Universal Health Coverage for Undocumented Migrant Workers in Thailand: Challenges in Policy Implementation

Background: The number of international migrants has been increasing from 2.8% of the world population in 2010 to 3.6% in 2020 according to a recent estimation of the United Nations (UN). One of the many challenges in migrants’ health is to obtain universal health coverage (UHC) in the host countries. The Sustainable Development Goals (SDG) urge policymakers to achieve UHC for all regardless of their nationality that each country is responsible for planning and implementing adequate policies towards migrant’s health. According to the Thai migration report in 2019, almost 5 million non-Thai are residing in Thailand. A majority are low-skilled migrant workers (LSMW) from neighbouring countries including Cambodia, Laos, and Myanmar (CLM). Only half of the LSMW, including the undocumented migrant workers (UMW), were covered by public health insurance in 2018. A signicant number of UMW has no entitlement to any health insurance due to various barriers. The study was to review the gaps and challenges in health policies related to migrant workers. Recommendation will be introduced as the conclusion. Methods: Literature review from Pubmed, Biomed Central, and Google Scholar and discussion using WHO Universal Health Coverage cube as a framework Results: From the literature review showed the evolution of Thailand’s migration policies and migrant health insurance schemes. Intersectoral collaboration among the Ministry of Interior (MOI), the Ministry of Labour (MOL), and the Ministry of Public Health (MOPH) has been established yet fragmented with bureaucratic nature.


Introduction
In mid-2020, approximately 3.6% of world population migrated across nations accounting for 280.6 million international migrants (1). They produce more than 9% of the global Gross Domestic Product (GDP) (2). Two-third are labour migrants. Various factors contribute to this mobility trend, including the shortage of low-skilled labour workforces in receiving countries, deteriorating economic situation and political con icts in sending countries, climate change, improved transportation worldwide, and human tra cking. During the last decade, migration is increasingly being recognised as an important social determinant of health and health inequities. The different phases of the mobility continuum (predepartures, travel and transit, arrival at the destination, integration and regularisation of the migration status, interception and return) can positively or negatively impact the health of migrants. It places migrants in conditions and social locations that may increase or decrease the vulnerability to ill health (3)(4)(5). When integrating in their new environment and social support networks, undocumented migrants, for example, commonly end up living in informal settlements and slums deprived from basic water and sanitation infrastructure and quality health services and forced to make a living by working in the informal economy (6). Low skilled migrant workers (LSMW) are often employed in the most dangerous, di cult and demanding sectors (so-called 3D-jobs), with low wages, harsh and hazardous working conditions, and absence of social protection rights and occupational health and safety regulations (7).
Hence, one of the many challenges in migrants' health seems to obtain universal health coverage (UHC) in the host countries. Approximately 4.9 million non-Thai population were residing in Thailand in 2018. This population includes stateless people, asylum seekers, refugees, international students and high-skilled professional, but about 80% are LSMW. With its stable economic growth (an annual GDP growth rate of around 4.1% pre-COVID- 19). Thailand is one of the countries in the Greater Mekong Subregion attracting the highest number of LSMW. The economic growth together with a steeply declined fertility rate and a fast-aging population creates a high un lled demand of labourers. Migrant workers played a crucial role in Thai workforces for more than two decades and accounted for 10% of the workforce and they will continue to be crucial human workforces in the next decades (8). The Royal Thai government signed therefore the Memorandum of Understanding (MOU) with the governments of Cambodia, Laos and Myanmar in order to recruit migrant workers. These migrant workers are engaged in 3D jobs in the informal sectors such as construction, seafood industries, agriculture, and domestic workers.
Currently, there are approximately 4 million LSMW from Cambodia, Laos, and Myanmar residing in Thailand (8). However, this number is likely to be underestimated as undocumented migrant workers who cross borders, stays and works without the necessary legal documents and work permits, are often not included in these estimations. The number of undocumented migrant workers is currently estimated to be as high as 800,000 to 1 million including their dependents.
In Thailand, migrant workers can become 'undocumented' for various reasons such as crossing the border with invalid travel documents, travelling or working when visa already expired or being born from migrant parents in Thailand without being registered with a valid birth certi cate (5, 6).
Their precarious status makes them more vulnerable to forced labour and exploitation. They are neither fully recognized as members of society nor entirely excluded as strangers. Undocumented migrant workers have no rights in terms of legal protection in the host countries.
Despite the fact that migrant workers are crucial to the Thai economy, the National Council for Peace and Order attempted to change the irregular pattern of migration along Thai borders in 2014 by criminalizing undocumented migrant workers. Employers would be ned for up to 24,000 USD per undocumented migrant worker while the migrants would be ned from 60 -3000 USD and/or imprisoned up to 5 years (10). The intension was to push employers to legalize the undocumented workers via the national veri cation process, however unexpected results emerged. More than one third of Cambodian workers left Thailand within 2 weeks after the announcement (11), which had important repercussions on the socioeconomic system within months. In 2017, The government, therefore, launched new laws and regulations to ensure undocumented migrant workers were not arrested and deported. In addition, they would be able to register for migrant health insurance.
Despite this evolvement of Thailand's migrant health policy and the development of two major public health insurance schemes, many challenges in accessing health services still exist among migrant workers, especially among the undocumented. According to the Thai migration report in 2019, the utilization rate of public health services was low among migrants due to social and nancial barriers (12). An estimated number of two million of LSMW are enrolled in the two main public health insurance schemes, accounting for 64% of the total LSMW. This number drops to 51% when undocumented migrant workers are included (13).
In this paper we focus on the UHC policy for undocumented migrant in Thailand. The initial hypothesis of our study is that an important number of UMW is not covered by any public health insurance scheme due to various barriers. Till now, few studies were performed in Thailand to describe and evaluate these barriers. Most publications focus on the political aspect of the migrant health policies (3,(11)(12)(13). This paper will, therefore, describe the implementation of the migrant health policy in Thailand using the UHC oating cube (14) and analyse the challenges undocumented migrants face in daily life. It aims to provide recommendations to policymakers to enhance the coverage of social protection, increase the level of responsiveness of its policies and reinforce the access to health care among the undocumented migrants in Thailand. Inclusion criteria were papers with focus on health policy, universal health care and undocumented migrants; free full text papers in English; papers geographically oriented to Thailand.

Materials And Methods
Exclusion criteria were papers with speci c focus on disease management; papers not related to undocumented migrants (with speci c focus on refugees, asylum seeker and displaced migrants or with speci c focus on universal health care to the Thai population); inaccessible papers; papers written in another language as English; duplicate papers. Therefore, a total of 40 documents were included in the review.

Data analysis
The universal health coverage cube framework was used to analyse the secondary data retrieved from the literature and document review. The framework serves to analyse universal health coverage (UHC) through three dimensions: population coverage, nancial coverage and service coverage as shown in Figure 1. Each dimension of the UHC cube will be described in detail. The population coverage entails the proportion of the population that has equitable access to essential health services. The nancial coverage dimension evaluates the level of protection over catastrophic health expenditure and out of pocket payment (OOP). Lastly, quality health services should be equitably available and accessible.

Results
Thailand's migrant health policy has been evolving under both political and economic pressure. Political pressure was strong from the communism era in the 1970s onwards and continued during several periods of internal con icts and political instability in the 2000s (9,16,17).
In the following paragraphs, rst, a description of the evolution of the migrants' policies in Thailand during the 1970s to 2014 will be provided. Secondly, the development of the health insurance schemes for undocumented migrant workers will be described. Lastly, we will analyse the policies using the UHC oating cube as framework.

Evolution of Thailand's Migration Policy
Four different phases within the development of the migrant policy in Thailand can be distinguished and are illustrated in Figure 2.
The rst phase started around the same time of the communism era in South East Asia in the 1970s.
Thailand allied with the US to ght against communism. Hence, the rst migration act was developed in 1972. It was designed to limit the rights of the migrant population in Thailand and revoked the nationality of people born from foreign parents, especially Chinese born (17). During this phase the rst public health insurance, the Low-Income Card Scheme (LICS), was launched for the poor and vulnerable people by the Ministry of Public Health (MOPH). Yet, migrants were not covered. In 1979, an immigration act was launched to deport undocumented migrants, including their dependents. Moreover, this act revoked the permission of temporary stay for migrants (9). They were not entitled to any kind of social protection including health care, education, and social welfare.
The second phase occurred during the economic boom in the 1980s -1990s. Due to the shortage of labour forces, the Thai government set leniency in migration laws and regulations to exempt seasonal, irregular and undocumented migrant workers to attract low-skilled laborers from neighbouring countries.  (17). However, the intention of the policy was to register these migrants and to screen for communicable diseases by giving an incentive for health insurance with yet limited bene t packages (12).
Between 1992 and 2012, more than 20 resolutions were endorsed by the Thai cabinet to allow certain groups of undocumented workers to remain working temporarily in Thailand. Since 2004, however, the cabinet started to enquire them to complete a 13 steps nationality veri cation process to obtain a temporary passport/certi cate of identity and a work permit (20). Only upon completion of this process, Latest data from the Thailand migration report 2019 showed that only 64% of the total registered migrant population were covered by one of the public health schemes. 36% remained uninsured. This gap increased to 51%, when undocumented migrant workers were added.
Several factors contribute to the low insurance coverage of undocumented migrant workers. Although undocumented migrant workers are entitled to public health insurance, both public insurance schemes require legal documentation (valid passport/work permits/temporary identi cation number). In order to obtain legal documents, undocumented migrant workers must pass the national veri cation process which is complex and variable from one year to another. The process requires inter-country and interministries collaboration and due to the political instability in the South Asian Region, it could take up to 6 months to nish the national veri cation request (9). Such delay discourages the employers as well as the migrant workers to apply. Private brokers offer services to mitigate this application process, increasing the cost to register the UMW (20). A cost that could be deducted from the wages of the migrant worker. However, if the migrant fails the veri cation process, they are not able to acquire work permits. Therefore, employers are hesitant to put the undocumented migrant worker through this system.
Despite the effort of simplifying the NV process and developing the OSS, the number of migrants who enrolled in the MHI was estimated to be lower than reality. Data from MOPH showed only 862,870 enrolments in the MHI while 1.28 million low skilled migrant workers were registered by the Ministry of Interior in 2018 (8). Institutional de ciencies hamper the undocumented migrants to enrol. The mandatory two-year enrolment with an annual premium of 50 USD does not t with the low wages earned by the undocumented migrant workers and the high mobility in the informal sector (21). The undocumented migrant workers cannot afford the MHI premium which is payable for 2 years upfront once the migrant registers. Usually, the employers will pay in advance but later deduct from the daily wages with interests (22). Moreover, the nature of undocumented migrant workers is the high mobility especially within the informal sector. They tend to move from one job to another because of higher wages or better job opportunities. Therefore, they prefer to remain undocumented as long as they do not get arrested. The national veri cation process and the MFI registration would tie them to the employer that les the request or pays the premium respectively.

Financial protection and equity expansion
Data from research conducted in Thailand showed that the out-of-pocket payments among uninsured migrants at both outpatient and inpatient departments was signi cantly higher than those who have MHI (23). The mean out-of-pocket payment of insured migrants was 1 USD/visit while the mean out-of-pocket payment of uninsured UMW was as high as 75 USD/visit (23). Children born from migrants are able to enrol in the MHI but limited till 7 years old. Therefore, parents pay 100% out-of-pocket payment if their children age over 7 years old are sick. For example, the cost of a normal delivery at the district hospital is estimated at 300 USD/patient, including 2 days hospital admission and post-natal care. Migrant women without insurance have to pay the total amount out-of-pocket payment at the point of service. They often try to borrow money from friends or employers, but if they cannot, they will not attend ANC and/or will only go to the emergency service when labour starts, as emergency care is free of charge. However, in case of complications, their debt can increase with a cost for a caesarean section as high as 500-1000 USD/patient. Additional indirect costs such as the transportation to the provincial hospital, caregiver, hospital admission fees, etc. are also out-of-pocket payment.
Catastrophic health expenditure is especially high if undocumented migrants have chronic diseases.
Although most migrant workers are young and healthy, they often are exposed to unhealthy working and living conditions (24), for example, a high risk of spreading pulmonary TB. They are not able to receive proper treatment since the cost is relatively high in comparison to their low wages and anti-TB drugs are only available at hospital level. Uninsured undocumented migrant workers are less likely to visit a public hospital out of fear of deportation. Instead, they often seek medical care elsewhere including selfmedication, private clinics or they return to their countries. Working in 3D jobs increases the risk of workrelated injuries, or work-related illness leading to disablement, mental, sexual and behavioural disorders (25). Disabled migrants may lose their jobs without awareness of the disabled fund and unemployment bene ts they are entitled to. The MHI extended the bene t packages in 2013 in order to cover some catastrophic health expenditure (CHE) such as HIV treatment and renal replacement therapy (9). Nevertheless, there are indirect costs incurring from chronic diseases which are not covered by the health insurance such as sick leaves, work-related injuries bene ts, and unemployment bene ts.
The gap in equitable expansion of nancial protection is also observed among migrant's dependents, especially children over 7 years old. They are required to pay the same annual premium of MHI as adults (17). However, they are not eligible for MHI since one needs a work permit to register as adults. Children less than 15 years are not allowed to work by Thai law. Due to this unclear policy, some hospitals stop selling the MHI card to children over 7 years old (17). Therefore, when migrant children have a serious illness, the parents pay 100% OOP, putting the family at risk for nancial hardship.

Service coverage
Public health facilities are the main service providers for both Thai and migrant workers. Insured migrants can access public health services regardless of their nationality or insurance coverage. However, uninsured migrants have to pay OOP at point of service, varying from less than 5 USD to more than 100 USD, depending on the severity of the illnesses. Several factors contribute to the lower utilization among undocumented migrant workers.
The rst signi cant obstacle is the language barrier (26). A systematic review of reported challenges in health care delivery to migrants and refugees showed that the language barrier leads to a lower utilization of services and misunderstandings between providers and patients (27). Although UMW can access rst line health centres (FLHC) across Thailand at a fairly low cost (usually less than 5 USD/visit), most are non-migrant friendly. To mitigate, The MOPH has started a training program for migrant health volunteer (MHV) since 2003, in collaboration with IOM and the United States Agency for International Development in 6 provinces (28). They are trained to assist migrant workers to access hospital services, by translating and facilitating the dialogue with the providers (8). The MHV helped in the provision of preventive and reproductive health services (28). However, as a voluntary based program, the scaling up of this program to national level is still a challenge (16).
Secondly, public health care resources are shared among the Thai and migrant population (29). Data from Khaoyoi hospital in 2017-2018 showed that 80% of the ANC visits were migrant women. Yet, the hospital does not have the resources to hire a translator (source: health record from Khaoyoi hospital). This leads to frustrations among nurses. At the outpatient department, around 10% of the patients are non-Thai speaking migrants. According to the author's experience, as a director of the district hospital, complaints were led about the fact that migrants take over the resources for out-and inpatient care at least once a year (source: Khaoyoi hospital monthly report). Migrant workers are seen as a burden to the system (29).
Furthermore, there is a mismatch between operating hours of public hospitals and the long working hours of undocumented migrant workers. The hospitals as well as FLHC operating hours are from 8am to 4pm on weekdays. Normally, migrants work from 7am to 8pm. Therefore, if they are not severely ill, they often prefer self-medication, bought in local drugstores, or traditional medicine (29).
Distance from the workplace and the nature of the job entails additional barriers. For example, migrant female sex workers often work in remote areas along the Thai borders where FLHC is inaccessible (30). Another example are the migrant shermen who have been in a situation of exploitation in Thai shing industries for decades. The high mobility of shermen and the nature of their work, far from the mainland, are barriers in accessing health services (31). Both migrant sexual workers and shermen are more likely to visit private health providers where they pay 100% out of pocket.
Fear of arrest and deportation is another challenge in accessing health services especially at public health facilities (26). Moreover, the lack of awareness of their rights are common in both insured and uninsured migrant (26). These issues are largely due to the widespread of human tra cking in commercialised seafood industry, constructions, manufacturing industries in Southeast Asia (31).

Discussion
Thailand has been progressing towards providing UHC to all people regardless of their nationality since 2004; yet, gaps in policy implementation persist (8, 9,16,17). Several migrant policies have been endorsed by the Royal Thai government in response to the national security situation, the economic pressure, and the burden it entails for the public health system in the past decades. The progress in population coverage for low-skilled migrant workers has signi cantly improved with a coverage of 64% in 2018 (8). However, our analysis showed that there were challenges and limitations in providing UHC to undocumented migrants. The accessibility to basic health services remained limited. Indeed, ensuring social protection in health for the vulnerable population is more than providing population and nancial coverage (44). The registration of the non-Thai population and enrolment in a public health insurance scheme is not su cient to expand UHC in an equal manner.
Our analysis showed that barriers in accessing health services exist among both uninsured and insured migrant workers. Obstacles are arising due to limitations in terms of communication because of language barriers, differences in sociocultural background, lack of nancial and social support, discrimination, institutional de ciencies and fear of arrest and deportation, to name a few. Data from literature reviews across Asia Paci c countries and Europe showed similar barriers among migrant workers in access to care (37,(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57). Loganathan et al pointed out that in Malaysia health services were mostly inaccessible for migrant workers (41), therefore the latter would only seek health care when seriously ill. This is similar to the results observed in Thailand. The preference among undocumented migrant workers, to rather seek health care from private providers, was also observed in other receiving countries in SEA such as Malaysia and Singapore (37).Migrant workers are often unaware of their rights in terms of health insurance coverage (30). The ILO report in 2011 stated that 71% of the male migrant workers in Singapore did not have or were unaware that they were entitled to health insurance (43).
According to the study, the underpaid migrant workers were not sure who should pay for health insurance (38).
Despite its efforts, Thailand has not yet been able to "leave no one behind". Analysis shows that there are critical challenges to include UMW into the famous Thai UHC (9,16,17,44). The notion of providing UHC to everyone residing in Thailand has its advantages within a public health and economic perspective. However, adding the low-skilled migrant population into its health system is politically and socially sensitive.
The con ict between the Thai national security and the claim for human rights had a remarkable impact on the migrant policies. The main philosophies behind most migrant related policies since the 1970s were either restriction or legalization of the LSMW rather than empowerment of their human rights (9,16,17,44). The post-coup policies, focusing on criminalizing measures for the UMW and their employers, has put the UMW in a more fragile status than ever (10). Providing LSMW equal rights in social health protection has not yet been the priority of the Royal Thai government. However, its growing economy will most likely continue to depend on young and healthy LSMW from neighbouring countries in the next decade. Long-term commitments in migrant policy such as strengthening the bilateral MOU for formal recruitment with CLM countries (20), the development of co-nancing mechanisms in health insurance for LSMW between countries (37), and migrant-friendly services have been developed (45), but challenges persist.
Eventually, the socially excluded UMW have been marginalized in every aspect of life, let alone their rights in accessing health services (21). Our analysis showed a certain level of discrimination as well towards migrant workers as they are seen as a burden to the Thai health system (29). The stigmatization of LSMW in health care providers' perspective is that they are source of communicable diseases (45). Some health care providers and native population look down on LSMW since they are from low-income country engaging in the 3D jobs.
Social medias have in uences in Thai population's negative attitudes towards LSMW as they are 'illegally' work and stay in Thailand (45).

Conclusion
Through the short-term policies on migrant workers, the health system has not yet been designed and adjusted for the extra 4 million LSMW. The sociocultural differences and health seeking behaviour were rarely documented. Most policies regarding migrant's health are added onto the existing health infrastructures, leading to a shortage of resources at all levels. The norms for public resources, including human resources, are based on an estimated target population within the Thai community. Migrants are not included (46).
The MOPH has started migrant-friendly services since 2013 to improve access for migrant workers regardless of their insurance coverage (16). Until recently, migrant-friendly services are only available in six provinces (45). Based on the previous evaluation of the services, there are possibilities in reducing gaps in access to care, providing affordable services, and increasing participation of other actors such as migrant's family members, employers and health providers (45). The accomplishment of the services mainly caused by the public-private collaboration between health sectors and NGO's. Nevertheless, there were challenges in providing migrant-friendly services such as the cultural insensitive of health care providers, limited number of MHV, and lack of nancial support from the government to scale up the services.  Timeline of migrant policies development in Thailand (1972 -present)