In 2006, 20-year-old Malarvizhi* walked into a Primary Health Centre (PHC) in Villupuram district as a sanitary worker after being roped in through the village panchayat. Three years later, she, along with many women like her, was brought under the ambit of the Reproductive and Child Health (RCH) scheme, and their monthly pay was hiked from ₹500 to ₹1,000. Today, she and 3,100-odd sanitary workers continue to work for 12 hours a day, with no weekly offs, no maternity leave and benefits, for a pay of merely ₹1,500 a month.
While joining the Tamil Nadu public health sector in 2015, little did Bharathi* know that her career path would be paved with struggles and protests. A staff nurse, she was recruited through the Medical Services Recruitment Board (MRB) for a pay of ₹7,700 a month. After a series of protests, the first in 2017, her salary rose to ₹14,000. Another struggle for ‘equal pay for equal work’ got her a 30% increment in 2020.
C. Venkatakrishnan was among the first 16 dentists to be recruited to work at PHCs in 2004. Starting with a daily honorarium of ₹500, it took almost 12 years for him to get a consolidated pay of ₹20,000 a month. After numerous struggles, the 48-year-old secretary of the Tamil Nadu Primary Health Centre Dental Surgeons Association, along with 384 of his colleagues, has been receiving a salary of ₹34,000 a month since 2021.
Even as Malarvizhi, Bharathi and Venkatakrishnan are hoping against hope that their services will be regularised, hundreds of contractual staff, especially those recruited for COVID-19 management, saw their hopes come crashing down on March 31, 2022, when the Health Department terminated their services. The services of about 1,820 medical officers and 1,420 multipurpose health workers, who were initially recruited for ‘Amma mini clinics’ and later roped in for COVID-19 management, and 800-odd nurses, who were appointed tide over the COVID-19 crisis, were terminated.
Contractual recruitments are not new for the health sector. But in the last few years, there have been numerous protests from the contract workers demanding regularisation of services and a better pay. While officials feel that contract employees take up the work knowing very well the conditions and temporary nature of the job and it is close to impossible to regularise the services of all of them, workers flag certain concerns, most importantly the poor pay.
“In Tamil Nadu’s Health Department, contractual appointments started for the first time in 2004 when doctors were recruited for a salary of ₹8,000 when the old pension scheme was scrapped. After repeated protests by various government doctors’ associations, contractual recruitments were withheld for doctors for the next 15 years. It was re-introduced during the pandemic and for the Amma mini clinic scheme. In the meantime, it slowly started for the other cadre during the financial year 2006-2007. The contractual recruitments were intensified by the National Health Mission,” an official source said.
G.R. Ravindranath, general secretary, Doctors Association for Social Equality, pointed out that there were no contractual recruitments before 1990. “It was the World Bank, while dictating policies as part of its investment in the public health system, that called for temporary employees on the basis of contract and outsourcing methods. The advent of the National Rural Health Mission brought in more contract staff across segments that included doctors and nurses. Today, we have outsourced security and housekeeping services. These are jobs that come with no socio-economic security, no job security and zero benefits on a hire-and-fire basis. In the long run, this will help privatisation of the public health system,” he said.
An analysis has shown that the quality of healthcare service was better with regular employees, he added. “Contractual appointments are against social justice. Social justice is not only reservation in education but also fulfilment of economic equality. The contract system needs to be abolished,” he said. One point of view is that the quality of work dropped because of lack of commitment, especially when they are not paid adequately.
Making contractual recruitments during times such as COVID-19 is something unavoidable, said K. Senthil, president of Tamil Nadu Government Doctors Association. “But even in such cases, persons who have worked for a stipulated period should be given priority, incentive marks for consideration in future recruitments. We have always been against contractual appointments to regular vacancies of doctors. However, contractual appointments in the lower cadre (the non-technical cadre) is inevitable. They should be granted a decent pay and prioritised for regular appointments after completing five or 10 years.”
P. Saminathan, president, Service Doctors and Post Graduates Association, observed that contractual appointments were against the basic tenets of reservation. “It also prevents the movement of doctors, who are already working in primary and secondary healthcare institutions in rural areas, to the tertiary care centres,” he said.
Not an equal world
For a long time, ‘equal pay for equal work’ has been the battle cry of the contract staff. “I do the same work as a regular staff nurse. I have the same duty roster and shift system. But unlike us, a grade II nurse gets ₹36,000. During afternoon and night shifts, one nurse manages a floor with 60-70 patients. But we do not complain about the workload. In seven years, the services of only 3,500 nurses have been regularised. The process has been too slow,” Bharathi pointed out. They work with zero benefits, no maternity leave or medical leave.
“A number of nurses who were pregnant and lactating struggled but worked during COVID-19. But does anybody care?” she asked.
Before being recruited for the mini clinic scheme for a pay of ₹60,000, 28-year-old Karthik Kumar* worked in a private clinic for a salary of ₹35,000. He had cleared the MRB exam in 2018 but scored low marks. “So, when this opportunity beckoned, I attended the interview amid objections from my family. Many of us worked for eight months in the first wave of COVID-19, followed by another seven to eight months in the second wave. We were posted for all kinds of duties — at block PHCs, mobile fever camps, vaccination and deliveries — and also filled in for regular doctors. There was a hope that our work during the pandemic will be recognised. But at the end, none of our pleas for job security was considered,” he said.
With ₹1,500 a month, catering to the basic needs of her family is close to impossible for Malarvizhi. Her husband is an agricultural labourer and the couple cannot afford to send their eldest daughter to college. “I have completed 15 years as a sanitary worker and all that I need is an increase in salary, whether or not the government is willing to regularise our services,” she added. “We have no weekly offs. We request the doctor or staff nurse for leave, if needed. In fact, there is no official attendance registry for us, nor do we have uniforms.”
The wait has been long for Dr. Venkatakrishnan. “Till now, the Department hasn’t told us to stay or leave. Officials keep telling us that they will fulfill our demand, but there is a reason every time — no funds, low performance and so on. We were recruited on a six-month contract through the State Health Society in 2004. We have struggled at every juncture to get equal rights and equal pay. The only hope is that one day, we will be made permanent,” he said.
Problems aplenty
About 7,243 nurses were recruited through the MRB in 2015 on contract, and they are working in government hospitals, medical college hospitals and PHCs. This was followed by the recruitment of about 1,788 nurses in 2016, 800 in 2018 and 1,725 nurses in 2019. “Of about 11,500 nurses, 8,000 are currently working on a contract basis,” said N. Subin, general secretary of MRB Nurses Empowerment Association.
When recruiting nurses, the Health Department appoints them on contract and they are absorbed into the time pay scale after two years. There is no direct permanent recruitment for nurses, he explained.
“Currently, the nurses selected through MRB are working on a contract basis under NHM. As of now, the services of only about 3,000 nurses were regularised, and for the rest, it remains a distant dream, unless the government comes out with a strong policy decision in support of nurses and midwives,” he said.
About 4,800 nurses recruited in 2015 and 2016 have not been made permanent for non-availability of vacancies in government hospitals for six to seven years, he said, adding: “The strength of regular staff nurses remains stagnant in the State. The number of medical colleges and the number of beds have increased. We still have a situation in which one nurse will have to take care of patients in three wards,” Mr. Subin said. The government should create new posts for nurse as per the Indian Public Health Standards and create permanent posts in PHCs so that all contract nurses can be absorbed, he added.
There is another set of contract nurses. In 2020, the Department recruited nearly 3,200 nurses for managing COVID-19 from the MRB reserve list for a salary of ₹14,000. While 2,472 of them were retained, the services of 818 candidates were terminated, S. Rajesh, general secretary, MRB COVID-19 Nurses Association, said. “A total of 804 posts, including 420 upcoming retirement posts and 275 grade-II promotion posts, will be available soon. All of us should be regularised,” he demanded.
Impact on health sector
The latest to join the bandwagon of contractual/temporary staff are Women Health Volunteers (WHVs) and Mid-Level Health Providers (MLHPs). While MLHPs are paid around ₹10,000, WHVs are given an incentive of ₹4,500. “This low pay and lack of timely disbursal of salary has led to high attrition rates, especially among those working in urban areas,” an official source said.
Lack of interest among employees reduces performance and lack of ownership leads to compromise in public service, he said, adding, “We have recurrent expenditures on capacity-building and a high attrition rate among contractual employees. There is no career growth for contractual employees, including increase in dearness allowance as recommended by the pay commissions. They also face a lot of mental pressure of being on a static salary for decades. There is no pay and employment protection for the contract staff.”
A number of association representatives pointed to Chief Minister M.K. Stalin’s promise in the DMK’s election manifesto (point number 356) that all contractual doctors and nurses would be made permanent.
An official said it was always advisable to have a long-term appointment in the health system to ensure retention of knowledge and experience. “In many cases, it is not a one-time contact with the health system for the family but it is continuous engagement with our field workers, sometimes even for generations. In an emergency situation for a short time, for filling up gaps in the existing staff position, we can hire on contract. Over a period of time, it is always advisable to have recruitment by following procedures, including communal rotations,” he said.
He further added, “We need to understand that temporary appointments will not be made permanent. In fact, it is the written agreement that it is purely temporary and will not be made permanent. However, this does present an ethical challenge where we need to give some consideration to persons working on a temporary basis while recruiting for permanent posts. At the same time, it should not affect the recruitment where everyone should be given an equal opportunity to get into the government system.”
Health Minister Ma. Subramanian said his aim was to do away with contract recruitments in the future. To ascertain the exact number of contractual workers in the State, a directorate-wise list was sought.
“We cannot make contractual staff permanent, and they join knowing that condition. For instance, doctors recruited for mini clinics for a year came in with a condition that they cannot seek regularisation. Still, considering their work during the pandemic, we decided to give them priority while filling up vacant posts through the MRB by awarding marks. We had already prioritised persons who worked during the pandemic while recruiting for 7,200-odd posts for the Makkalai Thedi Maruthuvam scheme. Hundreds of nurses and health inspectors, who were granted 20 marks on a priority basis, have joined the scheme,” he said.
The Minister said no reservation policy was followed while making contractual appointments earlier. “This cannot be the case. So, we have clearly stated that even for a small number of vacant posts, it should be through MRB.” Regarding better pay, he said contractual staff of NHM were given a 30% increment. “We are taking measures to regularise the services as per legal provisions,” he said.
(*Names changed on request)
