All three categories of barriers of the HCAB model – financial, cognitive and structural – were represented in the data in several ways, as was the barrier of distrust in public health care services (see Figure 1). Despite identifying these different barriers, many workers did not find their overall access to health care unsatisfactory. Moreover, the barriers to access to health care seem to follow social determinants in society; the challenges are related to factors such as income, type of employment and migration.
The critical component of financial barriers in the HCAB model is the cost of health care . Although not a strong barrier for all participants of the study, costs were mentioned by some workers, and for them, it appeared to be a significant challenge. As could be anticipated, the price of health care as a barrier was related to the income of a person, as those with lower income saw it as a stronger barrier. Cost as a barrier was also indirectly linked to the level of informality of employment and gender – those in more informal employment settings, as well as all women, earned less and, therefore, the price of health services makes up a more significant portion of their income.
Those in the least formal form of employment were not provided any financial help with regards to health care by the contractor, while the two other groups were compensated for costs related to work injuries. The contractor in the most formal type of employment also paid for their workers’ other medical or health-related costs, paid for sick days off and provided free transportation to health care facilities when needed. Losing income as well as paying out of pocket for medical costs creates financial barriers for those who do not enjoy such benefits.
A typical structural barrier in the HCAB model is the distance to the health facility and the working hours of the health facilities . The workers noted that the opening hours of the health facilities did not allow them to visit the facilities after their working hours. The same challenge was present with the so-called health camps ran in the residential areas by staff of public health facilities. In addition, travelling to facilities kept the migrants from working that day, which was problematic. Structural barriers were least problematic for those workers in the least informal type of employment, as they had more support from their employer to access and finance health services. Distance and transportation were barriers to access to public health services in particular, as the workers lived in urban areas where private facilities were also available to them. There was, therefore, no general lack of services in their current locality, although it was noted as an issue in their home villages. Some of the workers from Karnataka were eligible for a below poverty line card issued by the Karnataka as part of the Rashtriya Swasthya Bima Yojana insurance scheme . This allows them to acquire certain services for free or at a lower price. The migrants, however, shared experiences of situations where they were unable to use the card as it was registered at their home village – a challenge caused by migration.
Lack of information on factors relating to health care or the inability to use such information create cognitive barriers. The participants of this study mostly had little knowledge of the health services available in their area. Those in the least informal type of employment were aware of the Urban Health Center because their employer had informed them about it, but most of the other workers were not aware of this. Information was mostly not acquired from official sources but from informal networks such as neighbours, colleagues and family members. Acquiring and using healthcare-related information was limited by illiteracy and by lack of access to many technologies. These challenges were identified by both men and women, but seemed to be stronger among women. Migration caused a cognitive barrier in the form of language skills. Some workers found it challenging to know about health and health services because they did not speak the local languages.
Distrust in public health services as a barrier
During data collection, distrust in public health care services was found to be very high among the participants, and during data analysis, it was added to the HCAB model as a fourth category of barriers. Distrust in public health care services stemmed from perceived lack of quality of care and perceived lack of responsibility and interest of the staff. The quality of public health care services was seen as satisfactory, but still as notably worse than the quality of private services. Lack of quality was explained as, for example, issues with the availability of medicine and equipment as well as long waiting times and delays in service. Also, participants of this study felt the staff of public health care facilities show less responsibility for their work and less interest in the wellbeing of the patient than the staff of private facilities. These views on public health services, which were based on both negative experiences and views shared in informal networks, were expressed by respondents as widely known shared facts. While all groups of participants in the study expressed distrust towards public health services, those in the most informal type of employment as well as all women had a slightly more positive view on public services than the other workers.
Distrust in public health care services is caused, in addition to the reasons above, by a number of mechanisms in society. It is based on a broader concept and discourse on the trustworthiness of public services and local government [25,26]. It cannot, therefore, be solved by only focusing on the issues of quality and staff responsibility, but must be seen as a component of a broader discussion on political and societal trust. Distrust is, however, no inherent feature for only public services. Examples from Somalia suggest that also private health services can be distrusted if they are poorly organised or pressured by social instabilities .
Intertwined categories of barriers
As Figure 1 illustrates, in this revised HCAB model, all categories of HCAB (financial, structural, cognitive and distrust-related) are connected. First, financial and structural barriers work together to hinder access when health services are only available at times and places that force a person to stay away from work when using them, which directly cuts their income. Second, structural and cognitive barriers interlink, for example, in cases where service providers are unable to provide health-related information in languages that internal migrants can understand. Third, an example of the connection between financial and cognitive barriers is a situation where internal migrants are not aware of public facilities available to them and therefore seek health care in the private sector, resulting in an added financial burden. The three intertwined categories of barriers were expressed widely and equally among participants, and none of them was significantly stronger than the others. Distrust in public health care services, on the other hand, was the most strongly expressed barrier to health care access.
Structural barriers, such as the quality and availability of equipment and medicine and waiting times, and cognitive barriers, such as inadequate counselling by staff members, are factors contributing to distrust in public services as a HCAB. Distrust, on the other hand, creates financial barriers as the clear majority of internal migrant workers choose private services over public ones, thus facing high prices and the inability to access care because of the costs.