New Delhi: In May 2021, Rakesh Deo, a migrant worker living in Pochanpur village in south-west Delhi, paid Rs 350 to his contractor's son for online Covid-19 vaccine registration for himself and his wife. "How am I supposed to register online for vaccination using this?" he said, pointing to his old and battered mobile phone loosely held together by a black tape.

With no internet service and a broken phone, Rakesh relied upon information from his contractor who informally made it compulsory for his workers to get vaccinated though there was no industry- or state-mandated mandate. Many migrant families in construction settlements near Pochanpur similarly depended on their contractors and employers for vaccine information.

Digital registration to get vaccinated had been one of the biggest hurdles that workers willing to get immunised faced, we reported in June 2021. Not only did the workers struggle in accessing the CoWin website, vaccines were not always available--vaccination across India had slowed down due to vaccine shortages, as IndiaSpend reported in April 2021.

By the end of May, the shift from online to on-site registration and walk-in vaccination was expected to bring welcome change. But problems persisted, making vaccination for migrant workers difficult at both source and destination, numerous migrant workers and civil society volunteers interviewed from May to August said.

However, in Shivpuri district of Madhya Pradesh (MP), which records a high rate of outmigration, intermediaries such as employers and civil society volunteers helped improve vaccine uptake at the community level. With the help of this case study, we examine how civil society can ensure vaccination access for marginalised workers in a rapidly privatising welfare system.

Limited rural public healthcare capacity

Largely rural and tribal, Shivpuri sees single males as well as families migrate to the neighbouring states of Delhi and Gujarat in search of daily wage work.

With the onset of the second wave of Covid-19, Pichhore town of Shivpuri, like many other parts of India, saw a janata curfew. The local administration popularised 'Mera gaon, meri suraksha' to emphasise the importance of restricting cross-border movement. The fear of the second wave, curfew in the town, and lockdowns in the destination states triggered a rapid return migration of daily wage workers to their homes, where they were quarantined for 14 days upon arrival.

Rural Pichhore with a population of about 180,000 has one community health centre and small private clinics. "With the onset of the curfew, people were rapidly moving back home and looking for vaccines; but how was one clinic supposed to handle so many people?" said a community agent of Chalo Network, an organisation which provides last-mile financial services to migrant households through an agent network.

Back in May, only government health centres in the area were empowered to hold vaccination drives as private clinics had limited credentials and lacked infrastructure for storing vaccines.

To tackle the capacity issue, the community health centre worked with Chalo Network agents and social organisation Gram Vaani--which works to improve grassroots information--to set up multiple vaccination camps in the area.

Vaccine hesitancy

This improved the supply of vaccination services, but misinformation about the side-effects of vaccines created vaccine hesitancy in the community and left many people hesitant. Migrant worker Ranjan Kumar in Shivpuri said his family was opposed to taking the jab since a neighbour had fallen sick after vaccination.

Dharmesh Dubey, a Chalo Network supervisor, said that low levels of digital access and lack of information about vaccines sent many locals after alternative traditional practices--visiting local saints (babas for nuskhas) to prevent/treat Covid-19, for instance--instead of getting vaccinated. "The resistance was coupled with fear in migrants who returned; they stopped recognising themselves as workers from Delhi due to the fear of being forced for vaccination to avoid further alienation in the community."

As an attempt to mitigate the growing vaccine skepticism, Chalo Network in Shivpuri used community agents and leaders to spread awareness about the merits of vaccination.

By collaborating with medical healthcare professionals and anganwadi workers, the CSO volunteers initiated a conversation about vaccination and created awareness with verified information. The volunteers also collaborated with local fair price shops to undertake advocacy among people who came to collect their rations, and mobilise the community against misinformation, Chalo agents told IndiaSpend.

Barriers in digital access and documentation

Roadblocks still remained. A community banking correspondent agent, who works in Pichhore for financial service delivery, and did not wish to be named, told us, "Over the last few months, people slowly started getting ready to take the vaccine but were still prevented by their [lack of] access to stable internet or devices which would enable them to register on the CoWin app. In many other cases, just like non-Covid times, people didn't have documentation such as Aadhaar which would allow them to get the vaccine."

In informal conversations, a Chalo community volunteer said that before the pandemic, many locals had to pay bribes, varying from Rs 600 to Rs 1,200, to middlemen to get their documentation in place. After Covid, as the need for documentation for vaccination grew, bribery increased.

To counter this problem, in Pichhore, civil society agents expanded their services to return migrants and the rural community by facilitating documentation and CoWin registration. They also followed up to ensure that vaccination certificates were provided on the phone and as printouts. "Initially people did not know how to obtain the praman patr [vaccination certificate]. When we started following up with them on the certificate two-three days after the vaccination, it not only helped with the paperwork but also built trust and enabled them to encourage more people to get vaccinated," the community banking correspondent agent said.

Vaccine reinforcement by employers

Issues of access and hesitancy were rampant in the rural community. But an overwhelming fear of losing work and income among workers who otherwise migrated to cities forced them to take up jobs in semi-urban areas or in seasonal farming. Workers such as Rajesh, 24, expressed the dual resentment of having faced "exclusion and marginalisation in cities alongside facing stereotypes upon return--as someone who brought Covid with them from the cities".

In order to overcome vaccine hesitancy, employers tied up with civil society organisations (CSOs) and health centres to conduct vaccination drives for their workers.

"In Pichhore, organisations such as Sewa Bharti and GAIL Limited set up vaccination drives to promote the uptake amongst the workers. We would talk to workers coming to the vaccination drive and follow up with them post vaccination to give them confidence which was otherwise shaken upon their return from the city," said Dubey, the Chalo supervisor.

Issues in destination areas

In the urban areas of Delhi-NCR and Mumbai, migrants highlighted a different set of issues. "I hardly have the same ease of access in Delhi as I have back home… here for everything I have to depend on the thekedar [contractor]; be it getting ration, doing paperwork or visiting a private clinic close to the worksite," Mahinder Singh, a daily wage worker in Delhi, said.

A sub-contracted worker in the informal economy, he said he was unable to access welfare benefits announced during the pandemic and the erratic payment of his wages reinforced his sense of insecurity. Many workers like him returned to their hometowns to a "relative sense of safety", he said, with the family around if "something happened" on getting vaccinated.

The relative financial security and stability of migrant workers settled in one place for a longer period enabled them to access vaccination earlier on. But the economically precarious, circular and short-term migrants working as daily wage workers showed more hesitancy--the fear of the side-effects and the potential loss of income discouraged them from getting vaccinated, Gram Vaani members in Manesar said.

Covid trauma and institutional mistrust

In migrant destination areas, the fear of the second wave gripped many inter-state workers. Ajay, 29, a migrant daily wage industrial worker in Delhi-NCR, said that not only did his economic precarity increase during the lockdown, the health crisis at its peak also heightened mistrust in healthcare institutions. "When the rich are unable to get a bed in the hospital, who will look after us nobodies in the city?"

Nitu Devi, a migrant domestic worker from Umaria, Madhya Pradesh, working in south-west Delhi, recounted how the loss of work and the death of three family members shook her trust in the system. Lack of timely access to empaneled Covid-19 hospitals in Delhi, she said, made her feel the "brokenness in the system for us. As if our lives didn't matter here". With employers and resident welfare associations in the capital rapidly mandating vaccination for domestic workers as an entry criterion, workers such as Nitu experienced "unease, hesitance and pressure" in having to get vaccinated, especially when their own residential localities expressed fear and displeasure for vaccination.

Reopening of the economy and vaccination

In industrial areas such as Seelampur, Manesar and Mumbai, workers noted an uptake of vaccination due to employers' demand, but barriers remained. In May, interviews with Suresh and Jam Singh, migrant workers in Manesar, showed that while some work continued during the second wave, the employers mandated vaccination for the workers. During this period, the lack of availability of vaccination and issues of slot cancellation on the CoWin app created disruption in workers' access to vaccination. "Even when the requirement of online registration was done away with, limited availability of vaccination forced workers on the worksite to travel to neighbouring districts of Rewari and Farrukhnagar to get vaccinated. We took a day off and in addition spent money to commute for the vaccination," said Suresh.

In contrast, interviews with migrant workers in New Delhi and Mumbai in July highlighted that there was also a growing demand among workers for vaccination due to increasing employer and state mandates. The growing demand for the vaccination certificate to enter public buildings, public transport and apartment complexes has led many workers to overcome their fears of inoculation in order to sustain livelihoods.

However, the acceptance of vaccination has not translated smoothly to access--low digital literacy and vaccine administrators' insistence on Aadhaar for documentation in urban areas remain. "Where I stayed people were resisting vaccination; many even advised me against it, but my employer (memsahib) told me the society would not allow me to enter if I didn't get the vaccine," Rekha Devi, a domestic helper working in an apartment complex in south-west Delhi, said.

Potential for intermediary engagement

Rafi, a Gram Vaani representative working with migrant communities in Manesar, Haryana, emphasised the need for awareness campaigns at grassroots to avoid common misapprehensions and misinformation around vaccines in densely populated settlements.

Like the rural CSO-employer initiatives, by shifting from a forced vaccination mandate to a system where community volunteers and CSOs can partner with healthcare facilities to aid vaccination camps and awareness drives, the gaps in India's vaccine coverage of migrant workers can be filled.

In cities that host migrant workers, employers and civil society can enable workers' access to healthcare and vaccination, at a time when the urban healthcare system is rapidly privatising and the state capacity remains limited.

IndiaSpend reached out to the office of the Union minister for labour and employment, and the health secretary of the Madhya Pradesh government for comment. We will update the story when we receive a response.

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