The health and well-being of female labour migrants from Nepal: A Qualitative Study of Stakeholder Views

Female labour migration from the global south to the Middle East has increased in recent times. The rights and health of these women are often severely affected during and post migration. The aim of this study was to provide a clearer understanding of the process and context of female labour migration from Nepal. This included reasons for female labour migration, the risks, benefits, health impacts and measures to better support and protect women before, during and post migration. Data in this paper is based on semi-structured interviews conducted with ten key stakeholders (staff working with support organisations, policy-makers and researchers in the field) all with a professional interest in female labour migration from Nepal. It was found that government restrictions on female labour migrants working in the domestic sector increased undocumented migration through India, increasing the risk of trafficking and exploitation. D espite these risks, migration is attractive to many Nepalese women as it offers an opportunity to improve livelihood for them and their family. In addition, it can provide a ‘window to empowerment’. The study concludes that restricted migration, implemented in the name of protection, has undermined the rights, security and health of many Nepalese women.


INTRODUCTION
International migration has significantly increased in Nepal. 1 Between 2008 and 2017, government authorities issued approximately 3.5 million permits to travel overseas for work, predominantly to the Gulf Cooperation Council (GCC) countries and Malaysia. 2Although male workers dominate migrant labour, there are increasing numbers of women working outside of Nepal, especially in the low skilled sector. 3 Increasing financial contributions to the economy and family are important, however, these financial contributions bring risks to the life, health and wellbeing of female migrant workers and their families. 4,5Risks include violence, exploitation, occupational hazards, mental ill health and suicide. 6,7,8fficially it is estimated that only 5-6% of Nepal's labour migrants are women. 9It is widely accepted that this percentage is inaccurate because a large proportion of female migrant workers travel using informal routes (often through India) are hence are not registered in official statistics. 10Unofficial data estimate that 30% are women, representing 90% of all unofficial migrant workers. 11Unofficial or undocumented migration refers to workers travelling to destination countries unofficially via 'the open' Indian border.The increase in the irregular route is the direct consequence of the 2017 Government of Nepal ban on women seeking domestic work in the Middle East. 3 The ban, as with previous restrictions on female labour migrants, is viewed as a protective measure and a response to human rights violations in destination countries, particularly in the Middle East. 9The ban restricts women in their opportunities to migrate for work and, whilst some would argue it has been done in good faith, it is also gendered and patriarchal 1 .
Despite bi-lateral and international agreements to protect the rights of migrant workers, including the International Labour Organisation (ILO) Domestic Workers Convention 2011 (No 189), the risk of exploitation and abuse remains high for women working in the Middle East. 12Simkhada and colleagues 7 found that female migrants and particularly domestic workers are expected to work long hours and be available 'around the clock'.Breaks and days off are rare and most women do not have the freedom or rights to challenge their employers.
The kafala sponsorship system in GCC's regulates the relationship between employers and migrant workers and is used to control the labour market. 13In essence, 'a migrant's immigration status is legally bound to an individual employer or sponsor and the former is completely dependent upon the latter for their livelihood and residency. 12Restrictions on freedom of movement and social interaction significantly impact on the mental health and wellbeing of domestic workers and increases their vulnerability further. 4,7,14Female migrant labour in the low skill sector, or those regarded as 3D jobs -'dirty, demeaning and dangerous' 9 -has become the norm across the global south.
Research suggests that pre-migration preparedness is critical to reducing harms and risks related to domestic work and promoting empowerment. 6,15Safer migration projects in Nepal aim to reduce 'risky migration' rather than to stop it altogether. 11espite this, female migrants remain vulnerable to exploitation and trafficking and often take enormous personal risks in their migration journeys.Therefore, this qualitative study aimed to find out how key stakeholders with a professional interest in female labour migration viewed the migration process.The research questions focus on the risks, benefits and health impact of labour migration and the support and protection needed by female migrant workers before, during and post migration.

MATERIALS AND METHODS
The research design started out as a basic interpretative qualitative study using semi-structured interviews.As the research progressed the interviewer, with little prior knowledge of the context, became more aware of the social, cultural, and political aspects of the situation which were shaping the decision making of female migrant labourers, albeit from the perspective of the stakeholders.In this sense the research study and particularly the analysis became more critical.This was not pre-meditated and as such the process remained inductive.
A total of ten stakeholders with a professional interest in female labour migration with details outlined in Table 1 were interviewed in Kathmandu Nepal.Nine interviews were carried out face-to-face and one online using Skype in November 2019.Seven stakeholders were initially recruited via networks known by one of the researchers and the remainder by snowball sampling.Eight participants agreed to be audio recorded.Two participants refused to record the interviews.In these two cases, notes were taken by the interviewer and a second native-Nepali researcher who also acted as an interpreter when required.All interviews were largely conducted in English and lasted between 60 to 90 minutes.All audiotaped interviews were transcribed.Saturation point had been achieved by the tenth interview.
Initial data analysis began by reading through the transcripts and interview notes. 16After a second reading, the first author manually coded the data and further thematic analysis was conducted through NVivo Pro 11. 17  Five female and five male stakeholders were interviewed, representing advocacy Non-Governmental Organisations (NGO), International Non-Governmental Organisations (INGO), policy makers and independent researchers (Table 1).

Themes
Four themes were identified in our qualitative analysis:

A culture of migration: Desperation or empowerment?
There is a culture of migration in Nepal where 'the export of people is normalized' (P3).Poverty and the lack of local earning opportunities are the biggest drivers of female migration from Nepal.'For many women there is a lack of meaningful employment.Also, a mismatch in skills training and job opportunities' (P3).Whilst males face more pressure from their families to migrate, women often have their own motivations.For some women it is an opportunity to get away from oppressive social structures, which 'make them vulnerable at home' (P9).Informants discussed the multiple challenges that women face in Nepal including abandonment, low levels of education and violence.As such, 'women have higher levels of desperation to migrate' (P2).Despite many being aware of the risks involved one participant was quite clear that women often have little choice when facing domestic violence or abandonment: They have to go, women have to take responsibility for childrenfood, school and health services and for in-laws.Often illiterate, no jobs suitable, cannot access funding for business, the only option is what she knows, looking after the house and children, cooking and cleaning.Domestic work is the only skill she can sell in the market (P1).A major pull factor is the increasing demand for workers particularly in the domestic and care sectors in the GCC and East Asia.Socioeconomic changes in these countries have created an increased demand for domestic labour and carers; traditional female occupations viewed as the 'feminization of labour migration' (P5).'The ageing population and females going out to work means there is a gap in care and increasing labour market demand in the Gulf' (P3).Although economic push/pull factors dominated discussions, these, 'do not capture the nuances of female labour migration' (P2).The impact of conflict, the earthquake (2015) and trade blockade on the Indian border has according to one participant 'weakened social cohesion, created a loss of social capital, trust and collective' (P7).Some areas are well known for migrant labour recruitment especially districts near the Indian border and in the Kathmandu Valley.Several participants noted that recruitment 'agents are very proactive in districts with higher vulnerability and a history of migration' (P3).Women making decisions about migration is a form of 'social empowerment which challenges the patriarchal structure of Nepalese society' (P1).Exercising your rights of mobility is empowering and provides an 'opportunity to see the world, get out of the village and experience a different culture (P2).Aspiration is a key driver, evidenced through numerous success stories of returning women who have bought land, built a house and sent their children to school.Remittances have improved the socio-economic conditions for many families.Others want the same.In addition, as one informant reminded the researcher, 'Nepal is expensive: land, food, education and health care is expensive' (P4).Importantly, most female labour migrants will return with more skills than they left with: 'New skills -like housekeeping, using technology, caring' (P5).

Exploitation and Trafficking: "Many women go despite the risks"
There are several well-known risks related to labour migration and often women travel under no illusions: 'Many women go despite knowing the risks' (P1).Women expect the work to be difficult but soon find themselves 'working 20-hour days and experiencing inhuman treatment' (P3).Additionally, 'women are going for low skilled jobs in domestic service -which are often gendered and highly unregulated' (P3).The kafala system in the Middle East impedes several human rights including mobility rights.In addition, the 'police and embassy staff have no rights of entrance into private houses' and so help is unlikely (P5).One participant likened kafala to 'modern slavery' (P6).
Irregular or undocumented migration through India has increased since the Nepal government banned women working in the domestic sector in the Middle East.As one informant commented it is 'economic desperation with no option but to travel without documentation' (P7).A number of informants considered the ban gendered and paternalistic.'The logic of the laws is rooted in gender assumptions -largely the protection of females rather than their rights' (P2).Undocumented migratory patterns 'increases the risk of trafficking and abuse even before they reach their destination country' (P3).'Many women are taken without knowing the destination.Told they are working for a company or factory but are taken to a domestic house' (P1).
When the process of migration is not formal, the vulnerable population knows nothing about where they are going, what they are going to do, their rights, what are the services and benefits they can uptake.There is no signed agreement and what is going to be there for them in the future (P6).
Many women will continue to defy the ban because of the lack of employment opportunities at home.Women's access to employment in Nepal is limited and as one participant noted 'the social and cultural norms around employability don't help women' (P10).Nepalese women often feel like second class citizens.If they are illiterate or semiliterate, they have little choice but to accept domestic work, either at home or abroad which 'dominates the migrant labour market for those with no or low skills' (P6), and for many "domestic work is the only skill they have to sell' (P1).
The most vulnerable women are from low-status ethnic or caste groups.'They are vulnerable at home because of caste discrimination, social environment -poverty, violence' (P9).Traditional social structures mean that 'these women are socioeconomically, politically and culturally excluded in society' (P1).'The Tamang are a marginalised community and development is just not happening in those districts' (P6).Geographically risky areas include those around the Kathmandu Valley where Tamang people are largely situated and are well known areas where human traffickers prey on vulnerable women.'The Tamang are a vulnerable population re undocumented route and are at risk of trafficking' (P7).Also, exclusion and poverty are related historically to 'the lack of access to land which drives migration and puts you at risk of trafficking' (P7).Health Impact: 'Health is not important to them; they are there to make money' Informants talked of the health risks related to working long hours and experiencing hunger and sleep deprivation.Risk of abuse was raised in all interviews.'Abuse -verbal, physical, sexual -unwanted pregnancies, getting citizenship for their children adds to their problems' (P2).Women are often stigmatised when they return for leaving Nepal to work overseas in the domestic sector.'Stigma is a big problem; people don't want to marry women who have migrated because they link migration to sex work' (P2).Women returning under difficult circumstances, pregnant or having ran away in the first place, adds a further layer of stigma and impacts on mental health.Almost all informants spoke of mental ill health as the major health consequence of migration for many women.'Risks for men and women are similar but there are different exposures, female's usually domestic workers face social hazards, violence, abuse, mental health and suicide' (P8).There is 'mental health suffering but people are reluctant to talk' (P.3).Returning to Nepal with poor health is 'challenging -families don't always want them back if they are sick, and many don't want to return to their family or community' (P5), thus those returning physically and mentally broken attract further stigma and exclusion.
Access to health and social services for women in destination countries can be challenging even for those who have taken the documented route and in theory have contracts and health insurance.However, having a health insurance card does not necessarily equate with service utilisation.Many women do not have the language skills to navigate health services or negotiate time off with their employers to keep medical appointments.'Even if they have insurance, they can't read the information (written in destination country language) or they don't understand the process' (P4).There is a 'lack of education, communication, language barriers, even if they have access to a health facility they cannot always communicate with the doctor' (P8).'Even when insured they may avoid if related to violence or sexual abuse' (P6).Women taking the irregular route will not be insured for health and are unlikely to receive any medical care unless it is an emergency.'Health is not important to them; they are there to make money' (P8) in addition 'it is not a priority for destination countries '(P10).
Measuring the health impact of migration is under researched.There is not enough data on the health of women before leaving nor on return, so what is known 'is the tip of an iceberg' (P6).Pre-departure health checks, which in theory are compulsory for women travelling through documented routes, are largely absent for those going through the irregular route.In addition, there is a mismatch between pre-departure health checks and destination in-country health surveillance.It is not unknown for women to be sent back.One participant commented that 'if they don't like what they see they send you back' (P4).'Some people are sent back because ill health is detected, TB [tuberculosis] is a common reason' (P8).This has implications for cost and the loss of money spent on the process which is not covered by any national insurance or compensation scheme.This raises important questions about the validity and regulation of pre-departure health checks.
The government are currently reviewing migrant labour health policy.There is an awareness of a number of challenges, which include pre-departure health checks, health related information in orientation programmes and the role of government in the health of women returning from migration.Some potential initiatives include: increasing regulation of pre-departure clinics and importance of licencing and bringing up to international standards; introducing health insurance for all migrant workers; improving preparedness and input of health information in pre-departure orientation (P6).
Pre-departure orientation is an important element of preparing labour migrants for their new lives and work in destination countries.Most informants regarded the training programme as 'too generic and not targeted' (P4).The Government is currently reviewing the programme but needs to be more 'practical, sector and country specific' (P.4).Additionally, migrant workers require more information on 'rights and health related to occupational health and safety and sexual health' (P2).
A significant number of women and particularly those who migrate through the irregular route need rehabilitation on their return.Local organisations operate through the airport and pick up returning women not able to return to their homes.They provide emergency shelters, health checks and some treatment, accommodation, food, skills training and counselling.These organisations reunite women with their families and reintegrate them into the community.This is often challenging though as 'many don't want to go home; some are not welcome' (P5).
'There is a lack of support for reintegration especially for the most vulnerable women' (P2).Women returning broken and without the finances expected carry stigma and shame.This is all the more shocking that these are the very women who are most vulnerable in Nepalese society.

Rights vs Protection: 'Nepalese women are not safe or secure anywhere in the world'
The Nepalese government ban on domestic work was in theory to protect women from poor working conditions and the risk of abuse.This is challenged by many organisations and advocacy groups: 'the ban was implemented with good intention, but it is not working' (P6).The regulation of migrant labour is gendered because it 'focuses on the protection of families rather than their (women's) rights' (P2).Some of the stakeholders discussed the government role as being patriarchal and conforming to the norms of traditional society.'Patriarchy, power relations, women's inequality and poverty' drive female migration (P7).'Laws aim to be gender neutral' (P10) however, in Nepal the government focus 'is on male migration, women are neglected' (P3).'Nepalese women are not safe or secure anywhere in the world -the ban is based on security and protection, but they are not protected or secure at home' (P1).
As pressures increase from advocacy groups and IGOs to lift the ban, the government is currently considering options.Lifting the ban could reduce the risks for many women, however, one informant noted that 'even if the ban is lifted some women would still go through the undocumented route' (P5).Such is the power of the agents/recruiters, the 'middlemen' who still motivate and persuade women not able to meet the costs associated with legal migration to go over the border.Nevertheless, lifting the ban could improve a number of benefits for women, 'if women can go the legal way to the GCC then there is more chance for health checks, compensation and better health outcomes' (P5).
Advocacy is an important element of the work of local NGO's and intergovernmental organisations.One local NGO's aim is to 'reduce the vulnerability of women in migration and the risk of trafficking and human slavery' (P1).However, this can only be achieved by 'working to ensure the rights of women and migrant workers' (P1).One recurring theme was the importance of reaching out to women and providing information, particularly in high-risk districts.The focus is not to prevent migration but to increase awareness of the risks and facilitate an 'informed choice' and promote 'safe, orderly migration' (P6).Afterall, 'migration is a human right, but it needs to be safe and documented' (P10).
The Government of Nepal has a critical role in negotiating better working conditions for its citizens migrating for work in the low skill sector, though clearly this is challenging.Informants spoke of the need for collaboration with other sending countries and intergovernmental organisations.'Government needs to work with international bodies to put pressure on destination countries.Work with other sending countries to reach mutual agreement' (P3).Power lies with the destination countries and whilst the 'government policy is to push for bilateral government agreements on labour; however, many destination countries do not want to sign' (P3).

DISCUSSION
This paper highlights that female labour migration is becoming normalised in Nepal 18 , in other words, it has become part of the culture (theme 1).Women with higher levels of skill and education and those who can go through the formal route often do well and are not necessarily at risk. 19However, as noted in these findings an increasing number of women are taking an irregular migration route out of Nepal via India and often not knowing where their destination is.Moreover, they are leaving behind a vulnerable population of elderly and children in villages across Nepal. 7aws and policies in Nepal are still considered as patriarchal and gendered by many of the informants in this research.Migration is not gender neutral, yet migration governance continues to be 'gender blind' and patriarchal. 1,20 Tp.18 Nevertheless, the opportunity of earning a living that could take women and their family out of poverty, learning new skills, developing self-confidence and agency are important pull factors. 18 key issue that emerged from the interviews is where the boundary lies between labour migration, forced labour, trafficking and human slavery (theme 2), or what Yousaf refers to as the 'migration-trafficking nexus'. 24Trafficking is a challenging concept and the boundary between free choice migration and trafficking risk is a fine line.Trafficking includes a range of actions from the more obvious use of violence to the more ambiguous use of fraud and deception. 25omen who migrate through an irregular route are rarely aware of their final destination country and often misled about the job.As reported in this research irregular female migration is rife in Nepal and is linked to trafficking and gender-based violence. 26There are several districts in Nepal, even villages, that are well known to be risk areas for irregular migrant labour recruitment and trafficking 11 , which was reconfirmed in this research.Whilst no-one knowingly goes into a position of slavery the miss-selling of work, benefits and risks puts tens of thousands of women into precarious positions and many of these from the most disadvantaged and marginal communities in Nepal.
Our third theme is migrant health, which is increasingly recognised as important across a number of global agreements including the Sustainable Development Goals' (SDGs). 14Our interviewees noted that many women will experience extremely challenging working and living conditions which endangers their health and wellbeing as reported elsewhere. 6,4,27 Np.813In addition, many migrants have no access to basic health and social services and confirmed by the IOM 29 they have 'restricted or no access to legal, social, or health protection, including basic reproductive health rights'.Contracting STIs including HIV/AIDS and experiencing an unplanned pregnancy are health risks reported here and in other research studies. 4,30Health problems are intensified in destination countries by 'discrimination, language and cultural barriers'. 7ental health is increasingly seen as one of the biggest health threats globally and emerged as an important https://doi.org/10.46405/ejms.v3i2.384sub-theme in this research.Female migration is stigmatised in Nepal, and all too often is linked to sex work or promiscuity. 11uicide was mentioned in several interviews, though data is not available to confirm this, other researchers have found similar findings. 31Increasing mental health concerns have been found in returning migrants across a number of countries which has been linked to the abusive working conditions that many women suffer in the domestic sector. 8,27,32Women returning with mental health problems are further stigmatised in their communities and may not be welcome.In addition, the mental health infrastructure in Nepal is inadequate to support these returnee women traumatised by their experience. 31p.2 Rights, health and welfare need to be considered and promoted in all three stages of migration: pre, during and post. 9indings here question whether pre-departure health checks are rigorous enough even for women on the regulated route out of Nepal; clearly very little is known about the health status of women leaving Nepal on the irregular route.Tightening the regulation of pre-departure checks would be one way of enhancing women's health and ensuring timely treatment of pre-existing conditions.Nepal's recent National Health Policy (2019) seeks to address the health vulnerability of migrant workers and is currently developing a National Migration Health Strategy. 33This includes improving regulation of the predeparture health checks, monitoring and data collection, access to health services in destination countries and assessing the health of migrant workers from high-risk destination countries.This is an important policy development and highlights Nepal's commitment to the SDGs.
As part of rights and protection (theme 4), both the action of the government and governance processes are critical to SDG 10.7 facilitating safe, regular and responsible labour migration governed by well-planned and well-managed migration policies. 34Whilst there is common agreement that labour migration is beneficial to national development the ILO 35, p.9 reports that the 'development benefits of labour migration depend on the degree to which the migrants are protected and empowered by' both 'origin and destination countries'.The various bans on women working in domestic work across the GCC and Middle East has not provided the safety or security of these women as anticipated. 36A UN Special Rapporteur on migration regard bans as ineffective and often lead women to migrate through irregular channels, increasing their risk of trafficking. 33A recommendation given by the IOM report in 2019 suggested a review of the ban and it was clear from the informants here that the review was under way.
The government is aware of the current risks related to female labour migration and particularly those related to women taking the irregular route. 33They are currently working collaboratively with several IGO and NGO organisations across a number of districts to improve the safety of female migrants.This includes community-based projects raising awareness amongst women about the dangers of migrating through the undocumented route. 37Despite the good intentions of the premigration intervention programmes, these have had little effect to date in improving migration experiences. 11,38i-lateral country agreements are meant to protect workers' rights however, this is only recognised in those with formal contracts. 9Rights are further eroded in GCC countries which still operate the kafala system where the mobility of domestic workers is curtailed for at least two years. 31The ILO regard this scenario as 'ripe for human rights violations and erosion of labour standards'. 12It is another layer of practice in the migration cycle which disadvantages further some of the most vulnerable women on the planet.A practice, which sender countries and recruitment organisations contribute to, knowingly or unknowingly.p.814 CONCLUSION This research reflected that there is a culture of migration in Nepalese society.Increasingly women are following this culture by migrating to various countries for work.Nepalese female labour migrants are particularly vulnerable since the Government ban on domestic work and specifically in middle eastern countries where demand for unskilled labour remains high.The opportunity to improve socio-economic position, develop new skills and experience personal empowerment, have not been accessible for many women in Nepal.A structured and gendered society still dominated by patriarchy and religious traditions undermine the rights of many women to development opportunities at home and abroad.More recently in the name of protection women have been forced into a precarious situation taking an irregular migration route via India.This increases the risk of forced labour and human trafficking.
The opinion of stakeholders in this research highlighted a nuanced debate about the rights of women to migrate for work on the one hand, whilst needing to protect them from exploitation and trafficking on the other.The governance of international labour migration goes beyond the responsibility of a single state and given Nepal is a fledgling democracy, stronger global protective measures are needed.
Whilst nobody can predict the future of labour migration any time soon, there is still a role for improving the governance of migration on the one hand and developing employability and opportunities for women at home, on the other.Decentralisation of responsibilities and governance to provincial, district and ward levels could enhance development opportunities locally and reduce the risks related to precarious living conditions for the rural poor, especially women.This will take time and may not ensure the rights and freedoms of women in more traditional rural societies.Central government will still need to play a leading role in ensuring that the rights of women enshrined in the constitution are upheld.Safer migration processes could also be decentralized to districts, with improved pre-departure training, health checks and integration for returning women.Authors' Contribution: Conceptualization of the research project RK, EvT and PS; data collection and analysis by RK; review of data by EvT and PS and draft paper by RK.All authors assisted in the interpretation of data, manuscript reviewing and editing, and approved for the final submission.

Conflict of Interests:
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.Ethical Statements: I/We declare that I/we have taken all necessary ethical approval and permissions from our institution and/or department for conducting and publishing the present work, and don't have any ethical problems/issues.Statement for Data Availability: We attest that, if requested by the editors, I/we will provide the data/information or will cooperate fully in obtaining and providing the data/information on which the manuscript is based, for the examination by the editors or their assignees.
Coded transcripts and themes emerging from the data were shared and discussed with the co-researchers.Ethical approval was obtained from Liverpool John Moore University, UK Research Ethics Committee (UREC reference: 19/PHI/043) and the Nepal Health Research Council (Ref.163/2019).Informed consent was obtained from participants and all names removed from transcripts to maintain confidentiality.