Solving systemic violence against healthcare workers in India

Violence against healthcare workers is a chronic and growing problem in India. Siddhesh Zadey and colleagues look at how it can be tackled

In early June this year, an aggrieved mob made up of the family of a patient who had died brutally assaulted a doctor in Assam, India. A week earlier, a paediatrician from Chikkamagaluru, Karnataka, was ruthlessly attacked by the bereaved relatives of a 6 year old. These shocking events are only a handful of many incidents of violence against healthcare workers that take place globally each year.

The World Health Organization defines workplace violence in the health sector as any incident where a member of healthcare staff is abused, threatened, or assaulted in circumstances relating to their work, including commuting to and fro from work, and which involves an explicit or implicit challenge to their safety and wellbeing. It creates a ripple effect of harm. One of the authors of this article experienced assault in their hospital. After the incident, they developed a sense of fear while looking after their patients that caused both personal distress and affected the quality of care they could provide. 

In India, violence against healthcare workers has been a chronic, systemic, and growing problem over the past decade. Yet the covid-19 pandemic has seen a further increase in violence, making India one of the most unsafe countries for healthcare workers. Data from the Safeguarding Health in Conflict Coalition show that during the pandemic there has been a sharp rise in the number of healthcare workers assaulted in India, from 49 in 2017 to 155 in 2020.

Healthcare workers are four times more likely to be assaulted than other professionals in the general workplace, with junior doctors and nurses in government hospitals likely to be more at risk. Working in an emergency department, intensive care unit, or isolated area also seems to put healthcare workers at greater risk, especially during morning outpatient hours and late night shifts. Miscommunication between healthcare workers and patients and their visitors, dissatisfaction with care, delayed medical provision, violation of visiting hours, the psychological stress of a patient’s family members, denial of hospital admission, and the sudden demise of patients are all considered key factors in violence against healthcare workers.

Within the health system, improper management due to limited resources and staff in public hospitals, high care costs, and extended stays in private hospitals are key to inciting conflicts. During the pandemic, widespread fear, mistrust, and myths about covid-19 aggravated violence against healthcare workers. 

To counter this growing threat to healthcare workers’ safety, governments should enact and enforce strong legal solutions. Twenty five Indian states and union territories (UTs) have so far adopted the Medicare Service Persons And Medicare Service Institutions (Prevention of violence and damage or loss to property) Act that punishes violent perpetrators. Under this act, any violence against healthcare workers is a non-bailable offence (except in Chhattisgarh) and can lead to three years of imprisonment (except in Arunachal Pradesh, Punjab, Tamil Nadu, and Puducherry), with a fine of up to 50 000 rupees (US $674) (except in Arunachal Pradesh, Delhi, Haryana, Himachal Pradesh, Tamil Nadu, and Puducherry). States and UTs have modified the same act and, confusingly, several variations exist, with some more stringent than others. Yet four states and five UTs in India still have no law to tackle violence against healthcare workers. Even where legislation is in place, it’s been reported that fewer than 10% of the cases logged under this act reached the courts after charges were filed. Despite widespread recognition of the problem and several calls from medical associations, there is still no national legislation in place. 

A recent attempt to introduce The Healthcare Services Personnel And Clinical Establishments (Prohibition of Violence and Damage to Property) Bill at the central (federal) level was rejected by the Home Ministry. During the pandemic, the amended Epidemic Diseases Act (1897) is being enforced so that violence against healthcare workers is met with stricter punishments. However, it will dissolve once the pandemic is declared over, leaving the problem unsolved.

India needs to invest in the surveillance of violent incidents at national and local levels by creating a detailed database that helps us to understand the actual burden of the problem and formulate an effective prevention programme. Enactment of a central law and improved enforcement of existing state laws are steps that governments must take to grant justice to healthcare workers who have experienced violence and abuse in the line of duty.  

Steps can also be taken within hospitals to minimise the risk to workers. Hospital administrations should adopt standard protocols for violent incidents. Infographics shunning violence, alarm systems, improved security, strict weapons prohibition, grievance cells to lodge disputes, limiting the number of visitors, counselling for bereaved families, and mock drills training healthcare workers to take prompt action like notifying security in an escalating situation are all interventions that can reduce violence against healthcare workers. Emerging evidence shows that giving hospitals specific data on their organisation’s record of violence helps them to draw up effective action plans for violence prevention, leading to a lower incidence of violence. Hospitals should employ a representative to communicate with the media about such incidents. Zero tolerance policies towards violence, which clearly define unacceptable behaviour and the consequences of violation, also need to be in place.

The media also has a part in shaping public opinion about healthcare workers and in offering a balanced portrayal of their work, rather than a sensationalised one. News reports are an essential data source for the surveillance of violence against healthcare workers in India and, consequently, should be meticulously reported. The media has a responsibility to advocate for the lives of healthcare workers and broadcast awareness about legal penalties. 

Citizens have a moral responsibility to condemn any kind of violence against healthcare workers too. Solving this systemic problem will require citizen stewardship in activism, advocacy, and support for healthcare workers. Non-governmental organisations and civil societies can raise awareness, build bridges between communities and healthcare workers, and mobilise people to call on the government to take legal action and increase healthcare funding

Finally, at the individual level, healthcare workers should undergo training in safety and identification of early markers of violence to help them manage or prevent interactions that turn aggressive. De-escalation training can help healthcare workers to minimise the impact of violent incidents. But if violence does erupt, social media groups comprised of healthcare workers can be used to send emergency messages. Furthermore, involving patients in decision making and improved professional training on delivering bad news to patients and their families can reduce conflicts arising due to miscommunication. 

Violence against healthcare workers needs to be acknowledged as a social problem that requires action at multiple levels. Continued violence can lead to large scale unrest among healthcare workers that will, in turn, disrupt the health system and, ultimately, harm patient care. The rise in violence during the covid-19 pandemic, paired with the widespread recognition of the essential societal role of our healthcare workers, makes this an opportune moment to urge hospital administrators, policy makers, and politicians to act on this problem. Ensuring the safety of healthcare workers is a collective moral responsibility and pragmatic necessity for any law abiding society. 

Aatmika Nair is a medical officer at the District Tuberculosis Centre under District TB Control Society Mumbai, Maharashtra, India. She volunteers at the Association for Socially Applicable Research (ASAR), a non-profit non-governmental organisation in Pune, Maharashtra, India. 

Sweta Dubey is a practising doctor in Nagpur, Maharashtra, India, and a co-founder of ASAR. 

Vincy Koshy is a medical graduate from the Maharashtra Institute of Medical Education and Research, Pune, Maharashtra, India, and a research volunteer at ASAR.

Madhav Bansal is an ASAR research intern and a second year medical student at the Institute of Medical Sciences & Sum Hospital, Bhubaneswar, Odisha, India. 

Swasti Deshpande is a medical officer at Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India, and a research volunteer at ASAR.

Siddhesh Zadey is a senior research aide at Duke Surgery, a global health researcher, and a co-founder of ASAR.

Acknowledgements: We acknowledge the contributions of Shalmali Satpute and Kiran Khuntia for providing essential research assistance and data curation.

Competing interests: The authors have read and understood BMJ policy on declaration of interests and report no competing interests.