Impact of COVID-19 on those on fringes of healthcare: Urban & Rural Perspectives I Part 2


20 May 2020

Impact of COVID-19 on those on fringes of healthcare: Urban & Rural Perspectives I Part 2

For many living on the fringes of society, public health care services are often inaccessible. The impact of the COVID-19 pandemic on the most vulnerable populations of our society -- migrant workers, the urban poor and daily wage earners, tribal communities, and agricultural men and women -- are deep and far-reaching. In the ‘Webinar on COVID19: Ask The Experts – Part 6’, we explored the impact of the COVID-19 pandemic on the health of vulnerable populations. Our guest experts – Yogesh Kalkonde, Divya Varma and Gautam Bhan – discussed unique health challenges posed by the pandemic for urban and rural populations; communication and community engagement strategies to mobilize/reach help to the vulnerable communities; lessons for urban-planning from COVID-19; and, impact on the health of migrant workers and their entrenched relationship with urban India.

This is the second part of the edited excerpts from the webinar, wherein Divya Varma, Programme Manager at the Centre for Migration and Labour Solution & Policy and Partnership Lead at Aajeevika Bureau’s, brings forth the challenges posed by COVID-19 and lockdown on migrant communities.

India is increasingly being referred to as a nation of footloose labour. There is an increasing magnitude of migration from rural areas to the cities in search of livelihood. There are, unfortunately, no definite estimates but according to the last round of economic survey in 2019, it's about 139 million people.

They migrate seasonally from their villages to the urban areas. It could be short-term migration or long-term migration, anywhere ranging from 3 -11 months. But, the common factor is that most of them always go back home. Very few numbers of these migrants actually aspire to settle down in the cities. So, in a way, they maintain two homes, one in the village and another in the city. Mobility is a very important feature of their life as they keep moving from village to the city and between different work sites within the city. They sometimes move along with their contractors based on what their employment arrangement looks like, and they move from city to city in search of livelihood as well.

On the drivers of rural-urban migration

Some of the drivers that are driving people to the city on such a large scale are the decline in the rural economy due to the agricultural distress. There are many semi-arid regions in the country where the agricultural decline has been precipitated by climate change.

Among the urban centres where most of these people go, the construction sector stands out as the single biggest employer of migrant workers in the country, followed by domestic work, textile power looms & stitching garment units, mining & quarrying, manufacturing, and hospitality.  Agriculture is also a big employer which involves family migration wherein lot of women and children also migrate along with the men, and work in these farms.

There is certain directionality to these movements. For example, some of the major sending states are those that figure very low on social or human development. Some of the key receiving states are also biggest economic centres in the country today, like Kerala, Gujarat, Maharashtra, Delhi and Karnataka. Many of these workers come from historically marginalized communities such as tribal or aadiwasi communities; since they are often landless in their own villages, agriculture is again not a viable option for them. Therefore, this kind of mobility and migration adds another dimension of vulnerability to their lives. 

On vulnerability of migrant populations

If one examines the working conditions of these migrant populations, who predominantly work in the informal economy, their jobs are very low-value, low-paid and hazardous. There are no written contracts governing this kind of an employment arrangement between the worker and employer. Of course, there are many issues that migrant communities face that have been accentuated by the lockdown, but we need to remember that these are pre-existing long-standing vulnerabilities. These have only been compounded or precipitated due to the lockdown.

In addition to chronic levels of hypertension and diabetes, there is a large incidence of malaria, cholera and diarrhea. Add to this - precarious work conditions as well as congested living conditions - a combination that leads to the high incidence of tuberculosis besides various other occupational injuries, risks, accidents that all of them are subject to, on a frequent basis.

We carried a study to examine the extent of migrant workers’ access to urban public services, and how they feature in the imagination of the urban development policies in our country today. Some of the findings that came to light were that more than 90% of migrants are completely outside the ambit of the public healthcare systems in the cities. Other factors that put them at a disadvantage are unsuitable timings of our urban health centers where migrants will necessarily have to forego a day's wage, and linguistic barriers since they might not necessarily speak the language of the doctor or the nurse. Additionally, urban health centers and large public hospitals are very complex to navigate for an illiterate tribal migrant worker who comes from a rural area.

Even if we think about early childcare and immunization services, the incentives of ASHA and anganwadi workers are largely misaligned to the nature of life that these communities lead. For example, they're incentivized for immunizing a pregnant woman or a child; while the intent is to ensure the quality of quality and consistency of service delivery, but due to their mobile lives the migrant communities are unable to take advantage of such health incentives. The migrants and their families, especially their children who travel with them, are deprived of these critical services very early in their lives - a structural failure of our policies.

On systemic and structural gaps in public policies

If we were to examine some of the structural failures in our policies, migrant workers and their families are not part of the official enumeration at any level of administration. For example, the national level census or the national sample survey - the two largest data collection exercise in the country - do not capture migration in any meaningful way. There's no accounting for city- or state-level migration flows. They are not part of the official population of the cities and their settlements themselves are either in the periphery of the city or they live in the confines of the work sites. So, their settlements are never enumerated as official or authorized of settlements by the city municipal corporation. This makes them completely invisible to the policy design and policy implementation machinery. They get left out of the scope of critical public services, like water and sanitation, immunization and other Public Health Services.

Another significant structural issue in our policies is the sedentary bias. It means that in order to access every single public service, one needs to provide a proof of domicile or residency in the city. One has to provide an address proof that they are a bona fide resident of the city to be able to access a public service in the city. Our survey found that more than 95% of the seasonal migrants do not have a ration card in the city. This meant that during the lockdown, they were completely out of the purview of the Public Distribution System (PDS) shops. Even the relief package announced by the Finance Minister which sought to provide relief through existing channels would not be useful for the migrant workers because they are outside these existing channels.

Intensification of the ration food supply through the PDS has not been beneficial for the migrants. One needs to establish domicile to be eligible for a whole host of welfare schemes, including health at a tertiary level. So what do they do? Usually when people fall sick because they are unable to access the health system in the city, they generally go back to the familiar pastures of their village where they live in remote areas, and where the level of primary health care that's available is anyway suboptimal.

On the impact of COVID-19 and lockdown on migrant populations

If we were to examine the kind of COVID-19-specific or the lockdown-specific impact on the migrant communities, I think it's been written about a lot in the media. But again, I just want to emphasize here that in the communities we work we are yet to see a spike in the COVID-19 cases; there have been some positive cases, but most of them have been managed through isolation. Many are stranded in very unhygienic and congested conditions, but the lockdown itself has created conditions where it has become difficult to access healthcare for a large number of other people suffering other morbidities like hypertension and diabetes. 

The public health experts in our organization are expecting a huge increase in the non-COVID-19-related mortality in the short-term because treatment and care for other illnesses have been severely compromised due to the attention towards COVID-19. For example, there is a huge delay in sputum testing for tuberculosis; antenatal and immunization care has been largely delayed for a lot of pregnant women; and, people also are unable to step out in case of illnesses to access health care because of police harassment, especially in rural areas.  

There's a huge fear of COVID-19 among migrant communities. There is lot of mental distress and rise in suicides, and domestic violence is also a huge issue. Some of the solutions need to be around strengthening public primary healthcare systems, so that burden on the large hospitals can be minimized. In our tuberculosis centers, we are distributing one month supply of TB medicines in one go, and providing cooked meals to children in anganwadis in general. Aajivika Bureau has been arguing very strongly for the repatriation of migrant workers back home from the cities, of course, after putting in place health protocols and screening them for a symptoms. 

Enumeration and identification of these ‘invisible’ migrant settlements to ensure that they receive public health care services will be right step to take to reduce the impact of COVID-19 on these communities.

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Watch the webinar HERE.

Visit India Alliance COVID-19 Resource Hub HERE.