Today, one in every five Chinese is a migrant worker, or “Nong Min Gong” in Chinese, which literally translates into “farmer–worker”. These farmers have typically migrated from a poverty-stricken village in one of China’s inland provinces, become a worker at a factory or a construction site in a coastal, affluent city, and have been playing their part in making China the economic powerhouse it is today. Together, they constitute a massive wave of migration – one of the largest on the history of mankind – unleashed by the economic reforms carried out in the late 1970s, which saw China’s transition from a planned economy to a largely free-market economy.

Rapid economic growth usually produces winners and losers. One of the most acute expressions of inequality in China today is the fact that its 262-million-strong migrant worker population represents a group that is often systematically excluded from urban resources and opportunities, one of which is access to healthcare. According to the World Health Organization (WHO), China is ranked close to the bottom in terms of the fairness of its healthcare system, appearing at 188 out of 191 countries.

Conventional wisdom tells us that a migrant worker should be in better health than the average rural resident, because it is the young, healthy and entrepreneurial ones who have the mobility to migrate, leaving the old, sickly and disabled ones at home. This phenomenon, dubbed the “healthy migrant effect”, reflects the self-selection of healthy migrants and has been described in many migrant populations.

However, once in the city, migrant workers face significantly higher risks of getting ill as well as of not getting the needed treatment when they are ill. It has been well documented that migrant workers in China work for outrageous hours (often for 15 hours a day, 7 days a week) and minimal wages in hideous working conditions, which often expose them to various types of occupational hazards. Workplace accidents are common, health insurance coverage is low, and paid sick leave is practically unheard of.

According to the Ministry of Health, the most prevalent occupational disease in China is pneumoconiosis (a.k.a. “black lung disease”), accounting for 87% of the total, with a mortality rate in excess of 20%. Pneumoconiosis is a chronic disease of the lung resulting from long-term inhalation of dust and primarily affects miners, sandblasters and metal grinders – occupations that are predominantly undertaken by migrant workers. This, coupled with the hundreds of mining accidents that occur each year, has made China’s coal mines the world’s deadliest. In other industries, migrant workers are not entirely safe either. They routinely find themselves victimized by workplace hazards, accidents and diseases.

Compared to permanent urban dwellers, migrant workers face higher chances of poor health, yet lower chances of accessing and affording treatment. China’s social welfare system has been described by the Guardian as “inconsistent, inadequate, inefficient and often riddled with corruption”. A key institutional barrier that has prevented migrant workers’ equal access to healthcare benefits is the Hukou, or household registration system. Hukous are categorized into urban ones and rural ones, which give the holder different entitlements. When a person moves from a rural area to a city, his/her Hukou retains its rural status - the government has made it all but impossible to switch easily to an urban one, in fear of opening a floodgate for rural migrants. While the average urban employee is covered by the urban health insurance system (which is work unit-based, with employers and employees making contributions), migrant workers therefore find themselves excluded from these schemes.

A study by the National Center for Biotechnology found that when migrant workers get ill, their most common coping strategy is to “just hold on”, followed by self treatment with over the counter (OTC) medicines, using home remedies, and receiving care in private small (usually unlicensed) clinics. Visiting the hospital represents the last resort, used only when they have exhausted other options or find themselves seriously ill. This unwillingness can be explained by both unaffordability and inaccessibility. A report released in 2006 showed that the average inpatient care cost per person-time for migrant workers was 4745.5 RMB, while the average monthly income was only 970 RMB. Strict working schedules and long physical distances further increase the opportunity cost of seeking treatment in public hospitals.

This abysmal state of affairs is not just an infringement upon the migrant worker’s right to a healthy life, but also a social problem that can produce far-reaching consequences. The migrant worker, expected to be the biggest breadwinner of the family, can be turned into its heaviest burden, with medical bills often amounting to years of family savings. Moreover, with their high mobility, migrant workers are potential transmitters of communicable diseases, including Sexually Transmitted Diseases (STDs).

A lot can and should be done to improve the health status of migrant workers. For starters, the government should improve its health insurance system and push towards universal coverage. China's 12th five-year plan makes it clear that improving the safety net is a priority, and the government has conducted pilot projects to extend basic health insurance to migrant workers.

Improving health insurance coverage would be helpful, but is only part of the solution. Efforts should be made to change the fragmented regional nature of China’s health-care financing where coverage cannot be transferred when an individual moves to a new region. Such rigidity has prompted some migrant worker groups to advocate quitting insurance schemes altogether.

Another solution is the regulation and subsidization of private clinics, which are often unlicensed but popular among migrant workers due to their greater affordability and accessibility. If equipped with the proper resources and trained personnel, these clinics could become a realistic and reliable go-to place for afflicted migrant workers.

When Chinese leaders speak of the “Chinese Dream”, they are referring to the kind of striving spirit that has propelled millions of migrant workers to leave their villages in search of a better life.  The inconvenient truth is that these dreamers are often frustrated or even devastated by the harsh reality of unequal rights and unreasonable systems. It is time to reward the builders of China’s economic miracle with what they deserve.