Following the brutal rape and murder of a trainee doctor in Kolkata, the issue of violence against healthcare workers has come to the forefront, with medical professionals across India demanding the enactment of a Central law to protect healthcare workers. In 2019, a Bill on this issue was drafted by the Central government, but it never saw the light of day. Can a Central law ensure security for healthcare professionals at work? R.V. Asokan and Shanthi Ravindranath discuss the question in a conversation moderated by C. Maya. Edited excerpts:
Why has violence against healthcare workers been increasing across India?
R.V. Asokan: The violence that the postgraduate trainee doctor experienced (in Kolkata’s R.G. Kar Medical College and Hospital) is obviously very different from what doctors normally face. Generally, when there is an unexpected death, relatives sometimes get violent (with doctors and nurses). We have been seeing such incidents of violence in the last two-three decades. In fact, 25 States have enacted laws (to protect medical professionals), but unfortunately, there are very few convictions. The violence is due to patients’ expectations, high out-of-pocket expenditure, and the lack of proper communication between doctors and patients. It is a complex subject.
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Shanthi Ravindranath: WHO (the World Health Organization) says every country should spend at least 6% of the GDP on health. But few countries are doing this (India spend less than 2%). People need free, easily accessible, proper, and complete treatment. When they reach the hospital, they get angry because they are in distress. Ideally, this anger should be directed against the system. But unfortunately, it is taken out on the doctor who provides the treatment, who is the face of the hospital at that point, and who is in the emergency room. WHO also says violence against healthcare workers at the global level is 8%-38%. We need to increase GDP spending on health and strengthen the public health system so that people are provided proper treatment when they go to a hospital. This will help check such cases of violence.
Could better infrastructure and additional security measures in hospitals help?
Shanthi Ravindranath: Most hospitals, especially government ones and medical colleges, use interns, postgraduate medical students, and super speciality students to run the show. As the main healthcare force, these people are made to work continuously for long hours. They are emotionally exploited and verbally abused at work. So, we have to improve the healthcare system not just by improving infrastructure, but also by ensuring that doctors’ working hours are restricted to eight hours a day. Postgraduate students are there to learn and work, not to replace doctors who should be treating the patients. Recently, NMC (National Medical Commission) published a study which said that a majority of postgraduate students are suffering from mental health issues. This point should also be considered.
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R.V. Asokan: The issues of patient-related violence can be brought down by improving communication (between doctors and patients), ensuring safety measures, and placing a security protocol in all hospitals, especially medical college hospitals. NMC has already come out with an advisory for medical colleges (emphasising the need for each medical college to develop and implement a comprehensive policy to enhance the safety of students and healthcare professionals within the campus and hospital premises). This can be really helpful.
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Shanthi Ravindranath: I also want to add that every hospital should have a hospital protection committee to check all aspects of hospital security. There should be CCTV cameras and security personnel, who should be accountable for the safety and security of all the people working in the hospital, especially healthcare workers.
In 2019, the Centre had drafted a Bill titled ‘The Healthcare Service Personnel and Clinical Establishments (Prohibition of violence and damage to property) Bill, 2019’. However, the Centre took the stand that existing State and Central laws provide adequate legal protection for our health workforce and that all that we require in addition is the beefing up of security in hospitals. Do we need a Central Act to protect healthcare workers from violence?
R.V. Asokan: We don’t understand what the Central government is trying to tell us, because it was the Ministry of Health which had signed the office memorandum with the IMA (Indian Medical Association) in 2017 saying it will explore the possibility of a Central Act (to protect healthcare workers from violence). Had the government not known then that health as well as law and order are State subjects? If yes, why did it sign this?
In 2019, under the same Health Minister, the three Ministries of Home, Law, and Health drafted this Bill. I was part of the committee which drafted it. A lot of consultations were held before the Bill was drafted, but the Bill did not go to the Cabinet. Why did they lead us down the garden path?
R.V. Asokan: Now, the government is saying that it is not possible (to bring in legislation). During the COVID-19 pandemic, when there was large-scale violence against doctors in Hyderabad, the IMA had declared a ‘white alert’. We said that we would protest by lighting candles. The next day, the Union Home Minister met with the IMA at 11 a.m. and by noon, the ‘white alert’ was withdrawn. At 4 p.m. the same day, the ordinance to bring amendments to the Epidemic Diseases Act, 1897, was produced, which was subsequently ratified by Parliament. Why was that done? So, now, suddenly, how are they all saying a Central law is not possible?
The Supreme Court has now set up a national task force to look into the issue of the safety of healthcare workers. How does the IMA view this development?
R.V. Asokan: We welcome it. The Supreme Court is the one institution acceptable across party lines, religious lines, and professions. It has got so much credibility and respect and we will work with the task force. But if you go through the Supreme Court order, it is all about the safety , security, and working conditions (of healthcare workers). It does not talk about a deterrent law. What if there a violence? What will be the next step? Or are the existing laws adequate? Yes, there are 25 State laws, but where are the convictions? In my understanding, there was only one conviction last year in Tamil Nadu while there are hundreds of cases. In Kerala, since the law was made stringent following the murder of Vandana Das in 2023, the incidence of violence has come down. There were a few instances of violence and the State acted quickly. Kerala has also enacted a Code of Grey Protocol. We have asked the government to adapt this Protocol of the Kerala government too.
Shanthi Ravindranath: We need a Central Act but at the same time, a Central Act should not take away the rights of the State and that of the patients. A law can help in reducing the incidence of violence against healthcare workers, but policymakers should also examine why these incidents are happening. It is the responsibility of the government to see to it that the expectations of a poor patient who comes to the hospital, of free, fair, and total health care, are met. The public health system should be strengthened and out-of-pocket expenditure should be reduced.
Why do you think the Centre went back on its earlier intent of enacting a Central law?
R.V. Asokan: The government seems to have a problem acknowledging that there is violence against healthcare professionals in India. But the reality is for everybody to see. If you look at the issue of violence, corporate hospitals are much safer because of the security arrangements. It is mainly government hospitals and small and medium hospitals in the private sector which are exposed to this violence.
There is no dearth of laws in the country. Kerala framed legislation to prevent violence against healthcare workers in 2012, but it was not enough. While seeking a new law, what are the implementation challenges you expect?
R.V. Asokan: The 2012 Kerala law did not have teeth. The Rules were framed later. The law was not backed by the Indian Penal Code (now called the Bharatiya Nyaya Sanhita) or the Code of Criminal Procedure (now called the Bharatiya Nagarik Suraksha Sanhita). The police had no idea that such a law had come into existence. We had to show them there was indeed an Act to take cognisance of the violence against hospitals and healthcare workers. The Vandana Das murder changed things. Today, Kerala has a very strong law. At least in four or five instances of violence, after this law was framed, the police acted swiftly. So, a deterrent law which is implemented by the police on the ground and is understood by the public is very useful.
R.V. Asokan is national president of the Indian Medical Association; Shanthi Ravindranath, doctor-activist, is Secretary, Doctors’ Association for Social Equality
