Why hundreds of nursing graduates leave India each year

NEW DELHI: Sherin, 35 and a mother of two, has been working as a staff nurse at a private hospital in Kolkata for 15 years. Originally from Kerala, Sherin completed her General Nursing and Midwifery (GNM) education from Nightingale Institute of Nursing in Bengaluru, Karnataka. For six months now, she’s been preparing for the Occupational English Test (OET), an exam which assesses the language proficiency of healthcare professionals to help them migrate to foreign countries.

“Nowadays, we nurses are treated as servants, there is no respect and no proper work hours,” lamented Sherin, explaining her decision. She isn’t alone in seeking a better life abroad. Thousands of nursing graduates have similar ambitions and despite producing a large number of qualified nurses each year, there’s still a shortage in the country.

Union health ministry data from 2019 shows that India has 1.7 nurses per 1,000 population; the World Health Organization (WHO) norm is three per 1,000. Around 2 million nurses are required to fill this shortage. WHO estimates that globally, approximately 9 million more nurses will be required by 2030.

Data from the regulator, Indian Nursing Council (INC), shows sharp growth in the number of nursing education institutions in the last five years. Health minister Mansukh Mandaviya told the Lok Sabha in August 2023 that from 2014 to March 2023, the number of nursing institutes had grown by 36% and undergraduate seats by almost 40%.

After the COVID-19 pandemic, demand for Indian nurses has grown. Educators say if the government does not step in now to regulate and ensure quality, it will be too late. The sector needs investment, a regulatory framework to ensure pay parity, and positions for those with specialisation.

Sonali Tarachand Jadhav, principal, Ramaiah Institute of Nursing Education and Research, Bengaluru, put things into perspective: “We are not respecting our nurses. When we talk about health, the first set of people who come to mind are doctors. But if one looks at the data on healthcare human resources, 50% are nurses, the largest chunk. The remaining 50% includes doctors, paramedics and others.”

As per INC Nursing Council data, in 2016-2017, there were 20,43,289 registered nurses (RN) and registered midwives (RM) and 8,56,984 auxiliary nurse and midwives (ANM). By December 2022, there were 25,46,327 RN and RM and 9,96,962 ANM.

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Nursing courses, colleges, schools

In India, there are two types of nursing education institutions – nursing schools and nursing colleges. Both provide undergraduate and postgraduate courses. The ANM is a two-year diploma course; GNM, a three-year UG course; the BSc Nursing degree is a four-year programme; and the post-basic BSc Nursing, a two-year UG course for registered nurses. At the PG level, there are MSc Nursing and post-basic diploma in nursing.

Nursing schools offer GNM courses, and colleges BSc Nursing and other courses. In 2018-19, the course of Nurse Practitioner in Critical Care was launched.

Annual reports of the nursing council show an increase in the number of institutes. To give an example for BSc nursing, the sharpest increase happened over 2000-2005, when the number of institutes offering it jumped by 1,156.66%. From 2010 to 2015, the number of institutes grew by 27.54%. Over 2015-20, the growth stood at 18.11% and over 2020-23 (three years) it has been 11.67%, say the annual reports.

Number of nursing institutes: Past 6 years

Educators say the fluctuation in numbers could be due to tightening regulations by the INC or institutions failing to meet norms related to facilities or teacher-student ratio.

Judith Angelitta Noronha, dean, Manipal College of Nursing, Manipal, Karnataka, said: “The council has strict regulations. However, they have given permission for colleges with clinical facilities to enhance the seats and the government has given approval to start another 150 new nursing educational institutions in 2023.”

Nursing colleges: Lopsided distribution, ownership

Nursing institutions are not uniformly distributed. In 2023, The Hindu reported that there are no nursing colleges in 40% of districts and that 42% of nursing institutions are concentrated in the five southern states with the western states accounting for 17%. Data from 2022-23 shows that Maharashtra has the highest number – 713, followed by Karnataka at 668.

This has meant students moving out of their home states to study. “In my institute, the majority of the students are from West Bengal and Kerala. Earlier it used to be mostly from Kerala, but now the state also has a large number of nursing institutes,” said Jadhav. West Bengal students also travel to Bihar and Jharkhand.

More than 85% of institutes are privately-owned.

Nursing colleges: Ownership pattern

Source: INC annual reports

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Impact on nursing students

The dominance of the private sector has meant a high cost of nursing education. In a private institute in Karnataka, a BSc Nursing course can cost Rs 10-15 lakh for four years. Some also question the quality of instruction.

Aayushi Mahat, an associate professor at a private nursing institute in West Bengal, said: “We have seen several students who graduate from certain colleges in Karnataka and they do not know the basics. More than the students, the institutes are to be blamed because many of them do not have medical hospitals attached and students are left to fend for themselves even during the mandatory internship period in the last year of the course. As the admission process begins late in Bengal, many prefer to go to other states.”

Students studying in other states often find it difficult to get registered with their own state nursing councils. Sushmita Lepcha, working as a senior nurse facilitator at a Kolkata private hospital for seven years, graduated from Jai Nursing Institute in Gwalior, Madhya Pradesh. She has been unable to get herself registered as a nurse.

“The West Bengal Nursing Council’s examination is differently checked. In Gwalior, the weightage is 50% internal and 50% theory, while in Bengal they say it’s 75% theory and 25% practical. That is the reason I have not been able to get registered in my own state. INC also has no rules on it,” said Lepcha.

In her GNM course in Gwalior, there were 60 students, most from West Bengal. They are all unregistered and that is getting in the way of migration abroad as well.

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Migration of nurses

There is no government data on the migration of nurses. Kerala is widely believed to be the state sending the most nurses abroad.

The paper, Review of International Migration of Nurses from the State of Kerala, India, by Health Systems Research India Initiative Trust and WHO, says that the total number of nurses who migrated from Kerala through Overseas Development & Employment Promotion Consultants (ODEPC) from April 2018 to March 2021 was 1,216.

“Migration during 2020-2021 was twice the number in 2018–2019, though there was a 25% dip in 2019-2020. During this period, migration to the United Kingdom and UAE increased by 15.4 times and 3.3 times respectively but reduced towards Saudi Arabia to about one third. Even then, the number of out-migration was more than double that of those who returned home from abroad,” says the paper.

Though Kerala remains on top, a WHO report says that the hotspot of migration has shifted to north India especially, Punjab. Jadhav added, “Now with UK relaxing norms for clinical experience, we are going to see a lot more students moving out.”

Jadhav surveyed 1,408 nursing students from Karnataka, Kerala, Maharashtra and Rajasthan in 2021
for the study, The Sociodemographic Characteristics of Indian Nursing Students and Their Intentions to Migrate Overseas for Work. “54% of the respondents intended to migrate overseas. Better career advancement opportunities, better working conditions, higher pay, better lifestyle, were the reasons cited,” she said.

Nursing salary

In India, the starting salary of a nursing graduate ranges from Rs 10,000 to Rs 15,000 per month. The union government had recommended a minimum wage of Rs 20,000 per month for nurses in private hospitals. Following that, each state sets a minimum wage for nurses. But whether one is a GNM or a BSc nurse, the pay is about the same. Most BSc graduates end up working as staff nurses themselves and some teach, pursuing MSc and now even PhD.

Even at Manipal, almost 85% of the graduates leave the country within two years. “We graduate 100 BSc Nursing students per year. For the last three years, we have a record of 100% placement. Within two years, 85% of our graduates are placed abroad. Only those who wish to remain in India and take up government jobs or decide to be in the country stay back,” said Noronha.

Government jobs are limited, which explains the increased competition and coaching for AIIMS NORCET and other recruitment exams. The starting salary for nursing officers in All India Institute of Medical Sciences ranges from Rs 62,700 to Rs 1,00,000, depending upon experience.

Lepcha said, “Almost 80% of nurses working in my hospital are preparing for OET. However, it is a difficult exam to clear and the fee is Rs. 35,000. Exposure to the English language acts as a hindrance.” Lepcha, who belongs to a Scheduled Tribe, could have secured a government job but being unregistered has caused a problem.

Apart from the OET, the nurses also appear for the Commission on Graduates of Foreign Nursing School (CGFNS) for travelling to the United Kingdom, Canada, Australia, Ireland and New Zealand, and the National Council Licensure Examination (NCLEX) for the US.

As per statistics from the National Council of State Boards of Nursing, US, 4,268 Indians appeared for the 2022 NCLEX – the second-largest contingent after the Philippines and more than double the number to write the 2021 exam.

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Nursing education: Way forward

Educators say it is the time for the government to form policies relating to scope of work, pay and working conditions, and establish norms for nurse-patient ratios to retain talent.

Jadhav said, “It is high time the country needs to understand the importance of task shifting, task sharing. Getting nurses to do technical jobs only in the purview of doctors can be crucial. I have a colleague who moved to the UK who is working as a nurse radiographer, and has learnt how to do sonography. She already knew obstetrics and gynaecology. It is important that pay sales should also mention scope of work as per the qualification. Nurses can work in OPD, ICU. If that is done, pay regulation will also come into place.”

Adding to that, Noronha said, “Salary structures in private and government sectors need to be similar. Working hours of nurses globally are 36 hours with option for overtime. However, in this country, it is 48 hours with no overtime. Salary package in other countries is five times higher.”

Educators also highlight the need for having specialised nurses. Almost 10 years ago, PG diploma courses in neonatal nursing, orthopaedic nursing and 12 such programmes across specialities had been introduced. But with no takers the courses were closed.

“Creating a nursing programme and rolling out through an apex body is not going to help, we will have to create that supporting framework by creating positions for people who take up the course, ensuring standards for the programme. Most of them have no jobs despite the specialisation. If the government doesn’t intervene, the nurse practitioners course in critical care will die,” added Jadhav.

Talking about the need to update the curriculum regularly, Venkatesan Balu, principal of GITAM Institute of Nursing, Visakhapatnam, said, “Nursing education curriculum should be regularly updated to reflect advancements in healthcare practices, technology, and patient care.”

Noronha pointed to another problem, “The number of graduates opting to pursue their postgraduate education has declined,” she said. “The placement of postgraduate nurses in specialised clinical fields with increased salary packages is the need of the hour.”

But Mahat feels “it is more important to monitor the quality of institutes in the country”. She said: “Transparency needs to be established in the regulation part as well. Investment in nursing education by the government is prime and hopefully the announcement of 157 nursing colleges in partnership with the state and central govt will come soon.”

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Government initiatives

In 2023, Mandaviya had said that the requirement of a 100-bed parent hospital has been relaxed for hilly and tribal areas, to encourage the states to start nursing institutes. Student-teacher and student-patient ratios
were also relaxed and super-speciality hospitals were allowed to start MSc Nursing programmes even if they didn’t offer a BSc.

Under the centre’s scheme ‘Development of Nursing Services’, grants are given to states and UTs to upgrade schools of nursing into colleges.

In August 2023, the National Nursing and Midwifery Commission (NNMC) Bill, 2023, was passed. Under the NNMC Act, a National Nursing and Midwifery Commission and Autonomous Boards at the national level would be established. Corresponding State Nursing and Midwifery Commissions will also be set up to regulate and maintain education and service standards, oversee professional conduct, and manage online and live registers. It also states that the commission will implement a standardised admission process to ensure consistency across nursing education among others.