The key socio-demographic characteristics of all the participants in this study are presented in Table (1-2). Their age ranged from 20-48 years for FGDs, 23-58 years for IDIs and KIIs. Most of the returnee migrants were labours or hotel workers and spent between 6 months to 20 years in India. Key informants were working as a health professional, NGO staff, school teacher and local leader.
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
The FGD, KII and IDI participants reported having had mixed experiences of health services in India. Most generally agreed that health access depends on a combination of: where migrants live, the nature of the company they works for, the intelligence of the employer, their income level 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:
Without Aadhaar card, it is difficult to access health service. Those who go to India for the first time face a lot of troubles to access health services (KII, A representative of rural municipality, 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 , 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:
The key problem to migrant workers is the lack of information about available health services in India (KII, A health worker in Achham).
Some participants did, however, speak positively about facilities in India:
Most of the Nepali migrants visit government hospitals when they fall sick. In government hospital, health service is similar to what Indian get (FGD in Surkhet).
In one FGD the efficiency of making an appointment in India was praised:
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 participant was less positive about health workers in India:
Indian health workers delay our treatment if we introduce ourselves as migrants (FGD in Doti).
A returnee migrant worker who had had a health problem recalled the following experience:
I suffered from typhoid and malaria while staying in India. I got fair treatment from the health workers. I had heard that Nepali migrant workers are dominated in the hospital but I found no such discrimination (IDI with returnee male migrant in Surkhet).
One Nepali local leaders shared that Indian health workers do, in fact, treat Nepali workers fairly:
Providing medical care is part of humanitarian work. So, Indian health workers treat Nepali migrant workers fairly (KII, A representative of rural municipality in Achham).
Affordability of healthcare in India
Migrants make choices about visiting the doctor and/or hospital depending on how much they can pay. Our study participants agreed that most migrant workers are poor and only attend government health services, although some visited private clinics in India. Nepali migrants may receive limited support from their employer towards the cost of healthcare. For example, a returnee migrant worker said this about the sharing of expenditure:
If a company is well-established, it also bears part of the health cost. In my case, I pay myself, in hard times, I take a loan from my friends (IDI with a returnee male migrant in Doti)
Similarly, another returnee added:
Migrant workers approach to the government hospital to consult a doctor. One of the most frustrating of experiences is having to wait at the doctor’s office but workers are not allowing sufficient time for consultation. It’s difficult to afford private hospitals (IDI with a returnee male migrant in Kanchanpur).
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, and paid for workers’ health insurance, thus:
If workers claim medical expenses, the insurance company pays them. (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. For example:
When I fell sick, my company paid for me (FGD in Doti).
Barriers to accessing healthcare services in India
Barriers to accessing Indian health services included financial problems, language, discrimination and lack of knowledge about the location of health services. The comments below are typical.
If you are get caught by small illness, employer will pay for you. You have to bear the cost yourself if the illness is serious (FGD in Banke).
Others also mention language barriers and simply not knowing what was available locally:
Neither we are confident to communicate in Indian language nor familiar about the location of health center. In such situation, it is difficult to take health services (FGD in Kanchanpur).
Whilst unequal treatment of 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:
In India, many government hospitals are already overcrowded. In working place, it is difficult to migrant workers to get leave for doctor consultation (IDI returnee male migrant Achham).
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. A health worker explained:
In India, migrant workers are less aware of the availability of health services or health care system. Further, they experience a financial problem and also less confident to share their problems with doctors (KII with health worker in Surkhet).