The crisis within a crisis

2020 was the year we all dealt with uncertainty. The business world is constantly grappling with the unprecedented change and impact caused by the COVID-19. It is not just the trade and commerce industry, one of the most severely impacted sectors during Covid is the Healthcare sector.

With a remarkable recovery rate of 97.33% till February 2021, the workers in the healthcare sector emerged as our heroes. From showering rose petals to lightning diyas, we paid due respect to our frontline warriors in whichever way possible. But one question that jostles everyone is that why our warriors went on strike during the pandemic, why our heroes were unpaid for the thankless jobs they did?

Remember, doctors can’t earn their bread and butter with the diyas you light or the petals you shower!

Let’s check the financial health of our doctors and other healthcare workers.

During the pandemic, doctors went on a strike for non-payment of wages for three months and that too in the national capital, i.e., Delhi. Glimpses of the financial health of doctors and healthcare workers during the pandemic can be described as follows:

• Doctors of Kasturba Hospital threatened to go on a strike because the salary was not credited in the accounts of more than 3000 workers. Same was the case at many hospitals under North MCD.
• In Mumbai, India’s coronavirus hotspot, doctors working in civic body-run hospitals have got between a 30% - 50% pay cut.
• The Kerala government had moved an ordinance for a salary cut of all the employees including doctors and healthcare staff working in the state-run hospitals and clinics. According to the ordinance, an amount equivalent to a month’s salary will be mandatorily deducted from the employee’s account over a period of five months.
• The situation was no worse in the private hospitals. With drop-in the patient footfall, the lockdown further impacted the private health sector and resulted in job losses, pay cuts, or deferred salaries for doctors, nurses, and other medical staff. There was a 90 percent drop in OPD consultation. Consultant doctors who see patients at different hospitals are also facing the pinch.

Nothing could be more alarming than the country’s apex court to intervene to ensure that the doctors and the healthcare workers at the forefront of the mammoth coronavirus battle are paid their salaries, without any dues, with time. After due hearing of a plea by doctor Arushi Jain, The Supreme Court of India passed the following judgment:

“In war, you don’t make soldiers unhappy. Travel the extra mile and channel some extra money to address their grievances. Country cannot afford to have dissatisfied soldiers in this war which is being fought against corona”

There was a glimmer of hope that the pandemic would finally shift focus and attention to the healthcare sector, but all that has gone in vain. Instead, the loopholes of the healthcare sector started surfacing.

Another problem that came into the limelight was the difficulty faced by the Accredited Social Health Activists – or ASHA workers who are government recognized health workers who are usually the first point of contact in rural India, where it is often limited or no direct access to healthcare facilities.

More than one million of India’s ASHA workers went on a strike to demand job recognition, better pay, and proper protective gear. Enlisted under the 2005 national programme to boost healthcare services across rural India, ASHA workers worked for an average monthly wage of Rs 4,000 with a 33% hike in their basic salary. Labour economists and campaigners said ASHA workers were still hugely underpaid for their duties and earned about half as much as farmworkers employed under government job schemes. This amount signifies indignity to the workers who risk their lives to work for the wellbeing of others.

As per the All India Coordination Committee of ASHA Workers, there is no proper structure of one clear payment structure for the whole country. Many low-paid workers were working all round the clock when millions of migrant workers returned to villages from cities post-lockdown, and hence the reward that they get was no salary and pay cut at the end of the month.

Asha workers have emerged as the backbone of primary healthcare in India, yet the payment records for 195 workers in Maharashtra seen by the Thomson Reuters Foundation showed average earnings of 4,156 rupees in July – with an increase of 60 rupees from February despite the 1,000 rupees wage hike that was implemented in March. These workers are paid monthly honorariums – Rs 3,000 to Anganwadi workers in mini Anganwadi Centres, Rs 4,500 to Anganwadi workers, Rs 2,250 to Anganwadi helpers, and a minimum of Rs 2,000 to ASHAs. Further, performance-linked incentives of Rs 250 per month are paid to Anganwadi helpers, while conditional incentives allowed ASHAs to earn additional Rs. 1500- 2000 per month on an average, with state-level variations. But the only way that allowed the government to underpay their care workers to such an extent was through categorizing the women involved neither as government employees nor as contractual workers, but only as volunteers.

Too often, we overlook the heroism and dignity of millions of low-paid, undervalued, and essential health workers. The policy recommendations in this report aim to keep these workers safe on the job, compensate them with a living wage, support them if they fall ill, and give them the respect and appreciation they deserve.

Let’s not forget that doctors and healthcare workers cannot earn their bread and butter by banging utensils and showering petals.

Now, the question arises that what are the steps taken by the government to lessen the pain of our warriors who were already under stress and fighting for our safety during the entire pandemic?

The government approved Rs 50 lakh insurance cover for ninety (90) days to a total of around 22.12 lakh frontline health workers, on 29th March 2021. The medical insurance scheme would include sanitation staff, doctors, Asha workers, paramedics, and nurses. These professionals are not considering their own health risks and have been attending to Coronavirus patients

Some of the other measures taken by the respective state governments are as follows:

• West Bengal Government hiked the salary of healthcare workers by 44%-95% from Rs 3,125 to Rs 4,500 a month. Similarly, the honorarium for first-tier supervisors (FTS) has been increased 94.72 percent to Rs 6,500 a month from Rs 3,338. Terminal benefits for both categories have been hiked to Rs 3 lakh.
• Sharda Hospital in Noida has started an incentive scheme for 225 paramedical staff working in Covid wards by giving Rs 500 to nurses and Rs 300 to general duty attendants (GDA) including ward boys, technicians, junior assistants, as well as junior nurses per day over and above their salaries.

The Canadian government offered a hike in the salaries of healthcare workers even during the pandemic where the authorities faced a severe financial crunch. Similar efforts and steps have to be adopted by governments and authorities across the country as such gestures not only ensure financial support but also help to increase the morale and spirits of doctors during the toughest of times.

Clearly, the steps taken by the government are not enough to lessen the bad financial health that the healthcare workers are going through.

What could be done?

The answer to this lies in some of the simple strategies that government could adopt to increase the remuneration of our warriors:

The first step is to quickly assess the level and structure of health worker compensation to quantify the number of additional wages that should be paid. Health facility staff consists of frontline medical staff (doctors, nurses, community health workers) as well as non-medical administrative and support staff. According to the World Bank data, in many countries the total gross wages of health workers will consist of:

• Basic salary. This is based on pay grades in civil service pay laws or wage legislation for public health workers.
• Overtime allowance or compensation for overtime work. This is usually in the form of a percentage of basic pay for additional hours worked beyond what is normally specified.
• Hazard allowance or harmful work conditions allowance. These will be allowances as a percentage of pay for working conditions that are considered risky to the individual.
• Other allowances. These typically factor in seniority, additional training, or educational qualifications, as well as working in rural areas or remote locations.
• Performance pay. These are additional payments conditional on either inputs (e.g., working hours), outputs (e.g., patients treated), or outcomes (e.g., patient satisfaction).
• Per diems or salary supplements. These are usually for attending workshops or training and can be a significant (more than 10 percent) proportion of gross wages.

The following considerations should guide the design of additional remuneration for health workers:

• Legitimate: Governments need to clearly communicate the purpose of the salary increase and the categories of workers who are eligible. Given that all workers in a health facility are likely to be working extra hours and taking additional risks, the simplest criteria would be to include all health workers (medical and non-medical staff) in all facilities in the COVID hotspots. For fiscal reasons, governments may want to exclude non-medical staff; but this can breed resentment and disharmony within facilities. 
• Temporary: The supplemental pay should be a temporary “special allowance” that is authorized by a government decree, and it should be removed when the crisis ends. It should be a fixed nominal amount (instead of a percentage of pay) so that it is easy to administer and given to all health workers in designated localities. Governments should avoid changes to basic pay specified in the public sector salary legislation of the country, as these are likely to become permanent. The supplementary wages should be authorized on a monthly or quarterly basis, to provide governments with flexibility to adjust the amounts as the crisis evolves. 
• Easy to verify: Given that government capacity is stretched to the limits, any salary increases that require costly verification should be avoided. This criterion rules out performance incentives, as these require independent verification of the increased or improved inputs, outputs, or outcomes that condition the incentive. 
• Equitable: The pre-crisis wage structures are often inequitable and not transparent in many World Bank client countries. Often medical workers with similar skills and experience earn significantly different wages based on idiosyncratic factors that are difficult to justify. Doctors also often earn significantly more than nurses. The supplemental pay should try to reduce these pre-crisis inequities in wages to the extent possible. One way would be to provide lump-sum payments to health workers, rather than as a percentage of pay. These would be easier to administer as well as more progressive. The exact amount of the supplement would need to be based on data, but a good rule of thumb is that it should be a minimum of 20 percent of gross wages. However, the amount would have to be determined by the available fiscal space.

As uncertainty due to COVID-19 continues and employers try to respond to this unprecedented human crisis, they must also plan to recover and more importantly restore in the new normal. These measures could act as a guide to the government to consider the most undermined issue of these times, i.e., the compensation of the employees in the healthcare sector. The government should take appropriate measures, apart from part-time incentives or bonuses or providing insurance cover, to concretely building a systematic pay structure for the healthcare workers. More equitable pay, support, and better working conditions should be provided to the low-paid essential care workers like ASHAs and Anganwadi workers and helpers. In the end, I would like to state few lines from the book written by Mr. Milan Kundera – “Book of Laughter and Forgetting”(1979) -

“All of us are prisoners of a rigid conception of what is important and what is not, and so we fasten our anxious gaze on the important, while from a hiding place behind our backs, the unimportant wages its guerrilla war, which will end in surreptitiously changing the world and pouncing on us by surprise.”