India’s nursing workforce is overwhelmingly female, overwhelmingly from Scheduled Caste and Scheduled Tribe communities, and almost entirely invisible in public recognition of healthcare. When COVID-19 swept through India in 2020 and 2021, the nurses who staffed isolation wards, managed oxygen equipment, and held dying patients’ hands were disproportionately from Dalit communities in Maharashtra, Tamil Nadu, and Kerala – communities that had, generation by generation, entered nursing when other professional pathways were closed. Savita Hira Bodhi represents this category of worker: a Dalit nurse who defied the doubled stigma of caste discrimination and the devalued status of nursing to serve rural and urban poor populations who would otherwise have no care at all.
The Nursing Workforce: Who Actually Runs India’s Healthcare
India has approximately 3.4 million registered nurses, according to the Indian Nursing Council’s 2022 annual report. This represents a nurse-to-population ratio of approximately 2.4 per 1,000 people – well below the WHO benchmark of 3 per 1,000, and severely below the ratios of developed countries (Finland: 14.8 per 1,000, Norway: 18.8 per 1,000). But the distribution is the critical issue: nurses are concentrated in urban areas and private hospitals, while rural and tribal health facilities operate with severe shortages.
What the aggregate statistics do not capture is the caste composition of the nursing workforce. Multiple studies, including a 2018 survey by the Nursing Council of India and research published in the Indian Journal of Medical Ethics, have documented that Scheduled Caste women account for a disproportionate share of the auxiliary nursing midwife (ANM) and general nursing midwifery (GNM) cadres in government healthcare – particularly in states with strong historical conversion communities (Tamil Nadu, Kerala, Maharashtra, Goa) where Dalit Christian communities entered nursing through mission hospitals in the 19th and early 20th centuries.
This historical pattern reflects a specific social dynamic. Nursing, which involves intimate contact with the ill and dying – contact with bodily fluids that carries ritual pollution status in caste-orthodox frameworks – was work that upper-caste families steered their daughters away from. Christian mission hospitals, particularly those established by British and American missionary societies from the 1850s onwards, recruited nursing staff from among Dalit converts who had the most to gain from institutional training and the least to lose from the caste stigma attached to the profession.
The Double Stigma: Caste and Nursing
A Dalit woman who becomes a nurse in India confronts two intersecting forms of devaluation. The first is caste-based: she comes from a community that has been systematically excluded from social recognition and occupational dignity. The second is profession-based: nursing, despite being clinically essential, is poorly compensated, chronically understaffed, and socially undervalued across almost every healthcare system in the world.
In India, this double stigma has specific operational consequences. Dalit nurses in government hospitals have documented experiences of being assigned to the least desirable duties – morgue handling, isolation ward work, cleaning tasks – when upper-caste nursing staff are present. The hierarchies within nursing wards mirror, to a degree, the hierarchies outside them. A 2016 study in the Economic and Political Weekly by Dr. Rama Baru of JNU documented nursing supervisor behavior that systematically disadvantaged nurses from Scheduled Caste backgrounds in promotion decisions and ward assignments.
The intersection with gender is equally significant. Rural healthcare in India depends on three female cadres: ASHAs (accredited social health activists), ANMs, and GNM nurses. All three are underpaid relative to their male counterparts in comparable government roles, and the ASHA cadre – which disproportionately recruits from Dalit and Adivasi communities – is technically classified as “volunteer” rather than “worker,” which exempts the government from minimum wage obligations despite ASHAs functioning as de facto government employees.
“Every time someone survives sepsis in a government ward, the nurse who caught the fever at 2 AM is probably a woman from a Scheduled Caste background. No one will say her name in the discharge summary. But she was there.”
Dr. Pavitra Mohan, Public Health Specialist, in a 2021 interview on nurse recognition during COVID-19
COVID-19 and the Recognition Gap
When COVID-19’s second wave hit India in April-May 2021, the hospitals that saw the most acute pressure were government institutions serving the urban poor and rural populations – exactly the settings where Dalit nursing staff are most concentrated. The nursing and healthcare worker death toll in India during the pandemic has been difficult to quantify precisely, but the Indian Medical Association reported over 700 doctor deaths in the second wave alone.
Nursing staff deaths were less systematically counted. The Indian Nursing Council and state nursing associations compiled partial lists, but no comprehensive national registry of nursing staff COVID-19 fatalities exists. The nurses who died were predominantly women; the community recognition and compensation processes that followed were incomplete and inconsistent. Several states offered ex-gratia payments to healthcare worker families – but the eligibility criteria, documentation requirements, and processing times created barriers that disproportionately affected the families of contract and outsourced nursing staff (who were often from Dalit and Adivasi communities rather than from permanent government service cadres).
The pattern reflects a structural truth about how India values different categories of health worker death. A doctor’s death generates an obituary, a memorial service, and a named ward. A contract nurse’s death generates a file in a government office and, if the family is persistent, an ex-gratia payment processed 18 months after the fact.
The Comparison: How Developed Countries Value Nurses
Finland, which consistently ranks among the world’s top healthcare systems, has a nurse-to-population ratio of 14.8 per 1,000 – nearly six times India’s. Finnish nurses are represented by a strong national union (Tehy), earn a starting salary of approximately EUR 2,500 per month (roughly Rs 2.25 lakh per month at 2024 exchange rates), and have legally-mandated patient-to-nurse ratios in acute care settings. When Finnish nurses went on a one-week strike in 2022 demanding better pay and working conditions, the government was forced into negotiations within days because the healthcare system could not function without them.
Kerala, India’s most medically advanced state, offers a domestic comparison. Kerala’s nurse-to-population ratio is approximately 6.4 per 1,000 – nearly three times the national average (Kerala Economic Review, 2022). Kerala’s nursing workforce is organized, politically active, and has secured better wages and working conditions than most Indian states through successive union negotiations. The Kerala model – government investment in nursing training, recognition of nursing as a skilled profession with corresponding pay, and a culture of nursing as a family tradition in many communities – is the closest India has to the Finnish model.
The mechanism that created Kerala’s nursing culture is partly historical and partly policy-driven. Christian mission hospitals established in Kerala from the 1860s trained nurses from diverse backgrounds – including many Dalit Christian communities in Thrissur, Kottayam, and Pathanamthitta districts. These communities built nursing into a family profession over three generations, with women returning from Gulf nursing assignments with savings that funded the next generation’s training. This is exactly the kind of long-term human capital development that policy must protect and extend to communities in other states.
What Every Indian Can Do: Five Levels of Citizen Action
- Personal level: If you interact with a nurse in a government hospital, ask for their name and use it. Write it down if you intend to give feedback. When leaving hospital reviews or feedback forms, name specific nurses who provided care. The invisibility of nursing staff in patient experience is partly a cultural pattern that individual patients can change one interaction at a time.
- RWA/building level: Support professional training opportunities for young women from Dalit and Adivasi communities in your area who are interested in nursing. Many states have government ANM and GNM training schools with free tuition – the barrier is often information and family encouragement. Connect young women from such backgrounds with information about nursing career pathways through local NGOs and ward-level Mahila Sabhas.
- Ward/local body level: Demand that your local government health facility maintain and publicly display its nurse vacancy rates. The Right to Health framework (which Rajasthan has piloted and other states are considering) includes nurse-to-patient ratio requirements. File RTI applications asking for nurse vacancy data in every PHC and CHC in your district, and share the data publicly.
- City/state level: Advocate for regularization of contract nursing staff in government hospitals. Contract nurses (hired through outsourcing agencies rather than as permanent government employees) are paid significantly less than permanent staff for the same work and have no job security. Write to your state health secretary demanding that contract nursing staff be given equal pay, equal benefits, and a pathway to permanent employment. Reference the Supreme Court’s judgment in State of Punjab vs Jagjit Singh (2016) on equal pay for equal work for contract employees.
- National level: Support a Nursing Act that brings India’s nursing regulatory framework in line with international standards. The existing Nursing Council Act (1947) is pre-independence legislation that does not address contemporary nursing workforce issues: career progression, mandatory staffing ratios, nursing research, or post-graduate specialization. A comprehensive National Nursing Policy – which the Ministry of Health has drafted but not notified – would address the systemic undervaluation of nursing as a profession.
The Systemic Argument
Savita Hira Bodhi’s story – and the stories of hundreds of thousands of Dalit nurses like her across India – is not a story about exceptional individuals overcoming odds. It is a story about a system that has extracted skilled labor from a specific community without providing recognition, fair compensation, or career pathways proportional to the service provided.
A developed India needs a nursing workforce that is paid, recognized, and protected commensurate with what nurses actually do: they are the operational backbone of every hospital. The doctor orders the treatment; the nurse delivers it, monitors it, and prevents the complications that turn a recoverable illness into a fatality. India will not build a functional healthcare system without treating nursing as the skilled profession it is – and it will not treat nursing as the skilled profession it is while the nurses who fill the most difficult roles are from communities that the rest of the system ignores.
Explore More on India’s Health Equity Stories
India’s healthcare workforce and access gaps are documented across our coverage. Read about why rural Indians pay more per hospital visit than Swedes and the Forgotten Heroes series for more stories of Indians who served without recognition.
The Mission Hospital Legacy: How Dalit Communities Entered Nursing
The historical pathway by which Dalit communities entered nursing in India is documented and specific. British and American Christian missionary societies established hospitals across India from the 1850s onwards – in the South, the London Missionary Society, the Church Missionary Society, and the Basel Mission; in the West, the American Board of Commissioners for Foreign Missions; in Bengal, the Church Missionary Society and Baptist Mission Society. These hospitals needed nurses, and they recruited from among Dalit Christian converts who had limited access to other forms of skilled employment.
The Christian Medical College (CMC) Vellore, founded by Dr. Ida Scudder in 1918, established one of India’s first professional nursing schools and historically recruited from among Tamil Dalit Christian communities in Vellore and surrounding districts. Over four generations, nursing became a family tradition in many of these communities – daughters following mothers who followed grandmothers into the profession that had provided economic stability when no other skilled occupation was accessible.
By the post-independence period, this pathway had created a nursing workforce that was skilled, experienced, and concentrated in Dalit Christian communities – but had not been able to transition into the administrative and specialist roles that would have provided career advancement and higher compensation. The ceiling that kept Dalit nurses in bedside roles while non-Dalit nurses moved into supervisory positions is documented in the nursing workforce studies cited above, and reflects a pattern replicated in other professions where Dalit entry was facilitated by institutional programs without corresponding entry into leadership.
Rwanda’s healthcare sector offers a sharp contrast. After 1994, Rwanda invested deliberately in training community health workers who were representative of all Rwandan communities, and established career pathways from community health worker to professional nurse to specialist nurse that provided economic mobility without artificial ceilings. By 2020, Rwanda had achieved a community health worker density of one per every 100 households, with 75% women, and had reduced child mortality from 196 to 36 per 1,000 live births (World Bank 2022). The comparison is not that Rwanda’s history was simpler – it was immeasurably harder – but that a deliberate commitment to community-representative health workforce development produces health outcomes that elite-concentrated healthcare never achieves at scale.
India’s nursing sector has the historical foundation – the mission hospital legacy, the family tradition, the sheer number of trained Dalit nurses – to build a world-class nursing workforce. What it lacks is the policy framework that values nursing enough to pay it fairly, protect it from caste-based discrimination within hospital hierarchies, and create career pathways that allow the best bedside nurses to become clinical specialists and nurse practitioners. This is not a small ask. It requires changing both how hospitals are administered and how Indian society thinks about who does the work of care.