The ‘Spirit of Mumbai’ is a phrase many people like to use to indicate that life in the never-sleeping metropolis is tough, yet ‘worth it’. It’s a land of opportunity where people come to chase their dreams and change their destiny. So promising is Mumbai’s allure that every year, several thousand young men and women move here from far-off states, particularly Uttar Pradesh and Bihar. But is Mayanagri (the city of dreams) able to adequately take care of the health of its migrant population? 

An Empathy Exercise

Imagine you are a 19-year-old from Azamgarh in UP, and your maternal uncle got you a job at a factory on the outskirts of Mumbai. Your family needs all the financial aid they can get, as you have three other siblings and barely any agricultural land to cultivate in the village. You pack your bags and head to Kalyan (Thane district) via the Gorakhpur express, where you see thousands of young men just like you, headed to Mumbai for a better future. 

When you arrive at the place, it is loud, chaotic and unorganised. You live with six other men in a cramped ‘room’, the walls of which are so old and worn down that they may fall anytime. There’s an open drain just at the entrance to your building, which houses rats and breeds several insects. Your commute to work (walking) takes around 40 minutes one way, and you are expected to work almost 12 hours per day, or your salary will be deducted.

In the middle of this, you develop a toothache. You cannot afford to skip work to get it checked, even for a couple of hours, because you are new and at the risk of losing your job (many of the people who came to the city along with you still haven't found jobs, and you know you are replaceable). 

Someone gives you some gutkha (smokeless tobacco) to chew, and that helps with the pain. 

Eventually, the pain stops, but your gutkha habit continues. 

One of your roommates has been coughing perpetually, and he is urged to get himself checked, since there is a prevalence of tuberculosis (TB) cases in your area. Indeed, your roommate tests positive for TB, starts his medication, but refuses to isolate and move out because where will he even go? He has bills to pay and money to send back to his village every month. 

So you live with the looming threat of a chronic respiratory disease, added to the threat of your building falling upon you, dengue and other infections caused by disease-carrying pests in your premises, your rotten tooth and your now permanent gutka habit.

It happens one day. You wake up because your rotten tooth starts hurting severely, you have a fever, and half of your face is swollen. Your uncle takes you to the nearby municipal hospital, but you find out there is no dental specialist there. 

Then, you head to the nearest government hospital with a dental section, a 90-minute journey by the local train. They give you a list of medicines to take and inform you that surgery is required, which can be performed at the earliest after two days, since you reported late during the weekend, and the specialist staff have left. 

Feeling weak and in pain, on the journey back, you decide to visit a clinic near your room known for its cheap treatment rates. You and your uncle have already lost the day’s pay travelling in search of a doctor (almost 500 Rupees from each person’s salary), and visiting a private clinic will cost you a minimum of Rs 500 more. 

Your neighbour warns you that the ‘doctor’ running the clinic you end up visiting doesn't even have a medical degree, but he’s all you can rely on and afford at this point. You are forced to put your health in the hands of a compounder/technician and hope you will be okay.

Reality Check

Healthcare professionals from Mumbai, especially those in the public or social sector, away from fancy air-conditioned setups, know that Mumbai and its suburbs are short on government health infrastructure. The majority of the lower-middle-class and poor people are unable to access it. They have to resort to expensive private clinics (if affordable), trust-run or charitable hospitals, or low-standard medical setups run by underqualified or unqualified medical professionals, often referred to as "quacks" within the medical community. 

Seeking treatment at such setups puts these patients at risk for complications, which may worsen their situation. “There is a doctor at the corner, who for Rs 100 will put medicine in the tooth, and it stops the pain. He has a long line of people in front of his shop, since everyone goes to him even knowing he is not a real doctor,” Mushtaq, a 23-year-old construction worker, tells us. 

Since most migrants work excessive hours in their day and endeavour to save money to send back to their hometown as remittances, health expenditure often becomes an additional expense, one which has not been planned for. ‘I send most of the money I earn here back to my village, but this month, since my tooth is troubling me, I will have to work extra because I cannot afford to send a lesser amount home,’ says Rajesh, a casual labourer working as cleaning staff at a hotel. 

In the game of remittance saving, long working hours, expensive private healthcare, and overburdened government hospitals, these urban lower-middle-class and poor individuals are the ones who end up being hit the hardest.

Labour working in the organised sector, such as factory workers of large corporate firms, have access to healthcare through industrial health workers, workers’ union support and government schemes, such as the Employee’s State Insurance Corporation (ESIC). But not all migrants find jobs in the organised sector. 

Those in the unorganised sector, which is a significant number, lack job security and may not even earn wages that comply with the minimum standard set by law. They experience unsafe working environments, unhygienic living conditions and minimal to no access to quality healthcare. 

Given the high health risks, if a migrant worker falls severely ill, they may be forced to return to their original place of residence, leaving behind the Spirit of Mumbai and all they have worked towards. This only highlights the shortcomings in our public health system. 

The COVID-19 lockdown was a glaring example of this, when almost half the migrant population in Mumbai had to go back to their place of origin for various reasons, a major one being fear of contracting the disease and lack of access to affordable healthcare services to tackle it in the city.

Buniyaad

Some non-profit organisations have successfully attempted to address the issue of healthcare for migrant workers. Buniyaad, a social action group working with brick kiln workers in Uttar Pradesh, has been able to facilitate government services, such as health check-ups, vaccination drives and the issuance of BOCW cards (Building and Other Construction Workers) for workers migrating to these sites during the brick-making season. 

The BOCW cards not only provide financial aid for medical expenses, maternity benefits, and accident coverage, but also help workers acquire a pension, educational assistance for their children, and support for family members in the event of death. 

We spoke to some members of the Buniyaad team, who informed us that they faced challenges in convincing the brick kiln owners and the primary health centre (PHC) to participate in and conduct health check-ups and vaccination camps at brick kilns in Mathura, Jaunpur, and other districts in UP. However, the response from all three parties was positive after this first step was taken, and each party benefited from the exercise in some way. 

The PHC was made aware of this demographic of patients, since such kilns are far away from villages and cities. The kiln workers were made to feel seen and heard by both their employers and the government health authorities. Finally, the kiln owners were assured of healthier workers, as the message of health prevention and sanitation was reiterated amongst the workers. “Once all parties at stake understand the benefits of such initiatives, it is easy to sustain such practices”, says Alok Ranjan, one of the members on the field at Buniyaad.

The Way Forward

There is a need to expand healthcare services for the poor in urban areas. A recent report from the Ministry of Labour and Employment, which outlines the main schemes in place for the progress of India's migrant workforce, mentions the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). The AB-PMJAY was launched in 2018, but its benefits were extended to migrant workers in June 2020.

As part of the scheme, beneficiaries can avail of treatment at any empanelled hospital across India, regardless of their home state. Migrant workers and unorganised labour registered on the government’s e-Shram portal also gain access to 12 other government social security schemes. 

While these are considerable steps in favour of India’s unorganised migrant labour, the on-ground implementation of these measures has proven to be a challenge. Several times, migrants lack awareness of their eligibility for such schemes or face difficulties accessing these services due to the lack of a stable address and the informal nature of their work. 

Additionally, since PMJAY does not cover outpatient expenses such as first aid and emergency care, most low-income patients are unable to afford these out-of-pocket expenditures. Researchers suggest extending PMJAY benefits to outpatient care and the central government’s proactive role in capacity-building and regulation, not just policymaking, to help address the specific needs of unorganised and migrant labour in the country.

The term ‘migrant’ only appears once in our National Health Policy 2017, in the context of ‘prioritising addressing the primary health care needs’ of this vulnerable population. However, some states are leading the way for better provisions for them.

Kerala’s Public Health Act of 2023 particularly defines the term ‘migrant labourer’ as ‘people from outside the State and residing in the State for doing various works for the purpose of livelihood.’ It also outlines specific provisions for migrant workers, including regular health check-ups, recording the presence of communicable diseases among them, treatment for these diseases, and measures to prevent their spread. 

Rajasthan’s Jan Aadhar card initiative provides a single identity card which links multiple services, thereby enhancing access to various government benefits for migrant families across the state. 

But regardless of legislation and government processes, municipal hospital infrastructure needs to be expanded, as they are the first line of support for the urban poor. Specialised healthcare facilities (such as dental and gynaecological) also need to be updated in these establishments. 

Private players and non-governmental organisations can also render healthcare support to unorganised and migrant labour. Some non-profit institutions also provide support and outreach activities for migrants. The Basic Health Services Trust has successfully established primary healthcare services in high-migration communities in Rajasthan. They work with migrant labour engaged in stone carving, which is a profession with a high incidence of respiratory issues such as tuberculosis and silicosis. 

As we develop as a nation and build a rapidly growing economy, we must consider the needs of the migrant urban poor. They're the ones who lay down our roads, raise our buildings and make essential items for us in factories. Everyone deserves to earn a living to sustain themselves and their loved ones, and to be safe and healthy while doing so. While working to achieve universal health coverage in remote villages and forests, let’s not forget those who live among us in the cities, who are being left behind.

Edited by Parth Sharma
Image by Janvi Bokoliya