In Who Cares? Care Extraction and the Struggles of Indian Health Workers, editors Maya John and Christa Wichterich bring together a collection of essays exploring the extraction and undervaluation of labour in healthcare, specifically within the Indian context. This book is an urgent examination of how precarity and hierarchisation are baked into healthcare labour markets, and the detrimental consequences this has for nurses and other care workers, writes Tine Hanrieder.
This post was originally published on the LSE International Development Blog.
Who Cares? Care Extraction and the Struggles of Indian Health Workers. Maya John and Christa Wichterich (eds.). Zubaan Books. 2023
India is now the most populous country, and its health services are nowhere near keeping up with growing needs. The workers – mostly women – who provide badly needed healthcare work, are celebrated as heroes supporting the country through nightmares such as Covid-19. But most health workers are struggling, exploited, burning out in precarious jobs, or not even recognised as workers. And, as the editors of Who Cares? Care Extraction and the Struggles of Indian Health Workers explain in their introduction, while the nurse-to-patient ratio is far too low in Indian hospitals – averaging 1:40 in general wards compared to the World Health Organisation standard of 1:4 – migration to high-income countries is often the best option for nurses who need to repay student loans and support their families, and who hope to find decent work abroad.
Whoever wants to understand these dynamics and the many facets of healthcare work in India will find a highly rewarding read in the volume edited by Christa Wichterich and Maya John. It offers rich empirical material and a plethora of insights into an increasingly privatised and enormously stratified healthcare system which reproduces the exploitation and division of health workers and intersects with social, regional, gender, caste, and class inequalities.
The book is divided into a substantive introduction detailing healthcare economies and nurses’ labour struggles in India and two main empirical parts. Part I analyses different aspects of nursing in India. Part II focuses on migrant nurses in Europe and the Gulf. This second part also includes first-person life stories of migrant nurses, and a photo essay about South Indian nurses who migrated to Germany in the 1960s. These voices and visuals powerfully illustrate the complexity of migrant nurse experiences. While the devaluation of healthcare work is a worldwide phenomenon, it is also contextual. As this volume makes plain, Indian healthcare workers’ struggles are deeply intertwined with patriarchy, casteism, classism, and the privatisation of health services in the country. Furthermore, the experiences of Indian health workers are far from uniform: they are extremely segmented and stratified. Not only does India have an extreme pay gap of over 80 percent between doctors and nurses (compared to South Africa: 55; Argentina: 38; and Germany: 12 percent), but also the differences between categories of nurses and care workers are drastic.
This is amply demonstrated in the chapters from Part I by Panchali Ray (on nurses and nursing aides in Kolkata), Sneha Makkad (on fragmented unionisation in Punjab), Maya John (on educational hierarchies and segmented labour markets in India), and Christa Wichterich (on Covid-19 and the political economy of digitalisation). The most privileged and fortunate nurses can access highly competitive, subsidised education and tend to fill the coveted (well-paid and secure) jobs in public hospitals. It helps if you can afford private coaching to achieve this status.
But most nurses – usually those from lower classes and castes – are not that lucky. They enter the profession through private nursing education (accruing debt through student loans) and tend to work in poorly paid private sector jobs. Furthermore, a major workforce of unlicensed nurses, who are trained on the job but are denied any decent work or career progression, make up the invisible bulk of the nursing workforce. For the lower rungs, nursing work is marked by harsh conditions such as lack of access to toilets, not receiving their meagre wage on time, disrespect and sexual violence, and a massive, even violent repression of labour struggles and unionisation attempts.
And at the bottom of the pyramid, one finds again state-employed workers, however, they are not recognised as workers and thus lack labour protection. These are the ‘voluntary’ health workers such as Accredited Social Health Activists (ASHAs), Anganwadi workers and helpers and other workers deployed in government schemes. As Seemi Zafar’s chapter on ASHAs explains, their main income usually comes through piece-rate incentives. Perversely, this meant that during the Covid-19 lockdowns, when ASHAs were sent to the frontlines without protection and celebrated as national heroes, their net income decreased because they could not provide many of the standard services they are usually paid for. While ASHA workers’ protests and struggles have made headlines and led to several small wins, they are still not recognised as workers.
One important implication of this workforce fragmentation is the limited power to unite. Levels of unionisation are much greater for the higher rungs, and different categories of workers have different unions, who are divided rather than enabled to fight together. Furthermore, as John observes borrowing from Bhattacharya and Behal, labour organising is often ‘vernacular’, ie, grounded in caste or community allegiances rather than occupation. This complicates the prospects of organising for better recognition of health work.
While migration as an option and solution to domestic exploitation and student debts comes up across Part I as well, Part II shows in depth the ambivalence of nurse migration from India. The chapters by Margaret Walton-Roberts and S. Irudaya Rajan, Ester Gallo, Urmila Goal, Tanja Ahlin and Philomina Chakkalakkal, and first-hand accounts from nurses illuminate how migration can empower women nurses and support their families, but also involves huge sacrifices and deskilling along the way. The chance to migrate is often the only hope for better work, and these prospects also attract an increasing share of men to the nursing profession. Yet the journey, often a step-migration journey moving up the ladder from less to more attractive states or passing through exploitative hospitals to gather experience, is full of hurdles. Some Indian unions have turned to facilitating migration as the most pragmatic way of supporting workers.
Taken together, the essays in this book shed important light on the devaluation of labour in the globalised Indian healthcare economy. There is little, though, in terms of hope or ways forward: migration looks like the best option for many nurses. In the context of heated international discussions about brain drain, these are sobering analyses. As international recruiters such as the UK’s National Health Service are poaching Indian nurses, the government seems disinterested in capitalising on this rush for Indian nurses to ask for health system support in return. Worker empowerment seems out of sight, and a 2017 government decree to further contractualise nursing labour is further weakening the workforce.
Unions are busted or fragmented, and entrenched inequalities and social conflicts are reproduced. To propel change, the editors’ bets seem to be on uniting worker struggles across categories of workers and in contesting neoliberalism and privatisation more generally. As long as Indian healthcare remains underfunded, dysfunctional and keeps marketising, and foreign countries can poach Indian workers without meaningful compensation, the broader context for these struggles is anything but favourable.
This review gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics and Political Science.
Main image: Accredited Social Health Activists (ASHA) attend a leadership training/workshop at a health Centre in Cheyyur Kancheepuram, in Chennai, India. Credit: PSI via Flickr.
