On August 20, 2024 an order of the Supreme Court had highlighted the issue of absence of conditions of safety for doctors and medical professionals across the country. The issue was being discussed in the Supreme Court as a part of the systematic issues related to safety being raised by medical professions during the hearing of the suo-moto case over the rape and murder of a doctor at the RG Kar Medical College Hospital at Kolkata on August 9. The SC stepped in with a suo moto call after doctors, countrywide went on a strike following the Kolkata murder-rape, paralysing India’s health care services and generating a social media storm.
The Kolkata rape and murder case, a 31-year-old trainee doctor who was brutally raped and killed by a civic volunteer at the campus of Kolkata’s RG Kar Medical College and Hospital on August 9, 2024 is only one among the recent of horrific such crimes in a country that records 86 or 87 rapes every day. (Details can be read here) The young doctor was attacked while on night duty. Her body was found the next morning, bearing severe injuries to her eyes, face, mouth, neck, limbs, and private parts. The violence and brutality that the deceased had to suffer at the hands of the accused shocked the nation and led to widespread calls for vengeance and justice. Thousands of doctors and other medical staff had, thereafter, taken to the roads to protest the increasing instances of violence against medical professions, especially women, and to demand stringent laws providing for their safety.
The Supreme Court had, on following the nationwide outrage, taken suo-moto cognisance of the Kolkata rape and murder case, on a Sunday, August 18, and the bench of comprising Chief Justice of India DY Chandrachud, Justices JB Pardiwala and Manoj Misra heard the matter on August 20 and over the next days. The Supreme Court had reportedly said that “The reason why we have decided to take this suo moto matter is because this is not a matter related to a particular murder which took place in a hospital in Kolkata. It raises systemic issues related to the safety of doctors across India.”
In the first order issued by the bench on August 20, the bench directed the prompt establishment of a “National Task Force” (NTF) comprising of medical professionals to give recommendations –within three months–on the modalities to be followed all over the country to ensure the safety of medical professionals in their work spaces. The bench noted that several states such as Maharashtra, Kerala, Telangana, West Bengal, Andhra Pradesh, Tamil Nadu etc. have framed state laws to deal with violence against doctors. However, these laws do not address deficiencies in institutional safety standards. “Therefore, we must evolve a national consensus. There must be a national protocol to create safe conditions of work. If women cannot go to a place of work and feel safe, we are denying them equal opportunity. We have to do something right now to ensure that the conditions of safety are enforced,” CJI had orally stated during the highly publicised hearings.
It is essential to note that the said National Task Force will constitute a total of ten members (details below). The order provided that the NTF will be headed by Surgeon Vice Admiral Arti Sarin AVSM, VSM. Director General Medical Services (Navy). The other members of the task force are Dr D Nageshwar Reddy, Chairman and Managing Director, Asian Institute of Gastroenterology and AIG Hospitals, Hyderabad, Dr M Srinivas, Director of Delhi-AIIMS, Dr Pratima Murthy, Director, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Dr Goverdhan Dutt Puri, Executive Director, AIIMS Jodhpur, Dr Saumitra Rawat, Chairperson, Institute of Surgical Gastroenterology, GI and HPB Onco-Surgery and Liver Transplantation and Member, Board of Management, Sir Ganga Ram Hospital, New Delhi. In addition to this, the NTF will also include Professor Anita Saxena, Vice-Chancellor, Pandit B D Sharma Medical University, Rohtak, former Dean of Academics, Chief Cardio thoracic Centre and Head Cardiology Department AIIMS, Delhi, Dr Pallavi Saple, Dean, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, and Dr Padma Srivastava, formerly Professor at the Department of Neurology, AIIMS Delhi.
The bench said the cabinet secretary and the home secretary to the Union government, secretary, Ministry of Health, chairperson, National Medical Commission and president, National Board of Examinations shall be the ex-officio members of the task force.
The bench has also directed that the NTF formulate an action plan under two sub-heads –Preventing violence, including gender-based violence against medical professionals; and providing an enforceable national protocol for dignified and safe working conditions for medical professionals.
The intervention of the SC and formation of the National Task Force has been hailed by many as a significant step towards ensuring the safety of the medical professionals as well as changing the scenario of impunity and lawlessness when it comes to committing violence against medical staff.
While it is certainly a step in the right direction, such a significant move has unfortunately excluded a large section of health care professionals hailing from the informal sector. Despite a wider definition by the World Health Organisation (WHO) on who constitutes health workers, it appears that this vast network of women health workers in urban and rural India may not figure at all, especially as their work situations are not structured and easy to find solutions for.
The order specifies that the medical professions being referred to in the order are only interns, residents, senior residents, doctors, nurses and all medical professionals. This further begs the question of The same brings us to the question of whether, by limiting the ambit of the NTF to the aforementioned medical staff, the Supreme Court has implied that the issue of violence against medial professions is an issue of concern or restricted to only middle class workspaces and urban areas, when predominantly informal workers in the cities and health workers in rural areas –such as Accredited Social Health Activists (ASHA workers) and Anganwadi workers and gender violence issues faced by them –will not be looked into by the NTF?
The World Health Organization (WHO) defines health workers as people who work to improve health, including doctors, nurses, midwives, and other professionals. The same also includes health sanitation workers. The WHO classifies health workers into five broad categories: health professionals, health associate professionals, and personal care workers in health services, health management and support personnel, and other health service providers. Despite this, the said order of the Supreme Court overlooks the equally critical and vulnerable segment of rural health workers, including Anganwadi workers and Accredited Social Health Activists (ASHA).
Who are India’s ASHA workers? Employed under the Ministry of Health and Family Welfare since 2005—over 10.52 lakh ASHAs (2022 figures) who are trained female community health activists from our village communities who are those that reach our communities on basic public health.[1] Besides Anganwadi workers and helpers are part of the union government’s “services’ programme though there have been demands for regularisation and de-casualisation of their work. They provide and reach early childhood care, pregnant women and lactating mothers, monitor children’s growth and –with healthcare professionals—also reach and provide health needs like primary healthcare, referral services and immunisation. Presently, India has close to 12,93,448 Anganwadi workers and 11,64,178 Anganwadi helpers, not an insignificant number.
These individuals, who are the backbone of rural healthcare, face not only violence but also systemic neglect, low pay, and lack of support, making their struggles invisible in the broader discourse. While formal sector medical professionals receive attention and advocacy, the plight of these rural workers remains largely unaddressed, highlighting a glaring disparity in how we value and protect different tiers of our healthcare system. With a significant section of the medical staff absent from even being considered by a task force established especially to consider the concerns raised by medical professionals. Can safety be ensured for those in the medical fraternity of India without ensuring that those who are the most marginalised, ignored and vulnerable are excluded from being granted protection?
Details of the Supreme Court order:
The Supreme Court observed in its order that Medical Associations have persistently highlighted the lack of workplace safety in healthcare institutions. Noting that medical professionals, including doctors, nurses, and paramedic staff, have increasingly become targets of various forms of violence while carrying out their duties, the intervention of the Supreme Court thereafter outlines a solution. With hospitals and medical facilities operating 24/7, these professionals work tirelessly around the clock. The unrestricted access to all areas within healthcare institutions has further exposed them to potential threats. In moments of distress, patients’ relatives often hastily blame unfavourable outcomes on the perceived negligence of medical staff, exacerbating the vulnerability of those dedicated to saving lives.
Specifically referring to the difficulties faced by women, the order stated “Women are at particular risk of sexual and non-sexual violence in these settings. Due to ingrained patriarchal attitudes and biases, relatives of patients are more likely to challenge women medical professionals. In addition to this, female medical professionals also face different forms of sexual violence at the workplace by colleagues, seniors and persons in authority. Sexual violence has had its origins even within the institution, the case of Aruna Shanbag being a case in point. There is a hierarchy within medical colleges and the career advancement and academic degrees of young professionals are capable of being affected by those in the upper echelons. The lack of institutional safety norms at medical establishments against both violence and sexual violence against medical professionals is a matter of serious concern.” (Para 7)
According to the judges of the Supreme Court, the issue of safety of medical professionals goes beyond merely protecting doctors; rather it is to be taken as a matter of national interest to ensure the safety and well-being of all health providers. The court noted in its order that as more women enter the workforce in advanced fields of knowledge and science, it is crucial for the nation to guarantee safe and dignified working conditions. The constitutional principle of equality mandates this, leaving no room for compromise on the health, safety, and well-being of those who care for others. The bench then states that the nation cannot afford to wait for a tragedy, such as a rape or murder, before implementing real and necessary changes.
The order stated “The constitutional value of equality demands nothing else and will not brook compromises on the health, well-being and safety of those who provide health care to others. The nation cannot await a rape or murder for real changes on the ground.” (Para 7)
In the present order, the bench led by CJI Chandrachud identified several critical issues affecting medical professionals:
- Medical staff on night duty often lack adequate rooms for rest, with no separate facilities for men and women.
- Interns, residents, and senior residents are frequently subjected to 36-hour shifts in environments lacking basic hygiene and sanitation.
- The absence of security personnel at hospitals is more common than not.
- Medical professionals often face inadequate toilet facilities.
- Housing for medical staff is often located far from hospitals, with insufficient transportation options.
- Many hospitals lack properly functioning CCTV cameras for monitoring.
- Patients and their attendants have unrestricted access to all areas of the hospital.
- There is a lack of screening for weapons at hospital entrances.
- Hospital premises are often dingy and poorly lit.
The bench has ordered the constitution of a ten-member National Task Force so that a national consensus can be reached—through thorough consultation with all stakeholders—on the urgent need to establish protocols addressing the issues being faced by the medical fraternity.
Through its order, the bench empowered the NTF to make recommendations on all aspects of the action-plan on preventing violence and providing an enforceable national protocol for dignified and safe working conditions, as well as any other aspects which the members seek to cover. The order further noted that “The NTF shall also suggest appropriate timelines by which the recommendations could be implemented based on the existing facilities in Hospitals. The NTF is requested to consult all stake-holders.” (Para 14)
The Ministry of Health and Family Welfare will provide all logistical support including making arrangements for travel, stay and secretarial assistance and bear the expenses of the members of the NTF, the order stated.
As a part of clarification of who all will fall under the phrase medical professionals, the order stated that “It is clarified that the phrase medical professionals used in this judgment encompasses every medical professional including doctors, medical students who are undergoing their compulsory rotating medical internship (CRMI) as a part of the MBBS course, resident doctors and senior resident doctors and nurses (including those who are nursing interns).” (Para 13)
The complete order may be read below:
It is pertinent to highlight here that previously, in the month of July of 2024 itself, the Supreme Court bench of Justices Sanjiv Khanna, Sanjay Karol and Sanjeev Kumar had refused to entertain a petition filed by the Delhi Medical Association (DMA) seeking measures to prevent violence against doctors by observing that legislations are already in place. Moreover, the bench had clarified that the petitioners were at liberty to approach the concerned courts in respect of particular instances of violence. Thus, within a period of a month, the Supreme Court went from dismissing the issue of violence against doctors and medical staff by observing it as individual cases to the same being a “systemic” concern, following the outrage in the Kolkatta murder-rape case.
The order may be read here:
“Systematic” exclusion?
Healthcare workers (HCWs) are individuals who deliver care and services to the sick and ailing. This involves team effort from doctors, nurses, laboratory technicians, pharmacists, ambulance drivers, medical waste handlers, Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), Anganwadi workers and several others. ASHAs, ANMs and Anganwadi workers form an integral part of the grassroots-level health workers under the National Health Mission. As part of the government’s National Rural Health Mission (NRHM), a new group of baseline health workers called Accredited Social Health Activists (ASHA workers) was formed in 2005 to address health related demands of the rural population, especially women and children, who find it arduous to access basic health services.
In the ongoing conversations about the protection and recognition of healthcare professionals, the vital contributions of ASHA (Accredited Social Health Activists) workers, Anganwadi workers and sanitation workers are often marginalised, overshadowed by the focus on urban and elite doctors. These individuals are the cornerstone of India’s rural healthcare system, delivering essential services to some of the country’s most remote and underserved populations. Yet, despite their critical role, they are largely excluded from the protections, benefits, and honour that are routinely extended to their urban and formal sector counterparts. This exclusion highlights a deep-seated inequality within the healthcare system, where the labour of rural health workers is undervalued and their safety and well-being are neglected.
ASHA workers and Anganwadi workers, who are exclusively women, operate under some of the most challenging conditions imaginable. ASHA workers, for instance, are often responsible for covering large geographic areas, traveling on foot to visit households, educate families on health practices, and provide crucial services such as immunizations, prenatal care, and family planning. These tasks are physically demanding, and ASHA workers frequently face long hours without adequate rest or compensation. In some regions, they are expected to work for less than the minimum wage, a paltry sum considering the importance and intensity of their work. Anganwadi workers, who run rural childcare centres and play a pivotal role in early childhood development, face similar hardships. They manage not only the educational needs of children but also their nutritional and health needs, often without adequate infrastructure or support.
The vulnerability of these workers is further exacerbated by the lack of formal employment status. ASHA and Anganwadi workers are often classified as “honorary” or “voluntary” workers, which means they do not receive the same benefits as formal employees, such as health insurance, pensions, or job security. This classification leaves them in a precarious position, where they are expected to perform essential public health functions without the protections that should accompany such responsibilities. In addition, they are frequently exposed to violence and harassment, both from the communities they serve and from within the healthcare system itself. Instances of ASHA workers being attacked or threatened while conducting COVID-19 tracing or vaccination drives have been reported across several states, including Uttar Pradesh, Bihar, and Maharashtra. Similarly, Anganwadi workers often face neglect and abuse from families who do not fully understand or appreciate their role, yet they continue to work under these difficult conditions with little acknowledgment.
When it comes to the violence that Anganwadi workers and ASHA workers face, the data is scarce. However, even the minimal data shows that there is a severe problem. A 2016 mixed-method study involving 396 ASHA workers from rural Northern Karnataka found that 94% of participants had experienced violent incidents in the preceding six months. Similarly, a study conducted in Kashmir during the 2010 unrest, which focused on 35 ambulance drivers, revealed that 89% of those interviewed had faced more than one incident of physical harm, 54% had suffered physical assault, and 83% had experienced job-related psychological trauma. Despite the presence of a significant number of ASHA workers, Anganwadi workers and other informal medical workers and aides in India, there is a glaring lack of comprehensive studies investigating the violence they face. The scarcity of data highlights the profound gap in understanding and addressing the risks these essential workers’ encounter. These studies also provide that the violence that these workers face stems from failures at multiple levels. Grassroots and mobile workers, who operate outside of health facilities, lack any form of security, while those stationed at health facilities receive only minimal protection. Owning to a lack of research on this issue, more recent figures could not be quoted.
Despite these overwhelming challenges, ASHA and Anganwadi workers have been resolute in their fight for better working conditions and fair treatment. Over the years, they have organized numerous protests, strikes, and campaigns to demand higher wages, job security, and formal recognition of their roles. In 2020, thousands of ASHA workers went on strike across the country, demanding a fixed monthly salary of ₹10,000 and better protective equipment during the COVID-19 pandemic. Anganwadi workers have similarly taken to the streets, protesting against the inadequate wages and lack of support from the government. Their struggles have led to some victories, such as wage increases in certain states and greater visibility of their demands in public discourse. However, these gains are often piecemeal and do not address the systemic issues that continue to marginalize these workers.
The exclusion of ASHA and Anganwadi workers from the protections and accolades afforded to doctors and other medical professionals indulged in the formal sector is indicative of a broader systemic inequality within India’s healthcare system. While doctors and hospitals that are urban and in the formal sector receive government attention and resources, the women who provide essential healthcare in rural areas are left to fend for themselves. This disparity not only undermines the health and well-being of ASHA and Anganwadi workers but also threatens the overall effectiveness of India’s public health efforts. For the healthcare system to function equitably and efficiently, it is imperative that these workers receive the recognition, protection, and compensation they deserve.
In addition to this, the exclusion of informal sanitation workers from the protections and recognition given to other healthcare professionals further underscores the deep inequities within India’s labour force. These workers, often operating in hazardous conditions with little to no safety equipment, are responsible for some of the most crucial yet dangerous tasks in maintaining public health. They handle the cleaning of sewers, public toilets, and waste disposal sites, tasks that expose them to harmful pathogens, toxic substances, and life-threatening situations daily. Despite their critical role in preventing disease outbreaks and ensuring public hygiene, they remain invisible in the broader narrative of healthcare protection and support.
Informal sanitation workers hail from the most marginalised communities and are trapped in a cycle of poverty and discrimination. They work without proper training, protective gear, or job security, making them extremely vulnerable to injuries, infections, and even death. The risks they take are immense; it is not uncommon for sanitation workers to suffocate or drown in poorly ventilated and hazardous environments such as septic tanks and sewers. One keeps hearing of there being numerous reports of sanitation workers dying due to asphyxiation while cleaning septic tanks, a task often performed manually in the absence of mechanized alternatives. Despite these dangers, they receive minimal compensation and are often denied basic rights like healthcare, insurance, and pensions. Their exclusion from national safety protocols and labour protections is a stark reminder of the systemic neglect faced by the most vulnerable workers in India’s public health infrastructure.
As India a as country continues to address the safety and well-being of medical professionals, we must also confront and correct the disparities that leave rural health workers vulnerable and marginalized. If our efforts to enhance safety and protection focus solely on more visible or privileged segments of the healthcare workforce, we risk perpetuating existing inequalities and leaving behind those who are most in need. Ensuring the protection and empowerment of ASHA workers, Anganwadi workers and informal sanitation workers is not just a moral obligation; it is crucial for the success of India’s public health system. Their work is indispensable, and their contributions should be recognized and valued as such. The time has come for a comprehensive approach that ensures their rights, safety, and dignity, aligning the nation’s healthcare system with its constitutional commitment to equality and justice for all. For true progress, our reforms must extend beyond just some more visible and central urban centres and formal sectors to encompass semi-urban, non-formal and rural healthcare workers, such as ASHA and Anganwadi workers, and informal sanitation staff. By acknowledging and addressing the unique challenges faced by these essential yet overlooked groups, we can create a more inclusive and equitable system that genuinely safeguards all those who dedicate their lives to public health. Only through such comprehensive and compassionate measures can we hope to achieve a truly effective and just response to violence against healthcare workers.
[1] Despite long standing demands for being recognised as government workers, ASHAs are not instead classified as holding an “honorary/volunteer” position. They serve populations of approximately 1,000 in rural areas and 2,000 in urban settings.
Related: