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India: Angels Are Turning Red - Nurses’ Strikes in Kerala | B L Biju

25 December 2013

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Economic and Political Weekly, Vol - XLVIII No. 52, December 28, 2013

Angels Are Turning Red: Nurses’ Strikes in Kerala

by B L Biju

The nurses’ strikes indicated the outburst of the self-concealed and politically ignored labour’s unrest in the hospital industry. It is the beginning of a different form of class struggle, a demand for a more adaptive and communicative strategy from the established trade unions and the political left. This article looks at the labour-capital conflicts in Kerala’s hospital industry, class formation and unionisation of nurses and the approach of political parties and the government to the question of labour.

Since 2009, the nurses in India have been organising strikes against the ever-increasing exploitation of labour in the private hospitals. The strikes affect Kerala more because a large majority of nurses in India are from the state (Percot and Rajan 2007: 320; Nair and Haeley 2009: 14). In Kerala, even the nurses in private hospitals, who are traditionally refrained from any kind of trade union activities, also formed some politically independent unions in 2012, and their strikes met with some positive results. The increase in nurses’ wages in Kerala forced the corporate hospitals in Delhi, Hyderabad and Chennai to announce new wage package in order to prevent the possibility of nurses’ exodus to their home state.1 This article looks at the labour-capital conflicts in Kerala’s hospital industry, class formation and unionisation of nurses and the approach of political parties and the government to the question of labour.

Hospital Industry in Kerala

Modern healthcare institutions in Kerala emerged in the late 19th century. In the beginning, government institutions were few in number and majority of hospitals and clinics were run by the Christian missionaries and the doctor-turned-entrepreneurs. From Third Five-Year Plan (1960s) onwards, the scope of public health system expanded greatly to realise universal healthcare in the state. Nevertheless, since the mid-1980s the profit-driven private sector again surpassed the government (Kutty 2000). Fiscal crisis of the state government and changing health policy of the central government2 constrained the scope of state intervention in the health sector.

After economic liberalisation, many single-doctor clinics were closed down and small nursing homes were converted into big hospitals (Dilip 2010: 440). In addition to the community managements, the emigrant business class also began to invest in Kerala’s hospital industry by taking advantage of less state regulations, non-unionised labour and the vast consumer market.3 The emergence of big hospitals and the concentration of large number of workers in individual firms in due course provided the objective conditions for class formation and unionisation of the largest category of hospital employees – the nurses.4

In the highly competitive hospital industry, the strategies of managements for revenue enhancement and cost reduction face some constraints. Their attempt for revenue enhancement by increasing the treatment cost was constrained by the low cost healthcare provided by the evenly distributed government hospitals (Varatharajan et al 2002: 14). The quality concerns of the health literate population urged the private sector for huge spending on doctor’s salary and infrastructural development which in turn obscured the chances of cost-cutting. Thus, the private hospitals targeted the nurses’ salary and labour for cost reduction and profit.

Nurses as a Class

Nurses in the hospital industry are a class in itself in the three dimensions of class relations: property-wise (ownership of means of production and share in surplus), authority-wise (control over the means of production, production process and policy decisions), and in terms of quality of work (skills and expertise). But by virtue of professional qualifications and nature of work they are identified as a status group or a service class.5 In the authority hierarchy in hospitals the nurses occupy the position below the paramedical staff and clerks and just above the menial workers. In practice, their duties overlap with ward boys and sweepers in both the patient-crowded government hospitals and the labour-squeezing private hospitals. Even though the nurses are skilled workers, unlike the doctors they hardly fetch a brand name for their skill in the hospital industry.

In Kerala, the nurses have been prevented from becoming a class-for-itself by a number of factors such as political socialisation by family and church, predominantly non-left party affiliation, values prevailing in the workplace such as nobility and service and the presence of community managements as the employers. Their professional organisations such as Trained Nurses Association of India (TNAI) are also obstructive to their transformation into a class-for-itself.6 Since the nurses’ exploitation in the workplace has been fortified by the internalisation of service-mentality, in Kerala, the community managements make use of moral/religious principles to tame them.7 The principles of “moral economy”, gender and religion defined the subjectivity of nurses for a long period. The profession attained the status of salaried service only when the government hospitals came into being. The Kerala Nursing Council constituted according to Nurses and Midwives (Amendment) Act 1964 has no say in their wage and service conditions. Though the private hospitals are under the Industrial Disputes Act, no Industrial Relations Committee (IRC) was set up until 2012 because of the disinclination of nurses to form trade unions.

Earlier, the nurses in private hospitals were able to overcome the wage deficit through national and international migration. But, recently the increasing competition in the national labour market, declining wages, worsening service conditions and increasing cost of living discouraged national migration. The diploma holders were barred from nursing jobs in the Organisation for Economic Co-operation and Development countries (Walton-Roberts and Rajan 2013:219). Global economic crisis also caused the return of migrant nurses from the Gulf countries. Concurrent with this, the educational loan repayment liabilities troubled the young nurses who passed out from the self-financing nursing schools and colleges. The private hospitals in their home state appropriated this difficulty and asked the candidates to execute service bonds and to deposit Rs 25,000-75,000 at the time of joining service. The managements also impounded their original certificates to prevent inter-firm migration. Many of them received only part of the salary, that even not regularly. Recruitment agencies also deceived many of the jobseekers.

Since the nurses’ qualification remains the blind spot of Kerala’s health literacy, the managements were able to fill up the vacancies with trainees causing the disappearance of permanent jobs for nurses in the private sector. The proliferation of private self-financing nursing schools and colleges in the state, which provided the hospitals with a new investment option and resource for institutional expansion, has also enhanced the supply of labour.8 To save the labour cost in hospitals, the principals and teachers of nursing colleges/schools were directed by the managements to assign hospital duty to nursing students as part of internal assessment, without pay. Capital exercised free rein over labour in the absence of trade unions in hospitals and student unions in the nursing institutes. The hospital managements in collusion with doctors and powerful caste/community organisations acted as strong pressure groups to block political interventions in the workplace.9

Unionisation of Nurses

In addition to the emergence of big hospitals, stiff competition and increasingly labour-exploitative practices, the changes in gender and religious composition of the workforce also helped the process of trade unionisation. For instance, the increase in non-Christian nurses weakened the hold of religion in the workplace. The new generation from the same community also lost faith in the capitalist language of the managements couched in moral preaching. The labour unions were formed at the initiative of male nurses who were recruited in large numbers very recently.10 In the post-liberalisation period, the community managements also lost the dominance in the capital ownership in hospital industry. The moral fabric was destroyed and the capital revealed its deadly smile more plainly than ever before. Thus, the capital has to face the nurses as a class from which the submissiveness and religiosity have been receding fast.

More than ever after economic liberalisation, the “moral economy” that concealed the real economic relations in the workplace was contradicted by the logic of free market that governs the nurses in their daily life. For example, the young generation opted for this profession (after self-financing education) mainly due to the materialist ambitions fanned by the free market rather than due to moral compulsions or religious instructions. The transformation of health services into a fully capitalist enterprise brought to the fore the contradictory interests of labour and capital. By following the neoliberal rules of public finance, the fiscally troubled state has become reluctant to bridge the gap between the accumulation fund of capital and the surplus fund of labour through public spending for welfare of the workers. In fact, the nurses were self-unionised when the state, religion and the employers spoke the same language of capital. Thus, all that was solid melt into air.

Since 2010, some voluntary associations and professional organisations registered under the Kerala Societies Act organised strikes in different hospitals. When the news about the suicide of Beena Baby, a Malayali nurse in Asian Heart Institute at Mumbai following the harassment by management sparked an emotional fire among the nurses across India, some of them used it to bring up larger organisations. The United Nurses’ Association (UNA) in Thrissur and Indian Nurses Association (INA) in Kannur were the most successful. As a majority of nurses are from the central Kerala – the political stronghold of Congress and its partner, Kerala Congress – some political leaders also patronised nurses’ unions such as Indian Professional Nurses Association (IPNA) and Indian Registered Nurses Association (IRNA).11

By using social media and college alumni associations they recruited members and formed units in different hospitals. When the managements challenged their privilege to organise labour strikes, they were re-registered as trade unions. Even though the Congress leaders supported nurses’ strikes outside Kerala, they prevented their trade unionisation inside the state due to the presence of Christian churches – the electoral ally of the United Democratic Front – in the camp of hospital managements. In fact, by outsourcing their leadership to political leaders from the Congress IRNA and IPNA deactivated nurses’ own representation in discussions with the managements and the government. The INA remains as a “facebook organisation” having less ground support.12

Rivalling other unions, the UNA grabbed more units in central Kerala and expanded its reach towards north Kerala where a large number of big hospitals emerged very recently. Its state-level leadership is composed of people having some experience in student/youth organisations affiliated to different political parties. For example, Jasminsha – the founder president of UNA was a Democratic Youth Federation of India (DYFI) activist. The agitation of UNA was a success in terms of participation of nurses and the organised pressure they exerted to force the managements and the government for deliberations.

Despite having a vertical hierarchy in organisational set-up and in decision-making similar to conventional trade unions, in practice the UNA resembles a “catch-all” organisation. It makes use of the identities of nurses as working class and professional community interchangeably. Nevertheless, the recent decisions of UNA to take disciplinary action against disobedient members show that it has been gradually transforming into a well-knit trade union. The auxiliary wings of UNA engage with the unemployed, the apprentice and the nursing students. They also formed Nurses’ Parents Association to deal with the educational loan repayment liabilities collectively.

UNA organises free medical camps for the poor to construct a “labour-community coalition” in their agitation. They also fought hospital corruption with the help of the visual media. Importantly, they communicate the message that their demands for wage and service conditions such as satisfactory nurse-to-patient ratio is in the general interest of public health. Such attempts were helpful to avoid a massive negative reaction from the public to their strikes though the agitations adversely affected the life-saving service.13 As a strategy similar to the left trade unions which use the neutral and egalitarian term “comrade”, UNA addresses its member as “angel” to cultivate a common identity over the intra-group differences.14

The most disturbing drawback is the inadequate and dithering presence of women in leadership roles despite the fact that the women massively participated in the agitations. Familial constraints and lack of leave from duty cause to reduce their effective presence in the organisational meetings. Their scanty participation in the social media discussions, due to various reasons, also indicates male dominance in the deliberations. Their interest declined mainly after the IRC announced the model wage package. They are also greatly disappointed by the quarrels between the male leaders of different unions.

The inadequate visibility of women in leadership positions and the self-assumed confidence of male leadership to fully represent “the other” actually constrain the UNA’s effectiveness to confront the capital by combining gender and class adequately. For instance, in the IRC the demands for wage got prominence over decent and convenient service conditions, mainly due to the lack of women in the negotiations. Moreover, the demand of UNA for male reservation in jobs may not get the exclusive approval of women. However, since the managements have stopped recruitment of male nurses to weaken the trade unions, the strength of women leadership would be very decisive in the future. In addition, the second order leadership of UNA varies in strength in different districts.

Political Parties and Governments

The nurses in the private hospitals were organised, while the conventional trade unions have been losing the political currency in Kerala.15 The Communist Party of India (Marxist) – CPI(M) – and the Communist Party of India (CPI), which officially supported the strikes, did not politically lead the agitation because the Left has been pursuing “welfarism” rather than hard trade unionism in the health sector. This was more so, since the low income groups, due to the high health literacy and the quality concerns, show an increasing dependency on private hospitals in Kerala, and any increase in the labour cost in private hospitals would lead to escalation of treatment charges costing heavily the poor. It loomed large when the Left Democratic Front (LDF) government (2006-11) decided to revise the minimum wage of nurses at Rs 8,000 in private hospitals in 2009. But simultaneously the government had taken serious efforts to revamp the public health system under the National Rural Health Mission to protect the low income groups (State Planning Board 2010: 11). This line of policy that aimed at balancing the labour rights in hospitals with the health rights of the poor could not be pursued by the LDF from the opposition when the nurses’ strikes broke out. This dilemma reflected in the Left’s approach to the strikes.

The CPI(M)’s strategy to designate DYFI and All India Democratic Women’s Association (AIDWA) together with the Centre of Indian Trade Unions (CITU) to support the strikes gave only mixed results. The hidden labour unrest in some loss-making cooperative hospitals in north Kerala under the control of CPI(M) also prevented it from encouraging nurses’ agitation across the state. In addition, the employees of private hospitals have been traditionally disinclined to trade unions, led by the Left. For instance, while Kerala Government Nurses Union affiliated to CITU claims strong membership, its employees’ union in private hospitals has a weak following. The CITU did not encourage category-wise unions in private hospitals at an early stage of class formation, and it was not prepared to recognise the nurses as a class-cum-status group. Like the conventional trade unions, the independent women organisations have also failed to engage with this predominantly women workforce in general, and their labour strikes in particular.

The UDF gained advantage from the difficulties of the Left. The government initially viewed the strike as an obstacle to its dream projects in private health sector. But, due to the political significance of the nurses from central Kerala and the church managements, it had to persuade both sides. Therefore, soon after appointing an expert committee to look into the nurses’ demands, the government announced sops to the private sector in the Health Policy 2013. To console the private sector further, it amended the Clinical Establishment Bill (2009) introduced by the previous government.

Rather than directly confronting the capital the UDF government attempted to calm down the agitators by means of token steps such as earmarking an insignificant amount in the budget to settle their educational loans. After 26 rounds of prolonged deliberations, the tripartite IRC announced differential wage system for nurses based on the number of beds in hospitals. The managements were empowered to hold decentralised negotiations with employees regarding the service conditions. They also obtained permission to continue the “trainee system” in the hospitals at a revised pay. The responsibility to enforce the new wage package is with the labour department. But, the power to take punitive action against the hospitals in case of non-implementation of the IRC decisions is with the health department that has been continually very congenial to the managements.


Unlike many recent upsurges, mainly led by youth in many places that disappeared after registering emotional reaction during the movement phase, the nurses’ agitation in Kerala boldly entered into the organisation phase. Importantly, due to its focus on workplace exploitation and demands for share in surplus the class identity of nurses was brought to the fore more effectively than ever before. The present independence of the UNA from political parties may not last long because in the practical situation of labour-capital conflicts the nurses as a class that confronts capital more directly in an organised industry require a political agency in the party system willing to force the capital for surplus sharing.

The extinction of small and medium private hospitals facing the brunt of both wage hike and the entry of big capital portends an escalation in hospital charges. Therefore, the mess between the interests of labour, health rights of the poor and the profit-minded capital hardly provides an easy solution. The extent of public support to the labour rights of nurses depends on the capacity of the public health system to meet the demands from the low income groups and to counterbalance the threat of lockout and capital flight. It necessitates a public health policy free from market fundamentalism.

The nurses’ strikes, which indicated the outburst of the self-concealed and politically ignored labour unrest in the hospital industry and the beginning of a different form of class struggle, demand for more adaptive and communicative strategy from the established trade unions and the political left. This is of great imperative since the nurses’ strikes have inspired some other non-unionised workforce such as the teachers in the unaided private schools and the employees of the emergent private financial institutions to form independent trade unions in Kerala.


1 The Hindu, 9 June, 2012.

2 In India, privatisation of healthcare began with Sixth and Seventh Five-Year Plans (Duggal 2005: 32-33).

3 In the two business meets organised by the United Democratic Front (UDF) governments in 2003 and 2012, the healthcare attracted investment proposals worth Rs 350 crore and Rs 3,700 crore, respectively.

4 There are 1,75,000 nurses in private health sector according to Kerala Private Hospital Association (The Indian Express, 15 December 2011).

5 In many recent nurses’ agitations in private hospitals, the status questions became so wedded with, and even relegated by, the class-wise demands related to distribution of surplus. The managements are more worrying about the nurses’ demands for surplus-sharing than those for status-sharing. The group of workers who demand for sharing the surplus cannot be reduced to a status group. In fact, only status-enhancing solutions to nurses’ issue is largely convenient to the interest of capital. However, the description of nurses as a class in hospital industry does not imply the negation of gender, caste and status components. Likewise, the latter cannot be assumed as entirely non-economic entities. Importantly, the male nurses in the profession bring different sort of gender questions, which have not been studied well by the concerned scholars.

6 TNAI’s policy and position statement speaks voluminously about restrictions on trade unionisation and strikes. It also forbids the trade unionised government nurses to gain dominance in its membership. With a biannual membership fee of Rs 3,500 it represents Indian nurses as a status group rather than a working class (See According to Nair (2012) the nurses’ strikes in Delhi since the 1980s have largely bypassed TNAI.

7 In Kerala, the lineage of “nursing as a noble service” originated from the missionary activities in the colonial period. The early nurses were nuns. The native women from the socio-economically backward families recruited (after conversion) as helpers regarded healthcare as a divine duty. The main source of their finance was charity of the wealthy. In the popular discourse fortified by religion, nursing is treated as a humanitarian service or a vocation instead of a paid labour (Nair 2012: 40-47).

8 There are 6,120 seats for BSc nursing of which 5,805 are in private self-financing colleges. Apart from five government medical colleges, 104 private institutions and eight institutions under state universities offer the course in self-financing mode. There are 218 nursing schools, 200 of them in the private sector, which offer Diploma in General Nursing and Midwifery (DNM). For DNM, there are 6,755 seats; 5,845 in private and 434 in government (Kerala Nursing Council 2012). In addition, thousands of nursing students from Kerala pass out from other states every year.

9 In Kerala, the Confederation of Private Hospitals brings together the Qualified Private Medical Practitioners and Hospitals’ Association, Association of Advanced Specialty Healthcare Institutions, the Kerala Private Hospital Association, Kerala Voluntary Health Services, the Christian Medical Association and the Catholic Hospital Association.

10 The foreign jobs and the demand for old age care attracted males to this profession. Since 2008 the nursing institutes reserved 5% seats to male candidates. As part of saving the labour cost, private hospitals recruited male nurses in the departments/units where more physical power is required to help the patients. The profit-driven strategy of the managements backfired when the male nurses took the leadership of trade unions.

11 Traditionally, Kottayam district is home to largest number of nurses in Kerala. The adjacent districts – Thrissur and Ernakulam – have the highest hospital density, besides having significant population of nurses.

12 On 20 May 2013 the INA organised a march in front of the state secretariat for termination of trainee system, minimum wage for all the nurses irrespective of the hospital size and male reservation in jobs.

13 The young journalists of visual media who face similar workplace exploitation gave publicity to nurses’ strikes to attract public sympathy.

14 Though the translation of “angel” in Malayalam – Maalaakha originally had a semitic religious connotation, later it became religiously neutral and most often used to denote females in the daily life conversations and popular culture. However, the exact gender identity of angels is a matter of dispute in different biblical readings.

15 Since the 1990s the CPI(M) moderated trade union struggles due to the declining economic productivity and growing unemployment in the state.


Dilip, TR (2010): “Utilization of Inpatient Care from Private Hospitals: Trends Emerging from Kerala”, Health Policy and Planning, 25(5), pp 437-46.

Duggal, Ravi (2005): “Historical Review of Health Policy Making” in Leena V Gangolli, Ravi Duggal and Abhay Shukla (ed.), Review of Healthcare in India (Mumbai: CEHAT), pp 21-40.

Kutty, V Raman (2000): “Historical Analysis of the Development of Healthcare Facilities in Kerala State”, Health Policy and Planning, 15(1), pp 103-09.

Percot, Marie and Irudaya Rajan (2007): “Female Emigration from India: Case Study of Nurses”, Economic & Political Weekly, 42(9-10), pp 318-25.

Nair, Sreelekha and M Haeley (2009): “A Profession on the Margins: Status Issues in Indian Nursing”, Occasional Paper No 45, Centre for Women’s Development Studies, New Delhi.

Nair, Sreelekha (2010): “Nurses’ Strike in Delhi: A Status Question”, Economic & Political Weekly, 45(14), pp 23-25.

– (2012): Moving with the Times: Gender, Status and Migration of Nurses in India (New Delhi: Routledge).

State Planning Board (2010): Economic Review (Thiruvananthapuram: Government of Kerala).

Varatharajan, D, Rajiv Sadanandan, K R Thankappan, V Mohanan Nair (2002): “The Idle Capacity of Government Hospitals in Kerala: Size, Distribution and Determining Factors”, Project Report, July, Achuta Menon Centre for Health Science Studies, Department of Health and Family Welfare, Government of Kerala, Thiruvananthapuram.

Walton-Roberts, M and S Irudaya Rajan (2013): “Nurses Immigration from Kerala: Brain Circulation or Trap” in India Migration Report 2013: Social Cost of Migration (New Delhi: Routledge), pp 206-23.

B L Biju (bijubl at teaches political science at the University of Hyderabad.


The above article from Economic and Political Weekly is reproduced here for educational and non commercial use