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 conflicts and political instability in the 2000s (9, 16, 17).
In the following paragraphs, first, 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 floating 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 first phase started around the same time of the communism era in South East Asia in the 1970s. Thailand allied with the US to fight against communism. Hence, the first 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 first 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. The Voluntary Health Insurance Card Scheme (VHC) was introduced in 1983 as a second public health insurance scheme by the MOPH (18). It was a voluntary premium-based insurance that costed 18 euro/year and covered up to 5 family members. Nonetheless, migrants were still neither eligible for LICS nor VHC (19).
The third phase was when Thailand achieved universal health coverage in 2002. The government combined the LICS and the VHC into the successful universal coverage scheme (UCS) for Thai citizens. The UCS covered only Thai citizens who were identified by a national identification number. All migrants (both documented and undocumented), stateless people, refugees, and asylum seekers were left out. In 2004, the MOPH were designated to develop the Migrant Health Insurance Scheme (MHI) to cover undocumented migrants (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 benefit 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 verification process to obtain a temporary passport/certificate of identity and a work permit (20). Only upon completion of this process, undocumented migrant workers could be enrolled in either the Social Security Scheme (SSS) or Migrant Health Insurance scheme (MHI).
The last phase started from 2014 onwards, after a period of political instability, internal conflicts and a coup d’état. The military government launched a new policy called “One Stop Service (OSS) registration”, that aimed to legalize undocumented migrant workers and enrol them in the migrant health insurance (MHI) scheme
During the past 4 years, more than 3 million UMW were registered by the Ministry of Labour (MOL). Yet, only 1.9 million were registered in one of the two health insurances schemes (the SSS and the MHI), accounting for 64% of total registered LSMW (8).
Analysis of the migrant UHC policy
1. Population coverage and equity expansion
The first important dimension entails the description and analysis of the population coverage. Thailand has a 99% population coverage of UHC since 2002 for Thai citizens: setting an example for other countries in the Greater Mekong Subregion (GMS). However, the coverage for low skilled migrant workers (LSMW), especially when including UMW from neighbouring countries, is still low.
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 identification number). In order to obtain legal documents, undocumented migrant workers must pass the national verification process which is complex and variable from one year to another. The process requires inter-country and inter-ministries collaboration and due to the political instability in the South Asian Region, it could take up to 6 months to finish the national verification 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 verification 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 deficiencies hamper the undocumented migrants to enrol. The mandatory two-year enrolment with an annual premium of 50 USD does not fit 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 verification process and the MFI registration would tie them to the employer that files the request or pays the premium respectively.
2. 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 significantly 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 self-medication, private clinics or they return to their countries. Working in 3D jobs increases the risk of work-related 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 benefits they are entitled to. The MHI extended the benefit 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 benefits, and unemployment benefits.
The gap in equitable expansion of financial 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 financial hardship.
3. 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 first significant 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 first 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 filed 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 fishermen who have been in a situation of exploitation in Thai fishing industries for decades. The high mobility of fishermen and the nature of their work, far from the mainland, are barriers in accessing health services (31). Both migrant sexual workers and fishermen 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 trafficking in commercialised seafood industry, constructions, manufacturing industries in Southeast Asia (31).