Sharad Kendre graduated from a nursing college in Maharashtra’s Latur district eight years ago. But he is still waiting for an opportunity to use his skills, even as the coronavirus pandemic strains the state’s public health systems and forces health workers employed in hospitals to work long hours without a break.

It has been over two years since Kendre applied for a government job.

Maharashtra government’s Directorate of Health Services had announced in February 2019 that it was going to conduct recruitment exams to fill more than 1,500 vacancies for staff nurses and specialist nurses in public hospitals across the state.

Such recruitment drives are not frequent. Like thousands of qualified nurses across Maharashtra, Kendre responded to the advertisement. Since he had a postgraduate degree, he filled up the application form in the specialist nurse category and waited for the exam dates to be announced.

But the exams were not held for two years.

On February 28 this year, when 30,000 nursing graduates finally sat for the exams, Maharashtra had already spent almost a year grappling with the Covid-19 pandemic. The virus had killed over 52,000 people in the state, overwhelmed hospitals and exposed the severe shortage of doctors, nurses and other healthcare workers that has always ailed India’s public health systems.

In March, by the time the results of the nursing exams were announced, Maharashtra had become the epicentre of the second wave of Covid-19, far more infectious and deadly than the first. With new virus mutations spreading fast in smaller towns and cities, prompt recruitment of additional nurses in public hospitals would have been the logical thing to do.

“But even now, specialist nurses like me have not yet been recruited anywhere,” said Kendre, who is among the top-three rank-holders of the exam.

Even graduate nurses who applied for staff nurse positions were recruited to various hospitals just days ago, on May 4. “I don’t know why they were not given appointments in March or April, when Covid cases were very high and hospitals needed staff.”

Officials from Maharashtra’s Directorate of Health Services did not answer phone calls or respond to’s email queries about the delays in conducting the nursing exam and recruiting nurses on the ground.

Sharad Kendre, a nurse from Latur, Maharashtra. Photo courtesy: Sharad Kend

A year of Covid-19

The recruitment delays are hardly surprising in a country that allocated just 0.34% of its GDP towards healthcare in the middle of a pandemic.

Despite warnings from public health experts, over the past year, both central and state governments have failed to expand India’s healthcare capacities, whether vital infrastructure like oxygen plants and ventilators, or its health workforce.

Since June 2020, the Central government claims it has hired 2,206 specialist doctors, 4,685 medical officers and 25,593 staff nurses in public hospitals across the country, through recruitments under the National Health Mission.

But these recruitments have fallen short of the level the country needs.

The Bihar Health Services Association, for instance, claims that nearly 30% to 40% of the posts for doctors and paramedical workers are still lying vacant in the state. The staff shortage has had fatal consequences for Covid-19 patients, who died gasping for air despite the presence of brand new ventilators in district hospitals, simply because there was no trained staff to operate the machines.

As the second wave of Covid-19 forces Indians to scramble for hospital beds, oxygen, medicines and even crematorium slots, public hospitals are scrambling to hire doctors, nurses and other medical workers. But in most cases, the jobs on offer are temporary fixes: short-term contracts with few benefits or safety nets despite the high-risk nature of the work.

On April 24, Bihar chief minister Nitish Kumar directed health officials to complete the pending recruitment of health workers. Bihar is not the only state which is waking up late to recruitments.

In Gujarat, civic hospitals are conducting walk-in interviews for hundreds of medical post vacancies that are yet to be filled. The Surat Civil Hospital, for instance, held interviews for the posts of 400 nurses, 20 specialist doctors and 600 Class-4 health workers as recently as last month. But only 10 nurses, four doctors and 50 Class-4 health workers showed up for the interviews, according to a report in Divya Bhaskar. Questions emailed by to Surat Civil Hospital asking about the lukewarm response to its recruitment drive went unanswered.

But Gujarat nursing union leader Vipulsinh Chavda had an explanation for it. There was no dearth of qualified professionals in the state, he said, but “people don’t want these jobs because they are all offered on a three-month contract basis”.

“Before Covid, at least they would offer five-year contracts to nurses in many places,” said Chavda, the president of the All Gujarat Nursing Union. “But now they just want people for a few months, till Covid lasts. Why would someone want such a job, with so many risks?”

At Mumbai’s five new Covid-19 centres established this year, nurses are being recruited on one-month contracts, which may keep getting extended as per need. “Many nurses would probably prefer unemployment instead of such an insecure job,” said Jibin TC, the state president of United Nurses Association.

Insecure jobs

The risk of working on short-term contracts in a pandemic is evident from the experience of Neel Patel, a 25-year-old nurse who works at Ahmedabad Civil Hospital.

Patel has had Covid-19 twice since the start of the pandemic. Both times, he was mildly symptomatic and was allowed two weeks of home quarantine before he had to plunge back into eight to 12-hour shifts at Ahmedabad Civil Hospital.

If he had been sicker and needed hospitalisation, he would not have been covered by any employee insurance scheme, because Patel has been hired on an 11-month contract.

His contract has been renewed twice since he began work at the public hospital two years ago, but his wages have not increased beyond Rs 13,600 a month, and Patel has no idea when he will be given a permanent job. His daily duties, however, are no different from the nurses with permanent employment who work alongside him.

“Right now in the Covid ICU wards, we have one nurse handling 16 patients at a time, so we are always on our feet running from one bed to another,” said Patel, who alternates between Covid and non-Covid wards every fortnight.

Every day, his work involves handling intravenous drips and oxygen masks, monitoring treatment, taking blood samples, giving status updates on each patient to the hospital control room every four hours and much more.

“It is difficult to take a break even for drinking water, because removing and wearing the PPE can take 15-20 minutes each time,” he said.

Because of staff shortage across various wings of the hospital where every bed is full, Patel and his colleagues regularly make heart-wrenching choices in Covid-19 wards.

“When multiple patients get serious at the same time, we cannot attend to all of them, so we choose to prioritise younger patients, those who are the only bread-winners of their family,” said Patel. “We try our best, but sometimes it is too late.”

A nurse administering oxygen supply to a coronavirus patient in Bengaluru. Photo: PTI

Leaning on students

On May 3, after the second wave had already claimed over 60,000 Indians in the span of one month, Prime Minister Narendra Modi announced “key decisions to boost the availability of medical personnel to fight Covid-19”. These decisions include postponing postgraduate medical exams to free up MBBS graduates for Covid duties and engaging final-year medical and nursing students in full-time Covid work.

Many states have already started deploying students for Covid duties, often for a pittance. On Monday, for instance, Himachal Pradesh offered monthly incentives of just Rs 3,000 for medical students and Rs 1,500 for nursing students working in Covid wards in the state’s public hospitals.

In Gujarat, second and final-year nursing students have been put to work since April 8, with a promised monthly stipend of Rs 12,000. “Last year because of Covid we had only online theory classes, so we have been told our Covid duty will be considered as our practical classes,” said Dhaval Parmar, 20, a second-year nursing student from Vadodara who is currently working in a Covid-19 testing camp with other students.

Parmar is happy to be contributing in the fight against the pandemic, but is aware that his college or the state authorities are not taking any responsibility for his safety at work. “When I started this work, I had to bring a signed letter from my father giving me permission to do the Covid duty and stating that I will take all precautions while working.”

While the services of students like Parmar could help ease the burden on overwhelmed hospitals, the Centre’s announcement on May 3 acknowledged that there are still vacant posts for doctors, nurses and allied professionals in the country. These are to be filled through an “accelerated process within 45 days through contractual appointments”.

According to public health experts and nursing unions, however, this approach of offering contractual rather than permanent jobs is one of the main reasons for the shortage of health workers across India.

Contract culture

In Gujarat, for instance, civic hospitals typically employ 50% of their nurses as the rest as contractual workers, says Chavda, president of a nursing union.

A staff nurse with a permanent job is paid better wages: Rs 31,000 a month, compared to Rs 21,000 or less paid to contractual workers. “Permanent staff get insurance, provident funds and other benefits that contract workers don’t get,” he said.

In Maharashtra, United Nurses Association’s state president Jibin TC points to an even wider gap between the pay scales of permanent and contract-based nurses: around Rs 55,000 for the former, and between Rs 20,000 and Rs 23,000 for the latter.

“This is why the governments here and in other states prefer not to hire permanent staff,” said Jibin TC, who believes this is the reason behind the two-year delay in Maharashtra’s recruitment exams for nurses. “The exams were for permanent positions, and they would rather get nurses and other staff on contract. These days the contracts on offer are very short – one month, three months, eleven months.”

In Ahmedabad, the civil hospital created more than 500 new vacancies for nurses at the end of March. “But so far, they have hired barely 30 nurses,” said Neel Patel, the nurse who works there.

‘We are exhausted’

The stalled recruitments have meant more exhaustion for nurses working at the frontlines.

Riddhi Rane is a senior nurse at KEM Hospital, one of Mumbai’s largest civic hospitals, attracting low-income patients from across Maharashtra. Here, the shortage of health workers has always been accompanied by an acute shortage of general infrastructure, which Rane describes in chilling terms.

“Before the pandemic, nurses were overworked because we had two or three patients per bed, and up to 120 patients in each ward,” said Rane. “Last year when Covid started, it got worse because even patients with mild symptoms used to rush to the hospital. But this year we are following Covid norms and restricting admissions to just one patient per bed. So things are more manageable for us.”

Nurses leave at the end of their shift at King Edward Memorial (KEM) hospital in Mumbai. Photo: Indranil Mukherjee/AFP

In Chhattisgarh, however, the second Covid wave has been anything but manageable for nurses like Debushree Saw. At the Chhattisgarh Institute of Medical Sciences in Bilaspur where she works, there are 300 nurses working in shifts to handle 700 beds. For the past few weeks, the beds have been full and a large number of nurses have caught the virus themselves.

“Right now, each nurse has to handle two or three wards at a time,” said Saw, the state president of the nursing union Chhattisgarh Paricharika Karmachari Kalyan Sangh. “We are exhausted and mentally distressed, but if we don’t do our duty, then hospitals will not run. And then who will look after patients?”

Saw’s union has spent the past six years urging the state government to increase the number of staff positions for nurses in state and district hospitals, primary health centres and community health centres. “But the government is simply not expanding recruitment, neither for permanent jobs nor on contract,” said Saw.

A policy of austerity

This shortage is being felt despite an abundance of trained nurses.

In 2019, the Chhattisgarh health department and the World Health Organisation conducted a “health labour market analysis” and found that the state had 25,000 to 27,000 qualified and registered nurses – an “oversupply” in relation to the number of nursing jobs available.

Even though there were 3,000 vacancies for staff nurses in public hospitals at the time, only 20% of available nurses had been recruited. Another 20-30% were recruited in private hospitals, while the rest were either unemployed or had left the market pool of job seekers in the state.

The report recommended conducting regular, annual recruitment drives for nurses, increasing salaries of contractual nurses and ensuring that contract workers were offered permanent positions after a period of time.

Since the report was published, the state government has, in fact, filled in many of the sanctioned staff nurse posts in the state. “More than 1,000 posts were filled through the State Disaster Relief Fund for Covid, hiring nurses on three-month contracts and then extending them,” said Sulakshana Nandi, a researcher on human resources for health and the state convener of Chhattisgarh’s Public Health Resource Network.

“But this is still inadequate if both Covid and non-Covid services are to run properly as per need,” said Nandi. For now, the state has suspended most non-Covid health services and diverted nurses from community and primary health centres to Covid centres.

“In all, Chhattisgarh needs around 1,500 to 2,000 more nurses, and there are enough trained nurses in the state to recruit from,” said Nandi. “But the failure to recruit stems from the idea of austerity in public spending towards welfare and human resources.”

This austerity, according to public health expert T Sundararaman, has been an intentional government policy for years. “There has been a certain commitment to keeping public health services understaffed. The general philosophy is to do the bare minimum and leave the rest to the markets, without quite understanding that everything is essential,” said Sundararaman, the global coordinator of the People’s Health Movement and one of the many health experts who had urged the Centre to fill healthcare workers’ vacancies at the start of the pandemic last year.

“This is the problem. Even when there is a clear requirement pointed out, the government’s policy has been to keep jobs at a minimum and make do with contractual staff,” he said. “It is a way of avoiding the social security benefits that come with permanent employment.”