Context:

Over the past four years, the Association for Socially Applicable Research (ASAR) has been actively working on research and advocacy to address violence against healthcare workers. ASAR launched an online petition urging the Central government to pass the Healthcare Service Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, 2019, and called for better implementation of state laws to garner over 1,70,000 endorsements.

Violence in Healthcare Settings

Definition of Violence in Healthcare

The World Health Organization (WHO), in its World Report on Violence and Health, defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” Healthcare settings encompass a wide array of services, interactions, and places where care occurs.

Understanding Violence in Healthcare Spaces

At this crucial moment, we must rethink our perspective on violence in healthcare. Healthcare settings are not confined to physical spaces such as hospital wards; they extend to the broader interactions of healthcare workers. For instance, when an ASHA worker conducts a COVID-19 awareness campaign in a village, she carries a healthcare space with her. Violence in these settings can be physical, sexual, mental, or emotional, with varying degrees of severity.

Healthcare settings expose both providers and patients to vulnerabilities. Risk profiles differ based on socio-demographic factors such as age, gender, and social status. Young women from marginalised groups, for example, face a heightened risk of violence. Likewise, patients from economically disadvantaged backgrounds, psychiatric patients, and the elderly may experience unfair or violent treatment in healthcare settings. Rich, upper-caste men, who often dominate the medical profession typically receive care in well-protected urban private hospitals.

The Dynamics of Violence in Healthcare

• Complexity of the Perpetrator-Victim Relationship : The perpetrator-victim relationship in healthcare settings is complex. There are instances of violence initiated by patients, visitors, or other healthcare workers against healthcare professionals. Conversely, patients may also suffer violence at the hands of healthcare workers. For example, women in healthcare settings often face sexual violence, regardless of the roles of the men perpetrating it. Lower-ranking healthcare workers—such as ASHA workers, midwives, and ambulance staff—are particularly vulnerable to violence due to a lack of security. Additionally, young trainees and resident doctors face physical and mental violence due to long work hours, heavy workloads, limited power, and a toxic work culture.
• Systemic and Structural Nature of Violence : Violence in healthcare mirrors broader societal violence. Structural aspects of healthcare systems, cultural elements, legal frameworks, and political influences contribute to violence. Consequently, marginalised groups, such as lower-caste women, are more vulnerable to violence in healthcare due to the injustices and violence they experience in society.

The Global Challenges and Responses in Healthcare Systems

• The Global Impact of Corruption on Healthcare : The World Health Organization (WHO) estimates that corruption costs nearly $455 billion annually, more than the amount needed for universal health coverage. In many developing countries, corruption, rather than a lack of funds, drives healthcare crises and poor outcomes. In India, while medical corruption often highlights private-sector issues, public health corruption is frequently overlooked. Human resource-intensive healthcare systems are particularly prone to corruption, including severe forms like sextortion, especially in underfunded and poorly overseen environments.
• Global Lessons on Addressing Violence in Healthcare : Many countries recognize the pervasive nature of violence in healthcare. For instance, in 2017, Taiwan enacted legislation to protect both healthcare workers and patients. This legislation enforces strict prosecution of anyone obstructing healthcare services. Hospital administrations are required to identify high-risk conflict areas, such as emergency departments, and implement stringent security measures. Taiwan prioritizes patient safety as a core responsibility of medical institutions, with severe penalties for violence against healthcare workers, including fines and imprisonment.

A Call for Policy and Legal Reforms

• A Shift in Perspective: From "Violence Against Doctors" to "Violence in Healthcare" : The issue at hand is not just violence against doctors or healthcare workers—it is violence within healthcare. This shift in perspective, though not entirely new, is essential for India. International humanitarian law (IHL) supports this view by mandating the protection of healthcare establishments, personnel, and the sick and wounded in conflict zones. However, the protection of healthcare should extend beyond conflict situations, particularly where violence is systemic. Healthcare spaces must remain safe and protected under all circumstances.
• The Need for a Deeper Examination : Improving security and infrastructure alone may not suffice; corruption's impact on both healthcare workers and patients necessitates a deep self-examination of the public health system. Swift justice in the Kolkata case is essential for setting a precedent and deterring future incidents. Unfortunately, India has historically struggled with delivering timely justice, leading to severe consequences.
• Eliminating Medical Corruption : The national task force faces a crucial challenge. It must develop a comprehensive plan to prevent and address medical corruption in the public sector, which requires input from public health experts, medico-legal professionals, and broader governance. Effective strategies must extend beyond just creating new legislation.
• Reforms for Transparency and Accountability : Reforms should enhance administrative transparency, accountability, and oversight. Crucial measures include effective whistle-blower protection, digitization of management systems, and establishing ombudsman roles to reduce political interference. Countries like Brazil offer valuable lessons in tackling political corruption in healthcare.
• Modernising Public Hospitals : Modernization of the traditional ‘command and control’ Indian public hospital is also necessary. While there are strong reasons for improving efficiency, the pressing moral and regulatory imperatives are now more evident than ever and can no longer be ignored.

Conclusion

Violence in healthcare is a nuanced issue, but it is clear that healthcare spaces must remain places of healing, free from violence. Solving broader social problems is the ultimate goal, but the immediate focus should be on the formulation and implementation of strong policies and laws that protect everyone in healthcare settings. While the long-term solution involves addressing deep-seated societal issues, the immediate need is for strong laws and policies that safeguard healthcare workers and patients alike. The emerging responses to health-worker safety remain reflexive and simplistic. There is a need to delve deeper into the underlying issues, such as corruption, and implement comprehensive reforms that address both safety and systemic problems in healthcare.

Source: The Hindu