Kerala Nurses, Minimum Wages, Fair Working Conditions

I would like to share my thoughts on current happenings around salaries and working conditions of nurses in Kerala. Though in this article I am mainly focusing on this subject, this is closely tied with few other topics of wider range. I have given links for such related articles, if you get a chance kindly go through them as well to understand my overall views.

Current scenario in brief

While many nurses feel that they are underpaid and also ill-treated in some private hospitals, many private hospital owners feel that it is unfair to say that they are just making profit without empathizing with hardworking nurses or other staff. Some say the agitations by nurses are politically motivated, and some say this was bound to happen anytime.

Few days back Balaraman Commission report (I don’t have a copy of this report yet, just got a chance to see excerpts in some websites) came and recommended a salary to nurses which is around three fold compared to that directed by Kerala Minimum Wages Act 2009 for Hospitals (sorry, this is available only in Malayalam, thanks to hyper Malayalam love of Kerala government).

Some view this as a justice that finally came to the rescue of struggling nurses and some view this as a death blow on entire Kerala healthcare system that is already fragile, especially in rural areas.

Nurses are equally important as doctors

Enough has already been talked about the overall healthcare sector and doctors, lets take a look at nurses as well. It wouldn’t be incorrect to say that they are the backbone of healthcare system (while doctors are brains?). In hospitals, they attend to the patients round the clock and take care of them. They may not be highly skilled, but they definitely have skills that are vital. They spend more time with patients when compared to doctors and play an important role in the patient’s physical and mental well being and recovery. Hence, if such class of people are ill-treated and dissatisfied, obviously it will affect the society as a whole.

Do nurses get at least minimum wages in Kerala?

Kerala government conducted inspection on private hospitals through Labour Departments and in Jan 2012 they published reports about gross violations in implementation of Minimum Wages Act and a few other Acts. I don’t have the link to the report at the moment, but here is a related news item:

http://expressbuzz.com/topic/gross-violation-of-norms-detected-in-hospitals/354089.html

On first look it appears as if private hospital owners are grossly insensitive towards their staff and are very greedy. However, as always, the story has multiple sides. In the defense of hospitals, the first and foremost thing I would like to say is that more than the greed, it was concern towards patients that made many hospital owners not hike staff salaries readily. They tried to do a balancing act and tried not to burden patients with a huge bill. That said, probably greed also played some role, I think.

Agreed that Kerala Minimum Wages Act 2009 for Hospitals probably had some flaws, and that’s why QPMPA went to court against it (I didn’t get a chance to study the case in detail yet). But meanwhile did all the hospitals collectively try to define an alternative (and better) framework and pay such minimum wages to the staff? I don't think any such formal effort has happened. At least no such thing has been implemented. That level of unity and will is lacking among hospital owners as well. Cost of various essential things was insanely increasing in last 2-3 years and yet (I believe) some hospitals maintained lower salaries just on the basis that there is a pending case against the Minimum Wages Act. I don't think it was fair thing to do.

Again, in defense of hospitals, I must say that some hospitals did go ahead and try to implement salary scale as per the Minimum Wages Act or something close to it; those are the institutions where management really empathizes with staff and has a trend of revising salaries time to time.

Another point to note here: I think its a well known fact that doctors' salaries have increased tremendously in last few years. Did all hospitals collectively voice against such trend and try not to pass on the burden to patients? I don't think so. This was accepted as an inevitable thing and a portion of burden was transferred to patients and remaining was taken up by hospital owners. What was the reason behind this? Was it simply driven by demand and supply equation? Or is it because most hospital owners were deep inside softer towards doctors they themselves being doctors? In any case, in this process nurses and other hospital staff were left out with pretty much same old salaries in many hospitals.

With respect to publishing the report, Kerala government also behaved somewhat hastily, I think. It is really good that they conducted extensive survey through Labor Departments and came up with a report on who is paying as per Minimum Wages Act and who is not. However, they hardly gave a chance to hospitals to correct the data wherever it was wrong initially, thus making the report more authentic and genuine. Did they fear that the data will be manipulated later or was it not done simply due to lack of thoughtful planning and resources? At least I can (unofficially) speak on behalf of our hospital that there was a clerical mistake due to which we got a poor score unnecessarily in spite of being quite fair towards employees overall. Also, most of the mismatch came due to DA differences and we have a perfectly acceptable explanation for the same, which is also an usual business practice that is widely carried across even today in many industries – the practice is to set DA once a year whereas labour officer considered monthly variations. This aspect was not at all considered by government while preparing the report.

Moreover, the categorization by government was a binary one – whether you are giving minimum wages or not, that’s it. There was no credit for employers who genuinely cared to pay the minimum wages, and perhaps missed few things due to different interpretations of the Act. If you go through the Act, you will realize that it is confusing at some places and various scenarios are not at all explained. I have seen even the experts in field keep debating over these interpretations. Then why only hospitals are shown under bad light for not following the Act? Is government also not responsible for passing a half baked Act?

As I see, the Act has quite many flaws and to read more about it, here is link to a separate article: Flaws in Minimum Wages Act 2009 for Hospitals in Kerala

In short, I am quite convinced that the compliance/violation report published by government is incorrect; but without knowing to what extent it is erroneous, it is hard to say what the right statistics is i.e. how many hospitals were really paying minimum wages, how many were at least near the magical mark, how many were grossly underpaying and also how many were overpaying.

I do sympathize with nurses and all other hospital staff wherever they are severely underpaid and are exploited. At the same time I am satisfied and proud to work in an institute where employees are treated quite well overall, and I am sure there are many such institutes overall.

Salaries specified under Minimum Wages for nurses – is it fair?

As I said above, I really think that Kerala Minimum Wages Act 2009 for Hospitals is a half baked one and is open for interpretations in many scenarios. That brings another important question – are the salaries recommended/specified in that Act fair?

I personally don’t think the wages specified in the Act are fair towards Nurses. I don’t think their skill level was recognized properly while drafting the Act. I have given more details about this in another related article: Flaws in Minimum Wages Act 2009 for Hospitals.

I wonder what were nurses doing at that time when the above said Act was drafted and being discussed! At least they woke up now, but are they going towards another extreme? A point to ponder upon.

Though some hospital owners in urban areas did feel the need to increase salaries beyond the specified levels in Minimum Wages Act, they were cautious as such a thing has to be done along with handshaking with other hospitals around and also it could not be done without burdening patients too much. However, some of the staff did get much better salaries when compared to minimum wages, and again there was no credit given to hospitals in the government report for such things. (I should admit that partial credit goes to simple dynamics of demand and supply too.)

In any case, I definitely think that there should be some scientific restructuring with respect to salary guidelines for hospitals in such a way that people should be paid higher for higher skilled work.

Violation of other Acts by hospitals hurting employee interests

Apparently the government report that came in Jan 2012 also talks about extra allowances not being paid for working on holidays, violations with respect to working hours, bad working conditions of the staff and so on. How true this really is?

With due respect to nurses who are truly suffering, I feel some of these problems are highlighted in exaggerated fashion just to get more bargaining power. You ask for more, bargain and settle for something in between – this is the standard mantra in India, isn’t it? So, why not exaggerate poor working conditions and at least get a pay hike? Maybe that’s the strategy, or maybe there are genuine and grave issues at some places.

I am quite confident that most hospitals wouldn’t have deliberately tried to deteriorate any staff’s working condition, but some of the hospitals might have tried to grow bit aggressively in spite of infrastructure/cost limitations and some workers might have felt that there is no proper focus on betterment of their working conditions. Or maybe with changing times certain facilities that were earlier perceived to be okay are no longer acceptable for current generation workers. I believe a more thorough study needs to be done on this and this should not be clubbed with the wage debate.

Challenges faced by hospitals with respect to nursing staff

Agreed that nurses have to be paid better in some cases and given better overall working conditions; but while debating about employer’s duty, it is also important to understand the problems they face for the particular labour force in focus. Recently human resource management has become tougher and trickier than ever in private hospitals, and nurses are no exception.

Lack of sufficient and quality workforce

As I understand,

-          A good portion of nurses go abroad for better salaries leaving Indian healthcare sector handicapped.

-          Quality of the nurses who come out with degrees from some other states is observed to be very bad in several cases – how do they get degrees without proper skill or education? Is Kerala government focusing on that point and pushing other state governments to conduct investigations?

-          It is observed that many young nurses no longer feel passion in serving the patients – maybe a reflection of the general indifference and lack of sensitivity in current generation can be clearly seen in young nurses too. Some senior nurses themselves agree and acknowledge this trend.

Many hospitals tried to solve some of the issues by starting Nursing Education Institutes (Diploma/Degree) themselves. But unfortunately more than appreciation and support, such hospitals had to face several critical issues. For ex: even a reasonable expectation that nurses should mandatorily work in the institute for a minimum period after getting their certificates was seen as illegal, whereas personally I really don’t see anything immoral in such strategy under the given circumstances. That was clearly not the case of exploitation, but was a practical balancing act in the best interest of everyone.

Government’s Role: Government cannot simply lay down guidelines that unreasonably affects a well running sector and let it collapse. It has responsibility in many ways to help such sector to sustain and grow in organic fashion.

In the current scenario, has government ensured that there is enough and quality workforce in market when it comes to nurses? Is it absolutely immoral if private hospitals try to do their best and serve people (and also do business) with whatever workforce is available even if they sometimes lack formal degrees or skill? Instead should they simply stop their work and let government face the heat and come up with the solution? How should private hospitals face tremendous and constant pressure from patient community for healthcare services?

So, when there is a lack in supply of qualified and quality workforce, how can a hospital ensure that everything is done in ideal fashion? Government should answer this question and nurses also should keep this in mind while fighting for their rights.

Other challenges related to private hospitals

So far we talked about a focused topic i.e. problems that are nurses facing in the private hospitals and problems faced by private hospitals due to nurses. But there are many other aspects to private hospitals – things they do right and wrong, challenges faced by them etc. Some thought on this is covered in a separate article:

Challenges faced by Private Hospitals in Kerala

What is a solution?

Any discussion of an issue without a solution recommendation becomes useless. I think there can be a variety of solutions for the problems stated above and my thoughts on the same is detailed in a separate article:

Solutions for problems in private hospitals in Kerala (Coming Soon)

About me

Here is a brief note about myself to give you some perspective about my writings related to Kerala healthcare sector. I am neither a doctor myself, nor a healthcare professional of any kind, I acknowledge that my knowledge is limited in this area. I am further limited by language problem being a native Kannadiga in Kerala and many related communication by government getting published only in Malayalam.

However, these days I am actively involved in management of a private hospital where my father is a partner. I have worked in depth to ensure that salaries of all the staff are paid at least equal to or greater than minimum wages specified; having around 9 years of employment history myself, I am quite passionate in this area. During this process, I got an opportunity to hear opinions of many staff and also a chance to study their incomes/hikes from various perspectives, and also impact of the same on the institute’s profitability/survival. I have also been participating in some of the QPMPA discussions and learning things. This entire experience is an ongoing learning process and I am just sharing my current thoughts here.

With respect to this particular article, you can also view this as voice of a common man who is looking at the entire happening wondering what might be in store for himself or his family/friends in future when they become patients themselves and visit a private hospital.

I hope you have found this article thought provoking and some suggestions worth considering.

Disclaimer: The views expressed here are purely mine and do not reflect views of owners/partners/staff of the hospital where I am currently working; certain facts that I have stated is as per my best understanding but cannot be taken as official data. The intent behind this article is to provoke further thinking towards greater good with respect to healthcare field and definitely not to hurt anyone’s sentiments or create imbalance of any kind. Also, I humbly accept that this topic has a history and is multifaceted, and hence I may have missed or incorrectly written some points out of genuine lack of knowledge; kindly pardon me for the same and feel free to bring such things to my notice so that I get a chance to stand corrected.