The key socio-demographic characteristics of all the participants in this study are presented in Table (1-3). Their age ranged from 20-48 yrs for FGDs, 23-58 yrs for IDI and KII. Most of the returnee migrants were labour or hotel workers and spent 6 months to 20 years in India. Key informants were the highly educated person and worked as a health professional, NGO staff, school teacher and local leaders.
Findings are presented under four themes: (1) accessibility, (2) perceptions, (3) affordability of healthcare services in India and (4) barriers to accessing those services. Each theme is discussed below and relevant quotes are presented in support.
Accessibility of healthcare in India
Access to healthcare impacts one's overall physical, social and mental health status as well as quality of life. The FGD, KII and IDI participants reported having had mixed experiences of health services in India. Most generally agreed that health access depends on where a migrant lives, the nature of the company he or she works for, the intelligence of the employer, the level of income earned and local transportation facilities. About half of the KII participants mentioned that Nepali migrants struggle to get health services because they lack the proper certification:
It is difficult for migrant workers to access health services at government hospitals if they don't have an aadhaar card (KII with chair of rural municipality in Achham).
An aadhaar card is an identification number provided to all people who live in India for more than 12 months, regardless of citizenship. The aadhaar programme, which is the largest biometric identification system in the world [14], gives every cardholder easy access to various government benefits and services.
Another reason provided for limited access to healthcare was participants’ unfamiliarity with the locations of services and their struggle to make effective decisions:
Many Nepali migrant workers do not access hospitals because they feel hesitant and they are unfamiliar with the system (KII with a school teacher in Kailali).
Some participants did, however, speak positively about facilities in India:
Yes, there are government hospitals as well as private clinics. There are no problems to speak of regarding access to health services (FGD in Banke).
For example, praising the health facility’s telephone system:
The health centre in my place was good. It used to issue tickets even over the telephone (FGD in Surkhet).
Perceptions of healthcare in India
Participants were asked how healthcare workers responded to returnee migrant workers when they sought treatment at health facilities. The majority of respondents had a positive attitude towards health service delivery in India. Most felt that they had been treated fairly at Indian healthcare centers. However, a few FGD participants expressed a fear of maltreatment and some reported having encountered discrimination. A typical positive view is as follows:
They say nothing bad to patients who go to receive treatment. They do as much as they can; otherwise, they refer them to other places (FGD in Doti).
One interviewee was less positive about health workers in India:
We are always afraid. We wonder if we will be given the wrong injection or have some organ taken out of our bodies (IDI with returnee male migrant in, Doti).
A participant who had had a health problem recalled the following experience:
I suffered from illness in India. I was admitted to the hospital. I received good treatment. I did not feel discriminated against for being a migrant laborer. I had heard that they behave differently to the people with look like janajatis- [=low caste] but I have not faced such a situation so far (IDI with returnee male migrant in, Surkhet).
One Nepali health worker shared that Indian health workers do, in fact, treat Nepali workers fairly:
Indian health workers do not discriminate between Nepali and Indian nationals (KII with a health post in-charge in Achham).
Affordability of healthcare in India
A number of returnee migrant interviewees stated that most Nepali migrants visit government hospitals and health centers but that some go to private hospitals. Migrants make choices about the hospital they visit depending on how much they can afford. Nepali migrants may receive limited support from the companies they work to cover the cost of healthcare. For example, a returnee migrant worker said this about the sharing of expenditure:
We have to bear costs ourselves. If a company is well-established, it also bears part of the cost of health treatment for its employees but in the majority of cases, we have to pay for ourselves (IDI with a returnee male migrant in Surkhet).
Similarly, another returnee added:
Ninety-five percent of Nepali brothers and sisters pay for health services on their own. Only in five percent of cases do employers bear the health expenses of their workers. Health services in government hospitals are cheap but those in private hospitals are expensive and not affordable for all Nepali migrants (IDI with a returnee male migrant in Achham).
Since a small company is less likely than a big one to provide insurance coverage or cover the cost of healthcare during an illness, migrants employed by small companies are less likely to get health services in India. Some companies are very supportive:
If companies are good, they support their workers. For example, one diamond company insures the health of its employees. If workers claim medical expenses, the insurance company pays them. Not all companies provide insurance facilities, however. (IDI with a returnee male migrant in Kanchanpur).
Indeed, in a few cases FGD participants mentioned that they had received financial support from their employers for medical treatment in India:
When my rib broke while I was working, my company bore the cost of my treatment. (FGD in Surkhet).
When I fell sick, my employer paid for me (FGD in Banke).
Barriers to accessing healthcare services in India
Despite the above reports of easy access to healthcare in India, some FGD participants had faced a number of barriers to accessing and using health services. These included financial problems, language barriers, discrimination and lack of knowledge about the location of health services. The comments below are typical.
If you have money, you can get the medicine nearby; if you don't, you can't (FGD in Banke).
Others also mention language barriers and simply not knowing what was available locally:
It is more difficult to seek health services in India than in Nepal due to the language problem and unfamiliarity with the location of health services (FGD in Achham).
Whilst unequal treatment as a Nepali was also highlighted:
Indians discriminate against Nepali people, doctors neglect us, Indians cut queues, and hospitals and doctors charge high fees (FGD in Surkhet).
Other challenges to accessing healthcare services mentioned by several returnee migrants included the lack of information, overcrowding in government hospitals and not getting time off work from their employers for treatment:
We do face different setbacks. First, we don't have enough money to get treatment in advanced hospitals. When we don't have an aadhaar card, officials don't admit us. Our citizenship papers aren't useful for accessing health services (IDI returnee male migrant Doti).
If you are sick, there is no one to take care of you. Even if friends and relatives live nearby, they cannot give you time as they are busy at work. If someone takes care of a friend, he will be scolded by his boss for not working (IDI returnee male migrant Kanchanpur).
A number of KIIs highlighted that language barriers, delayed receipt of salaries and the passiveness of individual migrants also prevent migrants from seeking healthcare services:
In India, migrant workers have to bear the cost of treatment on their own. Not getting paid on time also affects their treatment since they have to take a loan to pay for health services (KII with local representative in Surkhet).
Nepali migrant workers cannot express their problems effectively. Unlike their Indian counterparts, they hesitate to mention their problems and hide their illnesses. Thus, their treatment is not effective (KII with local representatives in Surkhet).