Archery is popular in parts of tribal India. It is a precision sport - how close to the target can one shoot? What if this target is moving all the time? Even former World #1 Deepika Kumari would struggle. There is a similar issue in the delivery of health services. Several Indians, even pregnant women, move frequently making it difficult to ensure delivery of end-to-end care during the 1000-day period from pregnancy till the child turns two.
So, how many Indians migrate? Census 2011 pegged total migrants at 450 million (hypothetically, to understand the scale, if they constituted a separate country, it would be the third most populous country in the world after China and India), of whom 13% (~60 million) are inter-state migrants. The Economic Survey 2016-17 estimated annual work-related inter-state migration at close to 9 million people (higher than Census 2011 figure of 3.5 million)
Migration is rising and will likely rise further. Annual labour migrant growth rate increased from 2.4% (1991-2001) to 4.5% (2001-2011) with out-migrants in the 20-29 age group doubling in the latter decade. As per Census 2011, 69% of migrants are women. As one would expect, the Economic Survey shows that net in-migration is higher in urban centres such as Delhi, Maharashtra, Goa and Tamil Nadu while states with traditionally poor health outcomes including Uttar Pradesh, Bihar, Jharkhand and Madhya Pradesh have the highest net out-migration.
Recently, while travelling in a district with poor health outcomes and a large tribal population, I noticed a curious phenomenon. Several couples migrated to urban centres immediately after marriage. However, most of them would return to their home village within a year, with the woman pregnant and close to her delivery date. As a result, when she gets registered for ante-natal care, her pregnancy is in her last stages.
A 2013 study by AIIMS researchers Kusuma, Kumari and Kaushal looked at migrant maternal health-seeking behaviour with respect to ante-natal care and institutional delivery, in Delhi. The results are striking - only 49% of recent migrants received the desired 4 ante-natal checks. Record of home-based post-natal care for recent migrants was also much lower than settled residents
It may be inferred that migrant women may have inadequate access to care both due to lack of knowledge and relatively unwelcoming service. Various studies, Indian and international, show that migrants have poorer maternal health indicators than natives.
In India, it is typical for pregnant women to return to their parental homes at the time of delivery. It had its genesis in the idea that women could pay due attention to their health needs and get relief from domestic and work-related burden. It is now an ingrained custom followed in many parts of the country. Often, therefore, women register their pregnancy and get early ANC checks elsewhere before returning home for final checks, delivery and postnatal care. Due to the lack of continuity of service providers, care is compromised.
Moreover, some states - notably Madhya Pradesh, Tamil Nadu, Telangana and Odisha - offer conditional cash payments on fulfilment of certain conditions - stipulated ANC checks, institutional delivery, birth registration, early breastfeeding and immunisation. Such schemes also encourage women to return home to deliver. That said, the Pradhan Mantri Matru Vandana Yojana (PMMVY), a similar scheme offered by the Central Government, allows women to avail cash benefit irrespective of location within India.
Migration is a reality. What can be done to ensure that women receive appropriate care, irrespective of migration? First, there is a need for improved and targeted supply of healthcare services to migrants. Government and civil society, particularly in urban centres which are the hubs of in-migration, must work together to address the specific needs of the migrant population. Health workers must be encouraged to reach out to migrant population to ensure that they are not left behind.
At the same time, it is important to ensure that frontline workers, both serving beneficiaries at in-migration locations and those serving beneficiaries on their return to home stations are incentivized for providing health services - this should be regardless of the origin/domicile of the beneficiary. A frontline worker serving an out-migrant, or an in-migrant woman should at the least be entitled to her incentive pro-rata for the ante-natal or post-natal services rendered.
Solutions such as a unique ID (probably Aadhaar) and electronic health records can help increase accessibility and portability of benefits. They can also enable citizens to avail benefits of state-specific schemes irrespective of geographical location. Further, empanelling more accredited private facilities can help migrant workers access care more easily without worrying about losing benefits.
There is also a pressing need to drive awareness regarding the need for continued care during pregnancy, safe delivery and appropriate post-natal care. People need to know that they can access maternal health services wherever they are, and the need to carefully maintain the Mother-Child Protection (MCP) card containing records of care received.
The public must also be made aware of the various benefits they are eligible for in order to ensure safe pregnancy and childbirth. To build awareness and educate citizens on maternal health and related entitlements, the role of frontline health workers is key.
Migration brings along with it, numerous struggles. Migrants lose various social entitlements, including PDS, due to registration at home location. Maternal and newborn care is too important to be optional. Areas with in-migration must reach out to migrant communities to achieve greater access and improved care. Simultaneously, citizens should be educated about the need for quality, consistent maternal care and the associated rights and entitlements.
(The writer is the CEO, Antara Foundation. He has worked in management consulting with Arthur D Little and KPMG)