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UHC for the Modern Migrant: Lessons Learned from China’s Hukou System

By Elena Schmider
on September 21, 2017

With the majority of the world’s population living in urban settings, strengthening the capacity of social systems to adequately respond to the needs of mobile, urban populations, and revisiting older policies that no longer fit the needs of increasingly urban populations, is critical in the quest for universal coverage. Today’s urban societies feed a globalised network of markets, which in turn dictates the hierarchy of economies worldwide. For developing countries, the struggle to urbanise and diminish the comparative advantage that the world’s largest economies hold over their own is a long and competitive process.

For China, however, the struggle lies not with advancing the process of urbanisation, but in controlling it. With a population exceeding 1.3 billion, the Chinese government faces an ongoing effort to regulate internal migration towards the country’s most urban and affluent regions. China’s movement away from socialism, and towards policies of more open economic reform in 1979, has had a significant impact on the country’s development, and as a consequence, socialist policies of old needed to adapt to the increasingly capitalist orientation of China’s economy. The household registration system (the hukou system) constraining the free movement of labour is a prime example.

The hukou system permits Chinese citizens to access welfare services such as health and education only in the area where they were born, and prohibits migration without great financial cost and the official consent from the government. The policy has acted as the chief deterrent of internal migration for nearly seven decades. Whilst the policy was originally a method of guaranteeing the distribution of entitlements such as healthcare and insurance to Chinese citizens, the system now arguably counters the values of modern Chinese society, which increasingly demands free movement. Despite the regulatory hukou system, a vast population of workers migrates illegally to cities in China’s Special Economic Zones each year. The World Health Organization (WHO) and the International Organization for Migration (IOM) both recognise that migration has a direct impact on the health of established communities, and only more so when illegal or unregulated migration occurs. This is highly relevant to the case of China’s urbanisation process, where migrant workers from rural areas pour into urban societies, disregarding the regulations of the hukou system. Furthermore, there are few systems in place to account for migrants in China and their health and protection. Firstly, the current healthcare system in China is limited by its links to the hukou system. According to the hukou system, if a person wishes to move permanently to another region in China, they must apply and pay for a new hukou, which is an expensive and lengthy undertaking. Increasingly, migrants opt not to buy a new hukou, not only because it is expensive, but also for the future prospects and security of returning to the land and entitlements they left behind. Without the appropriate hukou, accessing healthcare insurance is difficult and expensive. As a consequence, a large portion of China’s migrant population is left untreated and unable to access health insurance.

Further complicating the matter, unbinding employment contracts pose a critical issue for migrants and their entitlement to insurance and reimbursement for workplace injuries and diseases. Employers of illegal migrant workers are often not held accountable to workplace health and safety regulations and insurance entitlements for their employees because of the informal nature of the contracts given. Thus, migrant workers who develop diseases or injuries directly linked to the workplace have little-to-no proof of employment when seeking reimbursement for treatment. For example, this is commonly the case for workers that develop Pneumoconiosis, a kind of lung disease that in China is commonly contracted in the workplace. Work safety bureaus and hospitals now conduct their own investigations into the employment situation of migrant workers without a hukou in each case – a decentralised solution to a broader systemic problem. The lack of recorded data on the health of migrant workers in urban settings makes the effectiveness of such initiatives difficult to determine and leaves the system unresponsive to workers’ needs.

In recognising key issues surrounding migrants and limited access to healthcare and reimbursement, China’s next step will be to continue to work alongside organisations such as the World Health Organisation and International Organisation for Migration to find an appropriate solution. The ‘1st International Forum on New Urbanisation, Health and Social Integration of Migrant Population,’ convened in Beijing in August 2017, opened up discussions about future plans for improving the health and health systems of Chinese migrant workers. Speakers from various organisations, countries and universities presented international experiences and approaches to managing the social impacts of migration.

Whilst China’s experience of New Urbanisation is unique, it is not unfamiliar to international experiences. China has been pragmatic and driven in seeking ways to facilitate a more inclusive environment for migrant workers in its social systems. Broader social policies have had to be re-examined and restructured to ensure that the health system can forge a more inclusive environment and respond to the population’s changing needs. This serves as a case study in the need for more dynamic social policies and their roles in helping countries move closer towards universal coverage and achieving the sustainable development goals.

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