As nurses leave in droves, Indian hospitals get a backache

The biggest of her problems is the lack of money. She slogs more than 12 hours a day, six days a week, yet only earns about ₹20,000 a month, more than half of which goes into repaying the loan she took to study nursing in a private college.

Jose’s day starts with checking the inventory and the handover of patient data from nurses in the previous shift. Then she proceeds to accompany the doctors on their rounds. Every day, the hospital handles about 10 deliveries and discharges, for which she must prepare the documentation. By then, it’ll be lunchtime, but sometimes she skips lunch to indent medicines for patients so she can leave soon after her shift.

But often, there are emergencies. Like a mother seeing blood in her breast milk, or a baby in the neonatal ICU developing a fever, or a child running around the corridor getting burned by hot water. And despite all that the nurses do to keep the hospital running smoothly, she said she has never received a word of thanks from the hospital staff or patients. Worse, she’s dismayed by the indignity meted out at times. She was threatened with physical assault just recently, by the father of a patient.

When she finally makes it to her hot and uncomfortable hostel room, she can’t afford to rest. Night hours are the only time she gets to study for the Occupational English Test, which healthcare professionals need to clear to land a job abroad—which she believes is the only way to escape her reality. She is inspired by her seniors in college who have moved abroad, who earn, she claims, about ₹30 lakh per annum.

“I come from a poor family, my father is an auto-rickshaw driver. I took up nursing because everybody said it’ll be easier to get a job after graduation. But I don’t want to live like this," she said.

An unlikely powerhouse

Jose is one of tens of thousands of nurses moving abroad, which renders the already moth-eaten Indian medical system even worse.

According to India’s ministry of health and family welfare, India has about 3.6 million registered nurses. According to the Indian Nursing Council (INC), an autonomous body under the ministry, established to enforce a uniform standard of training for nurses, India has 1.96 nurses for every 1,000 Indians, much below the World Health Organization (WHO) recommended 3 nurses per 1,000.

Numbers from other estimates can vary slightly, but they all point to the shortage crippling Indian healthcare services. “At nine physicians and 24 nursing personnel per 10,000 people, India trails the global median of 17 physicians and 39 nursing personnel. On this parameter, India lags behind Brazil (23 physicians, 74 nurses) and Malaysia (15 physicians, 35 nurses)," the 2021 draft red herring prospectus (DRHP) filed by Global Health Ltd (Medanta), a multi-specialty tertiary care provider, stated.

Historically, Kerala has produced the highest number of nurses in the country. According to the ministry, in 2022, Kerala had the second highest workforce of registered nurses and midwives (329,492), marginally behind Tamil Nadu (348,538).

But the numbers don’t reflect the states the nurses actually belong to.

Most states and Union territories which have a relatively high nurse-patient ratio—like Tamil Nadu, Karnataka, and Andhra Pradesh—have a significant number of nurses from Kerala. In fact, according to the management of various colleges, a chunk of students in nursing colleges in states such as Karnataka and Tamil Nadu are from Kerala, who find it increasingly difficult to get admission closer home because of the rigorous entrance exam.

In the global healthcare landscape, Kerala has emerged as an unlikely powerhouse.

The roots of this phenomenon trace back to the mid-20th century, when the Indian government, in collaboration with the WHO, launched an ambitious campaign to address the acute shortage of healthcare professionals, particularly nurses, in the aftermath of World War II.

With its strong tradition of education and high literacy rates, Kerala became fertile ground for nurturing a skilled nursing workforce. The state’s progressive social policies, including investments in education and healthcare, laid the groundwork for a robust healthcare infrastructure. Additionally, the region’s deep-rooted tradition of migration, spurred by economic opportunities both within India and abroad, played a pivotal role in shaping Kerala’s nursing diaspora.

Mass Exodus

As the demand for nurses surged globally in an ageing and post-pandemic world, Kerala seized the opportunity to export its most valuable human capital. The migration of nurses from Kerala as well as the rest of India has reached unprecedented levels, said Shoby Joseph, president of the Kerala-based United Nurses Association (UNA), considered the biggest association of nursing professionals in India. This has created a public health crisis in hospitals across the country.

According to UNA data, about 20,000 nurses graduate every year in Kerala, but more than 36,000 nurses leave the country. This is because even nurses from other states are choosing to exit through Kerala as the state has a robust ecosystem in place to assist them, said Joseph.

“We have to realize that this is a big health crisis," said Joseph. “A crisis created not because we don’t have enough nurses, but because we are doing a bad job retaining them," he said.

“The US and several European countries have an acute shortage of nurses, and they have reduced their eligibility requirements from three years of work experience to just one year. This has been a boon for many," explained Joseph.

It’s no surprise that today India is the biggest supplier of nurses to the UK—in 2022–2023, the number of Indian nurses overtook the number of Filipino professionals.

India-trained nurses and midwives rose from 17,032 in March 2016 to 55,429 as of September 2023, according to the UK-based Nursing and Midwifery Council, a regulatory body. Filipino nurses numbered 47,569 as of September 2023.

Indian nurses have also become a favourite of the US, where about 100,000 American nurses have quit due to burnout during the pandemic, the UNA said. Indian nurses are also placed in the UAE and other middle eastern nations.

Crisis at home

The relentless workload, financial burden, and limited career prospects that Jose spoke of was echoed by other nurses grappling with the harsh realities of their profession. While this sheds light on one aspect of the nursing crisis, the other story is the toll it is taking on quality medical treatment, underscoring the urgent need for systemic reforms to ensure the sustainability and resilience of healthcare systems.

A recent analysis by The Economic Times of IPO documents filed by hospital chains in the past two years reveals about 50% attrition among nursing staff, on average. The analysis showed far higher attrition rates for nurses compared with doctors and other professionals in several hospitals. In its DRHP, Mumbai-based Jupiter Hospital had reported 32% attrition among nurses in fiscal 2022; Global Health (Medanta) reported an attrition rate of 51% for the same year, while Yatharth Hospital reported 74% attrition in fiscal 2023.

Narayana Hrudayalaya, in its annual report for fiscal 2021-22, has said that Indian hospitals struggle with nurse attrition rates of 50 to 75%, and called it the greatest stumbling block for delivering healthcare. No service industry with this level of attrition can function without compromising on quality and patient safety, the report added.

How are hospitals dealing with such a dire situation? As experienced nurses leave, the burden falls on inexperienced trainees, leading to quality problems in patient care, and safety issues. A top official at one of India’s biggest private hospitals admitted that medication errors do happen because of the shortage of nurses.

“Hospitals are struggling to retain experienced nurses. Since most of them leave, and the rest are not well-trained, there’s no way to say with absolute surety how carefully they are doing the job. Errors can happen in a variety of ways. They can happen in the operation theatre when a wrong instrument is given to the doctor, they can delay procedures such as surgeries. The shortage affects every aspect of quality," the person said, requesting anonymity.

Within public hospitals which largely cater to the poor, the situation is worse, said a nurse who has 30 years of experience and is only a few months away from retirement.

“Take the case of Malappuram in Kerala. There are 72 institutions which can offer in-patient care. But since there is a shortage of nurses, only 24 are actually providing in-patient care. Mind you, Kerala is one of the better states (when it comes to healthcare). So you can imagine what’s happening with the rest of the country," the nurse added, requesting anonymity.

M. I. Sahadulla, the founder of Kerala-based KIMS Hospital, also shared the grim realities of the nursing shortage. Private equity firm Blackstone recently invested in KIMS through Care Hospitals, another south India-based hospital group, creating one of India’s biggest hospital chains, worth over a billion dollars.

With approximately 900 nurses and an attrition rate of 40 to 50%, Sahadulla said he has started offering sweeteners to retain experienced nurses, like giving jobs to their partners. The group has also reopened a nursing school that was shut down some 15 years ago owing to a lack of students.

Sahadulla said the problem extends beyond financial remuneration, and includes burnout, lack of upward mobility, and the strain on healthcare systems worldwide. “It calls for urgent reforms in nursing education, employment practices, and healthcare funding,’’ he added.

Regulations don’t allow more than 100 seats per nursing institute, which is inadequate, and there’s not enough oversight over subpar training and recruitment, he said.

“Doctors were also going away like this in the past, but today, they are staying back since they are getting paid a lot. Nurses’ salaries are not competitive, not only in government jobs, but also in the private sector. Besides, the government is not hiring much at all. The private sector is the one which is expanding. The government has introduced a minimum wage, which major corporate hospitals follow, but many private hospitals do not," said Sahadulla.

But even with minimum pay, why are the starting salaries of nurses languishing between ₹15,000 and ₹25,000 per month, and not on a par with global standards? Why can’t corporate hospitals pay nurses better?

“Hospitals are manpower-heavy. So, when the manpower cost increases substantially, the viability of the business becomes almost nil. Naturally, healthcare costs need to rise, which will become a socio-political problem," Sahadulla explained.

In the US, for example, they are much better paid, he asserted. “But their quality is also good, because they’re well trained. And then they stay put. The patient-nurse ratio is also less," he said.

Plus, consumer bills are largely covered by insurance in developed economies, whereas people mostly pay from their pocket in India, he added. “We are still in the evolutionary phase of insurance. People are paying very little for healthcare in the private sector. At the same time, they’re asking us to pay high salaries to the nurses. It doesn’t work,’’ he emphasized.

The central government appears keen to set things right. The 2023-24 budget had announced the establishment of 157 nursing colleges under a centrally sponsored scheme.

But it may take a few years to align India’s demand for nurses with the supply.