Ending violence against healthcare workers in India: A bill for a billion

In the recent article, Kharel discussed the Nepal Government's historic passing of an ordinance to protect healthcare workers (HCWs) and health institutions from the growing violence as observed in the pandemic.¹ Nepal has set a precedent for legal action on violence against HCWs (VAHCW) in other countries in the region, including India.

The World Health Organization has defined workplace violence in the health sector as incidents where staff is abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health.² From 2007 to 2019, India has seen 153 reported incidents of violent assaults against HCWs. This number, while underreported, is still atypically high for a country that is not in a conflict zone.^3,4 Our active ongoing surveillance of VAHCW in India with Insecurity Insight (II)⁵ has yielded 225 incidents in 2020 and 110 events in 2021 ranging from grassroots level workers to junior doctors in the hospitals. We also found that patients, relatives, and affiliated third parties are the perpetrators in most cases. The rise of violent cases in 2020 has been attributed to the COVID-19 pandemic.

The publicly available II data reveals that from 2016 to date, India saw a total of 220 reported VAHCW incidents contributing to 3.4% of the global incidents,⁶ though India contributes to less than 1% of the global HCWs.⁷ India had a rate of 3 VAHCW incidents per 10000 HCWs (based on health workforce counts for 2019),⁷ which was five times greater than the global rate. Among South Asian countries, India had the second most number of incidents and second highest rate after Afghanistan, which is considered a conflict zone. Nepal had a much lower rate (<1 incident per 10000 HCWs) compared to India, yet it recently passed the ordinance for protection of HCWs.¹ The VAHCW incidents rate in India was 57 and 850 times greater than that in UK and China - countries that have taken legal action against violence.¹ While the numbers are not comprehensive and should be cautiously compared across countries due to limitations in data collection, reporting channels, and context, they certainly point to the problem of VAHCW in India.

On April 22, 2020, India enforced a central act, the Epidemic Diseases (Amendment) Act (2020) which recognized any violence against healthcare service personnel as a cognizable and non-bailable offence.⁸ Under this Act, the perpetrators of violence would be imprisoned for 3 months to 5 years and fined 50,000- 2,00,000 INR. However, it is an inadequate and temporary solution to a systemic issue as it would be dissolved once the pandemic is declared over leaving this accreting problem unsolved.

The Ministry of Health and Family Welfare (MoHFW) has proposed a central bill titled ‘The Healthcare Service Personnel and Clinical Establishments (Prohibition of violence and damage to property) Bill (2019)’ with a clear definition of violence against healthcare personnel, health workplace, and health workforce, which is ill-defined in the Epidemic Diseases Act.⁹ This Bill proposes imprisonment for 6 months to 7 years with a fine of 50,000- 5,00,000 INR and in case of grievous injury, while the punishment would be for 3-10 years and with a penalty of 2,00,000-10,00,000 INR. In addition to punishment, the convicted person is liable to pay for damages in cases of vandalism and reparation of 1,00,000 INR for hurt and 5,00,000 INR for grievous hurt to the HCW victim. Most importantly, the Bill was framed and finalized through democratic engagement, seeking public suggestions, and hence has greater societal acceptability. However, it was rejected by the Ministry of Home Affairs stating that passing the Bill would set an improper precedent for other fraternities to demand exclusive protections based on their profession.¹⁰

There are state laws in twenty-five Indian states and union territories (UTs) called the Medicare Service Persons And Medicare Service Institutions (Prevention of violence and damage or loss to property) Act, 2008 that punishes perpetrators of violence against HCWs.¹¹ In most states with this Act, VAHCW is a cognizable and non-bailable offense with a fine of 50,000 INR and 3 years imprisonment. Other states and UTs have adopted different versions of this Act with varying levels of stringency.¹² Four states and five UTs lack any kind of law against VAHCW.¹¹ However, this Act lacks awareness among the police, which impacts its enforceability.¹³ For instance, according to a Right to Information petition filed by the Medicos Legal Action Group, Chandigarh asking police superintendents of Punjab and Haryana about the perpetrators punished under the Medicare Act found that not a single person was booked from 2010 to 2015, which was in stark contrast to the number of known violent incidents for these states.¹⁴ Therefore, existing state laws are weak in their implementation, vary a lot, and lack scope to protect all HCW cadres.

The medical fraternity wants to create a safe environment for all HCWs. Increasing incidents of VAHCW have resulted in multiple strikes since 2013, often led by trainees, residents, and young HCWs, in multiple places including Delhi, Maharashtra, and Uttar Pradesh.³ In 2018-19, 10 states had multiple strikes in response to bureaucratic and judicial inaction to incidents of violence against HCWs.¹⁵ Activists have also adopted the legal route such as filing a Criminal Public Interest Litigation (PIL) in the High Court of Judicature in Bombay, Maharashtra to improve the state's Medicare Act.¹⁶ In the affidavit submitted by the petitioner, the number of incidents taper throughout the cascade of legal action from the reports of VAHCW to conviction of perpetrators.¹⁷ In 2019, in the state of Maharashtra, out of 157 violent incidents, only 77 were reported, 71 were charge-sheeted, only two were decided, and none of them were convicted. The petition has argued that this pattern has continued through the years in the state. The PIL mentions several precedents and requests the High Court to exercise its power to make extensive changes in the Maharashtra Medicare Service Act such as: a) clearly defining workplaces and services, b) exhaustively enlisting healthcare personnel to be protected under the law, c) including different forms of damages including mental harassment and economic damages, d) introducing graded penalties fitting the severity of crimes and severe punishments for repeat offenders, and e) making vandals pay compensation for property damage. Setting up a distress helpline, creating a platform for HCWs to lodge complaints and conducting security audits of hospitals could be additional steps to mitigate damages due to VAHCW.

VAHCW is an urgent problem requiring attention from all societal stakeholders. It is not just a medical fraternity issue. It weakens the health system and affects the quality of services provided to patients, in turn, leading to more chances of violence. The key to breaking away from this vicious cycle is pushing for immediate zero-tolerance policies.

Contributors

Both authors contributed equally to the manuscript.

Data sharing statement

Data presented in this article are taken from publicly available courses. Links to the sources are provided in the references.

Declaration of interests

None.