Vandana Das, a young surgeon, was stabbed to death last month by a patient in India's southern Kerala state. The reportedly intoxicated attacker had been brought in by the police for a medical examination.

A few months earlier, a group of people had manhandled a senior cardiologist at a private hospital over the treatment of a patient. The doctor, however, had not been involved in the matter.

"At least five cases of attacks on doctors are reported every month in Kerala and more than 200 such attacks, including intimidation and threats, have been reported in the past three years," the Indian Medical Association's (IMA) Kerala president, Sulphi Noohu, told DW.

The organization is demanding comprehensive legislation to fight violence against health care professionals.

In 2019, there was a mass resignation of doctors in West Bengal after a mob attacked a junior doctor. The attack was triggered by the death of a patient, with the family alleging medical negligence.

According to a study by the IMA, over 75% of doctors have faced violence of some kind in the workplace. In most cases, the patient's relatives were actively involved.

Interns, students at risk in state-run hospitals

India does not have a centralized database on workplace violence against health care professionals. However, it seems that medical staff in government hospitals are bearing the brunt, in particular junior doctors, medical interns, and final-year medical students.

Several doctors' associations are demanding a central legislation to deal with the problem.

In April 2020, India introduced legislation that recognized violence against health care service personnel as a cognizable and non-bailable offense.

"However, with the pandemic over, that law lapsed," Manish Gupta, a doctor, told DW.

"We want an omnibus legislation to safeguard doctors. Existing state laws are weak in their implementation and lack the scope to protect health professionals," he added.

Too few doctors for 1.4 billion Indians

Looking beyond individual incidents, experts say the violence needs to be understood within the context of India's poorly funded public health system.

They point to problems, including improper management due to limited resources and staff, high health care costs, and extended stays in private hospitals, as factors leading to potentially violent situations.

Government figures show there are 3.4 million registered nurses and 1.3 million allied and health care professionals, including doctors, in the country.

This is far too few for India, which has recently overtaken China to become the most populous country in the world. According to the Indian Journal of Public Health, India will need at least 2 million doctors by 2030.

Patients pressured into expansive private care

The gap is exacerbated by other factors, such as the skewed proportion of the health workforce across India's states and across the rural and urban areas. There is also an imbalance between public and private health institutions, where patients are required to pay out of their own pockets for treatment.

"The violence is due to multiple factors. The most important is an overall loss of trust in the health care delivery system," Sumit Ray, a medical superintendent and critical care specialist at Holy Family hospital, told DW. "Over-privatization with major elements of secondary and tertiary care being provided by for-profit health care providers has led to escalating costs and significant out-of-pocket expenditures on health care," he added.

India spends just 1.2% of its GDP on public health and is in position 152 in the global ranking of public health spending.

Out-of-pocket health expenditure has forced many into debt. Millions of Indian citizens fall under the poverty line every year and are forced to sell assets and borrow money for treatment.

"This has led to significant indebtedness and when the outcome of the treatment is not what the family expects, it leads to violence. This is compounded by the fact that people don't see a recourse through judicial intervention," Ray said.

Doctors need more 'communication skills'

With many poor families pledging land as collateral for medical treatment in private hospitals, health care inevitably becomes a "business deal." They also expect better outcomes for the money spent.

"Another reason is the lack of training in good communication skills in our medical education, leading to a lack of ability among doctors, particularly young resident doctors at the frontline, to deal with fraught and stressful situations. Add to this the dangerous interventions by local politicians and hooligans who are out to prove their ability to intimidate health care providers," said Ray.

Verbal abuses can easily escalate when the patients and their relatives are already anxious about their financial survival.

"You do not need laws to deal with such issues," public health physician Vikas Bajpai told DW.  "What you need is a health system that is responsive to people's health needs in conformity with their dignity. Junior doctors end up bearing the brunt because they are the first in line of duty and manage the medical emergencies where such incidents are most reported."

Edited by: Darko Janjevic