
catching the virus and its spread. As per WHO guidelines, health workers should not be required to
return to a work situation where there is continuous or serious danger to their life or health. Health
workers' right to opt out of work when they are not provided with a safe working environment and
adequate protective equipment should be respected, without undue consequences.
Health workers who are pregnant, or have co-morbidities have higher chances to contract the
infection and develop more severe symptoms. They should not be put on duty in the COVID-19
ward and limit exposure to patients with suspected COVID-19. Instead, they should be assigned
appropriate tasks within their profession that does not expose them the virus and be accommodated
if they request so.
e) Training on procedures and infection risk management
Managing the risk of infection in health facilities, both in the public and private sectors, is essential
to ensure that health facilities do not themselves become hubs of infection. Part of the risk
management procedure is to ensure that all health workers understand the measures that are needed
to protect themselves, protect patients, and protect the facility. The government should implement or
direct facilities to implement appropriate training for the diversity of workers categories across
levels of risk.
The government needs to put in place online training programmes on infection control with a focus
on COVID-19 for the entire medical workforce in the country, facility-based training for the entire
workforce in each facility, including ASHA and community-based health workers attached to
different health posts. All health workers should be provided with communication materials in
different languages on the appropriate safeguards, including but not limited to PPEs.
The entire staff in all COVID-19 earmarked hospitals, ICU units, and isolation centres should be
given training and this should include both guidelines and protocols for COVID-19 care, as well as
personal safety, infection risk management and the use of personal protective equipment. The
government should provide guidelines for these procedures to be followed in private facilities. A
helpline should be set up for health workers who face challenges at their workplace, with a defined
procedure to register complaints and interventions to resolve them. In case private facilities fail to
follow the government guidelines and resolve issues with regard to adequate safeguard measures,
the state government should consider requisitioning these private facilities in order to avoid the
spread of the disease due to negligence of private operators.
f) Active involvement of representatives of health workers
The government should engage with trade unions of health workers to ensure that the guidelines effectively
reach all concerned health workers. For instance, there is a need for clear information and
training regarding PPE use, disposal, and care. Health worker unions are well positioned to contrib-
5
ute to this process, as they have the organizational ability to reach out to large sections of workers
quickly. Hence, we urge that different state governments involve health worker unions in the process
of information-sharing, training, and workers’ safety. Facility management should facilitate an
active role for health workers' representatives in determining safety measures and safeguards of
their health.
(g) organization of work in hospitals that minimises risk of exposure to healthcare workers
The other part of risk protection is the proper organization of work processes that would limit hospital
infection to patients as well as to (all) health workers. This is a part of most quality accreditation
programmes, such as the national quality assurance standards for public health facilities and
multiple systems for private healthcare facilities. However, only a small proportion of facilities are
registered under these frameworks. One of the reasons why Kerala has reported fewer infections
among workers and less spread of the virus overall is because it has much better level of accreditation
and infection control. The infection control component of the quality accreditation programmes
must be implemented universally across states, including in the private sector, along with a monitoring
mechanism by the government.
h) Wages and extra-time to be remunerated as per the law
As society recognises that health workers are contributing to the common good by standing at the
frontlines of the battle against the COVID-19 outbreak, longstanding violations of legal provisions
with regard to their wages should be acknowledged and addressed. Notifications should be issued
so that wages are provided as per existing government norms, and wage discrimination against
workers in informal employment should be addressed. The current budgets of most municipal
hospitals and state hospitals are too small to provide the legal wages to all workers, which has been
covered up through outsourcing of services such as cleaning and housekeeping.
The central government has formalised the central role of ASHAs in containment and community
outreach, highlighting once again their role as an essential workforce of the state health system. Yet,
the government guideline does not provide an additional budgetary allocation while, of course, all
other tasks are to continue - ante-natal care, vaccination, etc. A paltry Rs 1,000 per month for April
and May is to be paid by states from unspent money. Their contribution in the month of March is
not even acknowledged and, without additional budgetary allocation, most State governments might
not even pay this inadequate incentive. The government pretence that ASHAs are not workers of the
health system amounts to discrimination against an exclusively female workforce that is paid a
fraction of the prevalent minimum wage.
Central and State governments should make the required budgetary allocations to ensure that
ASHAs and other health workers deployed to respond to the emergency situation are provided the
remuneration they deserve, and at least as per the law. Such allocations should be incorporated in
subsequent annual budgets.
As the crisis intensifies, health workers will be asked to provide extra-time on a regular basis. This
extra time needs to be regulated to allow enough time-off to rest and recover. Healthcare workers'
burnout aids the spread of the virus. Breaks and time-off need to be maintained. Extra hours should
also be remunerated as per the law.
It has also been reported that public and private sector hospitals are forcing their staff to contribute
to the government relief fund from their wages, in part of in entirety. Health workers should not be
asked to compulsorily or voluntarily forego their wages in full or partly.
With the exception of specialised doctors, wages in private hospitals and other health facilities in
the private sector are abysmally low. This led to the Supreme Court recommending a wage increase
across the board in the private health sector (2016). The recommendation has largely been un-
6
implemented. In some states, such as in Delhi, the High Court directed the state government to
legislate towards the implementation of the Supreme Court recommendation. Yet, no such steps
have been taken. Considering that health workers in private facilities will also be involved in
responding to the COVID-19 epidemic, state governments should ensure compliance with the
Supreme Court recommendations relating to wages in private healthcare facilities.
Due to the financial crisis that preceded the COVID-19 pandemic many health workers such as
ambulance drivers, but also cleaning staff and ward attendants, had not received their payments for
months. The increased budgetary provision should prioritize payment of such arrears. As the
lockdown requires minimising non-essential activities and some workers have been asked to join
duty on alternate days, including for those working in hospital settings, special attention should be
given so that those working fewer hours because of the lockdown are paid their full salaries, even if
they are hired through manpower agencies, or on short-term contracts and other informal
employment conditions. For instance, safai karamcharis might find it difficult to travel to the
hospital they work in because of the shutdown of public transport. They should be considered on
duty for the full period of the lock-down. Finally, private sector hospitals are threatening to cut
wages in the month of April due to fewer patients and reduced “business” in that period. The
government should actively monitor that wages of health workers are paid. A health worker
helpline linked to both the Ministry of Labour and Ministry of Health should be available for
health-workers to notify non-payment of wages and arrears.
I) Adequate facilities across needs
Health workers working in high-risk areas, such as isolation wards, have to be provided the option
of adequate hostel accommodation so that they can avoid going home where there are old relatives
or young children whose health they are concerned about. They should not be asked to vacate the
hostel once their 14-days shift is over, as they risk to expose their families if they go back home.
Separate restrooms for medical personal in direct contact with COVID-19 patients should be
provided. Some states have taken steps to provide accommodation to doctors in hotels near the
hospitals where their work. There is no justification for the same benefits not being provided to
nurses and paramedics in direct contact with patients.
A large proportion of health workers are women who often face the double burden of housework
and care for their families as well as work outside the house. Adequate provisions should be made
to ease the burden of family care, including by providing options for crèche or childcare outside the
hospital setting. This is essential since regular childcare and schools are shut.
Soap and water should be made available in all facilities for workers and the public as a basic
hygiene measure. Hand sanitizers and detergent should be provided to all health workers on a
regular basis to facilitate personal hygiene.
Transport to the place of work, especially for those who do not have private transport, should be
provided, particularly if the lockdown is extended. There are reports of cleaning staff in cities such
as Delhi not able to join work due to the lockdown and decrease in public transport facilities. This
impacts the smooth functioning of hospitals, as well as creates hardship and stress for the workers
who are worried that their salaries will be cut for the days they are not able to attend work. ASHA
workers are facing similar issues as they have to travel from one house to an other.
Lack of nutritious food compromises immunity and puts health workers at risk of coronavirus.
Adequately nutritious food needs to be made available to health workers at the hospital, through the
public distribution system, or through other effective systems.
j) Stigma, social exclusion, violence and sexual harassment
We have seen during previous virus outbreaks that health workers are at risk of stigma and social
7
exclusion. Even during the current COVID-19 epidemic there are reports of health workers being
asked to leave their rented accommodation. Other reports have surfaced of health workers being
attacked or harassed during tracing of potential COVID-19 cases or during their routine service
delivery. Particularly distressing are reports of healthcare staff who have become victims of
COVID-19 being refused burial or cremation services because of such stigma, when it is well
known that there is little danger of infection from dead bodies. The government should take
appropriate steps to ensure a safe workplace and work environment, including a strong media
campaign to counter stigma of all forms, and appropriate orders to outlaw stigma and
discrimination. A grievance redressal mechanism should be put in place, including internal
complaints committee in case of sexual harassment.
Health workers, including nurses, bringing lapses in treatment and protocols to the attention of the
public or speaking out about their working conditions are being gagged and harassed. Hospital
management and administrators may be stretched but unethical practices cannot be allowed to
persist and health workers’ role as whistle-blowers should be protected.
Health workers also face violence and harassment from the police while travelling to work, or
crossing inter-state barriers to travel from home to their workplace. The government should order
health facilities to provide letters on the appropriate official letterhead to all health workers, with
an order to the local police and administration to allow their travel, so that they are not harassed
by the police and other officials when travelling to work.
k) Filling of vacancies with a perspective of long-term hiring
Existing gaps in human resources vary between states but are generally substantial. According to
information collected through an RTI in 2017, in the facilities under the Delhi government, 14% of
the sanctioned posts of general duty medical officers (GDMO) were vacant (though another 4%
were filled by contractual staff), and 20% of staff nurse posts were vacant (though the large
majority were actually filled by contractual staff). According to reports, in Uttarakhand, 50% of
sanctioned posts for medical officers and 31% for staff nurses are vacant. These vacancies need to
be filled urgently, with a perspective of prioritising long-term hiring. The waiting list of the Union
Public Services Commission (UPSC) and the Staff Selection Commission (SSC) should be used as a
base to fill vacancies in health facilities under the central government. The waiting list of the
equivalent board or commission under each state should be used to fill vacancies in facilities under
the state governments. Kerala has undertaken this process successfully, using online interviews and
video conferencing. More recently, the Government of Tamil Nadu has appointed 530 doctors,
1,000 nurses, and 1,508 lab technicians through this method.
Considering the lockdown and closure of inter-state boarders, the situation might arise where
candidates on UPSC) or SSC lists are not in the state where the post is available. In such cases, a
temporary adjustment between sanctioned posts under the States and the Centre can be considered.
Considering the need for additional staff, those currently employed on contract should be allowed to
continue with their services. However, hiring on a short-term contractual basis or through
manpower agencies should not be seen as an adequate solution for increasing staffing under the
impression that the time saved in hiring provides a considerable advantage. Those employed on
short-term contracts and contracted through third party agencies are at risk of discrimination with
regard to access to personal protective equipment, leave and other safeguards. This increases the
risk of infection of this vulnerable workforce and weakens the risk management process in the
facility ― putting the larger public at risk.
The public expenditure on health as a percentage of GDP for 2017-18 was a mere 1.28%, while
WHO advises for at least 5% of GDP. Increased budgetary allocation for health will be required to
fill existing vacancies and should be incorporated into subsequent annual budgets.
8
In summary, our demands are as follows:
SPECIFIC
1. The Government should provide updated guidelines regarding the rational use of PPE that
also cover non-COVID-19 facilities, facilitate the production and logistics of distribution,
increase PPE procurement orders to ensure adequate access to all health workers, and if
required, intervene in the market to ensure that PPEs are sent to the districts/regions where
they are urgently needed.
2. The government should ensure that guidelines regarding the use of PPE are strictly followed
in both public and private settings, and that there is no discrimination against workers on the
basis of hierarchy, employment status, or other reasons. A monitoring mechanism should be
put in place in order to enforce strict adherence to PPE guidelines in public and private
settings.
3. The government should ensure comprehensive health care free of cost to all health workers,
including outpatient, hospitalisation, and regular testing, with special attention to informal
health workers. Special provision of regular testing needs to be ensured for health workers
performing high risk tasks, even if asymptomatic.
4. The government life insurance scheme should cover all health workers including in private
settings and the estimate of health workers needs to be modified to reflect the real size of the
health workforce in order to avoid denial of compensation in the future.
5. Special paid leave in case of COVID-19-related sickness and quarantine should be provided,
including to workers on short-term contracts and employed through a third party. A special
compensation should also be announced for health workers who contract COVID-19 as an
occupational disease.
6. Health workers who are pregnant, lactating or have co-morbidities should not be put on duty
in the COVID-19 ward. They should be assigned appropriate tasks within their profession
that does not expose them to the risk of COVID-19.
7. Health workers' right to opt out of work when they are not provided with a safe working
environment and adequate protective equipment should be respected.
8. The government should facilitate appropriate training programmes and materials for the
diverse categories of health workers and for the different levels of risk depending on the role
of workers and the role of facilities.
9. Extra hours should be regulated and remunerated as per the law. Breaks and time-off need to
be maintained.
10. Adequate arrangements need to be provided to health workers in high-risk environments,
such as ICUs and isolation wards, including accommodation and separate restrooms.
11. The government should take appropriate steps to ensure a safe workplace and work
environment, protect health workers from harassment by the police and the community,
including a strong media campaign to counter stigma of all forms, and appropriate orders to
outlaw stigma and discrimination. A grievance redressal mechanism should be put in place,
including internal complaints committee in case of sexual harassment.
INSTITUTIONAL
12. Central and State governments should involve health worker unions in the process of
information-sharing, training, and workers’ safety. This will facilitate an effective outreach
to all concerned health workers. Managements should facilitate an active role for health
9
workers' representatives in determining safety measures and safeguards of their health.
13. The infection control component of the government's quality accreditation programmes
must be implemented universally across states, including in the private sector, along with a
monitoring mechanism by the government. In case private facilities fail to follow the
government guidelines and resolve issues with regard to infection control and other
safeguard measures, the state government should consider requisitioning the errant private
facilities.
14. Management of health facilities should make adequate arrangements for health workers at
the facility, including but not limited to options for crèche or child care, transport to the
place of work, an official letter and an order to the local police and administration so that
health workers are not harassed by the police when travelling to work, regular provision of
soap and sanitizer, and adequately nutritious food at the hospital or through other effective
systems.
15. Health workers who are not able to work on a regular basis due to the lockdown or due to
precautionary measures should be considered on duty and paid their full wages. All
governments and private facilities should refrain from asking health workers to
compulsorily or voluntarily forego their wages in full or partly. A health worker helpline
linked to both the Ministry of Labour and Employment and the Ministry of Health and
Family Welfare should be available for health workers to notify non-payment of wages and
arrears.
16. State governments should ensure compliance with the Supreme Court recommendations
relating to the long overdue increase of wages in private healthcare facilities. Relevant
directions should be issued in this regard.
17. There should be a health worker helpline that is able to provide online or telephonic support
to health workers in both public and private sector, and protect health workers role as
whistle-blowers without putting their jobs at risk. This helpline should register complaints
and grievances and be linked to competent authorities who would be responsible for taking
timely action on these complaints.
18. The waiting list of the UPSC and the SSC should be used as a base to fill vacancies in health
facilities under the central government. The waiting list of the equivalent board or
commission under each state should be used to fill vacancies in facilities under the state
governments. Health workers hired on a short-term contractual basis are a vulnerable
workforce at increased risk of infection. This weakens the risk management process in the
facility and puts the larger public at risk.
19. Central and state governments should/must increase their budgetary allocations for health in
order to cover health workforce-related costs, such as filling up vacancies, regularization of
informal workers including scheme health workers, payment of wages as per the law and
payment of arrears. This increase should be incorporated into subsequent annual budgets.
This will be of long-term benefit for strengthening the public health system in India, and so
we can cope better when the next health crisis hits us.
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