Characteristics of stakeholders
The majority of stakeholders were aged 40 years and older. About two thirds of participants were women. One third of participants had been working for more than 30 years. Over half of the participants were at senior professional level. About half of the participants were from the health sector. Approximately 40% of the attendees were from civic organizations.
Table 1 Socio-demographic characteristics of stakeholders engaging in the 1st and 2nd GMB
Variable
|
Category
|
N (percentage)
|
Age (years)
|
21-30
|
5 (25)
|
|
31-40
|
5 (25)
|
|
40+
|
10 (50)
|
Sex
|
Male
|
7 (35)
|
|
Female
|
13 (65)
|
Experience in the field of migrants’ health
|
<10
|
10 (50)
|
|
10-19
|
2 (10)
|
|
20-29
|
2 (10)
|
|
>=30
|
6 (30)
|
Career level
|
Coordinator
|
2 (10)
|
|
Middle
|
8 (40)
|
|
Senior
|
10 (50)
|
Organization
|
Government authority
|
|
|
· Health sector
|
10 (50)
|
|
· Non-health sector
|
1 (5)
|
|
· Civil society
|
8 (40)
|
|
Academic sector
|
1 (5)
|
Total
|
|
20 (100)
|
Key important themes identified from the GBMs
Five themes emerged from the GBMs: (i) NV process; the most critical step for legalising the precarious status of undocumented migrants; (ii) Interim period between enrollment in the SSS and the effective activation of insurance; (iii) Role of private hospitals in health examination before enrolling in the insurance; (iv) Practical problems originating from the difference in design between the SSS and the HICS; and (v) Data recording system of the HICS.
(i) NV process; the most critical step for legalising the precarious status of undocumented migrants
From the participants’ point of view, the NV process is the most critical step to determine whether an undocumented migrant will be insured as part of the government’s registration process, the OSS. The OSS is the official mechanism based on multi-sectoral collaboration across five ministries: (i) Department of Provincial Administration, the MOI of Thailand; (ii) Department of Employment, the MOL of Thailand; (iii) Immigration Bureau, the MOI of Thailand; (iv) the Social Security Office (SSO), the MOL of Thailand; and (v) the MOPH of Thailand. Once registered, the Provincial Administration Office collects the personal records of migrants with evidence of fingerprints. Then the registered migrant is given an identity card (pink-card) with a unique identity number printed on it (13-digit code). The Department of Employment then issues a work permit once the 13-digit code is confirmed. The registered migrants obtain a temporary passport and work visa by the Immigration Bureau. If a migrant is registered to work in the formal sector, he or she will be enrolled in the SSS run by the SSO. The SSS guarantees rights for medical services for all health-related conditions. Those working in the informal sector will be covered by the HICS, run by the MOPH.
The alternative national verification office is the MCMW [10]. This centre is located along the border of the migrants’ countries of origin. The chief executive officer is assigned by the deputy director of the MOL, Thailand. The mission of the MCMW is to coordinate with the provincial Labour office or the Bangkok Labour office to facilitate the NV and registration of personal records within an agreed timeframe. Furthermore, the MCWM gives feedback on challenges experienced during the process of NV to the deputy director of the MOL, Thailand in order to improve the quality of the service.
Once the NV is approved, the now documented migrants will be eligible to lawfully stay in Thailand for a certain time period (normally two years). The proof of evidence of completing the NV is a temporary passport or visa. If a migrant has not completed the NV, he or she will only receive the pink card as evidence of entering the legalisation process. This card shows information about employers and types of work the migrant is able to do. However, some participants said that there were some misunderstandings about the policy and not all government officers were knowledgeable about the NV process. Some officials still considered migrants holding the pink card to be illegal. This is one of the barriers which prevents migrants from accessing social security benefits, including health insurance.
“After the NV, migrants are legalized as they own a passport and a pink card. Information about each person is later identified in the civil registration section (CVS). While they are waiting for their name to be listed in the CVS, some government officers think that they are still illegal. And they also think that having a pink card refers to illegal status.” – Male participant, NGO
(ii) Interim period between enrollment in the SSS and effective activation of insurance
In principle, once enrolled in the SSS, there is a 90-day interim period until the insurance is activated. The migrants’ employers and the migrants are obliged to contribute to the payroll for 90 days until the right to the SSS insurance is activated. Therefore, during the 90-day uninsured period, the HICS is an option for insuring migrants. Although in principle the HICS is set for informal sector migrants, in practice the purchase of the HICS is not that strict and varies across hospitals. The MOPH has initiated many subtypes of HICS with varying periods of coverage (for example six-month, one-year, and two-year HICS), Table 2 [9]. About half of the participants emphasised that in the field there were always problems arising among some local health staff that tended to sell the six-month HICS or the one-year HICS to those facing the 90-day SSS-free period. From their viewpoint, this practice happened because the HICS sales mainly depend on the discretion of each individual hospital and some hospitals tended to sell the HICS with extended coverage in order to create a greater pool of revenue. In some circumstances, health staff became active agents in convincing employers to encourage HICS enrollment.
“The six-month or one-year HICS is more favorable than the three-month-HICS as practically a small number of migrant workers will use this right over the 3-month period. The six-month or one-year HICS is a better option because of the longer insured period. Sometimes employers thought that it was not their business (to buy the insurance for migrants) but the hospital insists (that migrants need to be insured by the HICS). The SSO also is not sure if after the three months the employers follow up the SSS for their employees again. It seems this mission (insuring) is not the responsibility of other ministries but of the MOPH ”. – Female participant, public health officer
Table 2 The Health Insurance Card Scheme for migrants and dependents
|
Social Security Scheme (SSS)
|
Health Insurance Card Scheme (HICS)
|
Beneficiaries
|
Migrants workers in formal sector
|
Migrant workers in informal sector, illegal migrants, migrant dependents
|
Governing body
|
The SSO under the MOL of Thailand
|
The Health Insurance Group (HIG) under the MOPH of Thailand
|
Financing mechanism,
|
Tri-partite contribution
Migrant workers aged 18 years and over who need to pay for 5% of their income to the SSS fund with subsidies of employers at 5% and Thai government at 2.75%.
|
Premium-based financing
The majority of revenues are pooled at the central MOPH and then decentralized to the local health facilities.
|
Coverage duration
|
Annual benefit coverage for medical expenses is valid if 3-consecutive payment is done.
|
1. Migrant aged 18 years and over
· 2,100 Baht (500 Baht for health check+1,600 Baht for health insurance) for 1 year
· 1,400 Baht (500 Baht for health check+900 Baht for health insurance) for 6 months
· 1,000 Baht (500 Baht for health check+ 500 Baht for health insurance) **Reserved for migrant workers in formal sector during the interim period of official approval from SSO for 3 months
2. Dependents aged 7 years and over but not more than 18 years
· 2,100 Baht (500 Baht for health check+1,600 Baht for health insurance) for 1 year
· 1,400 Baht (500 Baht for health check+900 Baht for health insurance) for 6 months
· 1,000 Baht (500 Baht for health check+ 500 Baht for health insurance) for 3 months
3. Dependents aged not over than 7 years
· 730 Baht (No health check fee + 730 Baht for health insurance) for 2 years
365 Baht (No health check fee + 365 Baht for health insurance) for 1 year
|
Contract facilities for health check and health insurance
|
Contract model with the National Health Security Office (NHSO):
Public hospitals (district and provincial hospitals) under the MOPH in the catchment area. Some were not under the MOPH but contracted with the programme of migrant health insurance. Private hospitals in the catchment area.
|
Contract model with the NHSO:
Public hospitals (district and provincial hospitals) under the MOPH in the catchment area. Some were not under the MOPH but contracted with the programme of migrant health insurance.
Private hospitals in the catchment area.
|
Benefit package
|
Comprehensive:
Outpatient, inpatient, accident and emergency, high-cost care;
Compensation at 50% of migrants’ income will be paid for hospital admission. This budget is under the workmen’s compensation fund for occupational injuries.
|
Outpatient, inpatient, health promotion, disease prevention services (including HIV/AIDS treatment, and other high-cost care; excluding renal replacement therapy for chronic renal failure and treatment for psychosis and drug dependence)
|
Source: Modified from Suphanchaimat et al. [9] and Division of Health Economics and Health security, Ministry of Public Health, Thailand (2019) [21]
(iii) Role of private hospitals in health examination before enrolling in the insurance
The participants said that, in the field, there were conflicting ideas as to whether and to what extent private facilities could take part in the health check for migrants before these migrants are enrolled in the insurance. This is because one of the pre-conditions for a migrant to obtain a work permit is to pass a health check, which screens for serious communicable diseases such as tuberculosis, filariasis and elephantitis [21]. The problem raised by the participants was that the MOL regulation allows either a private hospital or public hospital (with certified standards as approved by the Hospital Accreditation [HA] System, or the Joint Commission International [JCI] or International Standardization Organization [ISO]) to be responsible for the health check. However, almost all the contracted facilities of the HICS and the SSS are state run and the MOPH regulation does not specify that the hospital performing the health check must be the same hospital that provides the HICS. This approach creates some problems as the majority of private health facilities do not sell health insurance. Therefore, migrants gain the approval of the health check from such facilities but most of them did not continue to buy HICS normally sold by public hospitals elsewhere in the area.
Moreover, some MOL local officers denied the result of the health check particularly from private hospitals, as mentioned by the respondents.
“The problem is that migrants just went to private hospitals for their health check approval. Many of them do not go further to buy HICS at public hospitals near their workplace. Moreover, some providers perceived that the health check result from a private hospital is invalid (and did not allow migrants to buy the HICS further).” – Female participant, public health officer
Some participants stated that some provinces established an internal agreement among the health facilities within the province that only migrants passing the health exam from public facilities would be eligible to purchase the HICS. Some solutions were suggested by the participants. One participant suggested that the HICS regulation should be amended and this needs to be approved by the Cabinet.
“We communicated within our province to accept only those health check results from public hospitals and declined others from private hospitals or clinics.” – Female participant, public health officer
“We need a legal approach to tackle this challenge by revising the law and we need to propose this issue to the Cabinet. The Royal Decree for Health Examination and Health Insurance for Obtaining Work Permit at the status quo (that allows private hospitals to make out a medical certificate) should be cancelled.” – Male participant, NGO
(iv) Practical problems originating from the difference in the design between the SSS and the HICS
Most participants pointed to the problems involved with the difference in the payment methods between the SSS and the HICS. One of the common concerns was that some employers and migrant employees were not willing to have their salary deducted as a payroll contribution. In contrast, the purchase of the HICS is a lump sum payment once a year (or in two years according to HICS subtypes). Another problem raised was the legal basis of the HICS and the SSS. The SSS was established according to the Social Security Act 2010 [22], while the HICS was based on the Ministerial Announcement. The Act has a greater hierarchy within the law with a penalty specified for those breaching the law; but this does not apply to the Announcement.
“Some migrants declined to buy HICS once they came into Thailand. This is because there is no mandate that forces migrants to buy HICS” – Male participant, NGO.
This problem was aggravated during transition of job types when a migrant shifts jobs from the formal to informal sector. As mentioned, migrants in the informal sector are obliged theoretically to be insured by HICS, but without any penalty inflicted the enforcement of HICS enrollment is not that strict. Participants mentioned that apart from cost, the fear of being penalized was among key reasons that made migrants avoid government registration (which then resulted in missed opportunities to be insured with either the SSS or the HICS).
“If they have already paid for the SSS subsidy and if they later leave the job then they have to go for HICS.” – Male participant, NGO
“The SSS has advantage (over the HICS) because of the existence of the supporting law. If the employers do not follow this rule, there is no doubt that they will face a penalty. However, practically, some employers avoid this rule and leave their workers uninsured (either with the SSS or the HICS).” – Male participant, NGO
(v) Data recording system of the HICS
Most participants mentioned the poor management of the HICS reporting system. The MOPH did not report publicly how many migrants were insured with the HICS or the breakdown of the characteristics of the insurees (for example, in terms of sex, age, and occupation).
“The problem is that the number of HICS sales should be publicly reported in the database of the Division of Economics and Health Financing, Ministry of Public Health. But now it seems we can’t track which group buys HICS the most and how many HICS are sold. This results in difficulty to monitor and evaluate HICS progress.” – Male participant, NGO
Some informants said that it is difficult to report these numbers, as many health facilities are hesitant to report exact HICS revenues to the MOPH. According to the regulation on HICS financing, part of the HICS revenues should be pooled at the MOPH so it can allocate funding back to local health facilities upon requests for reimbursement for high-cost treatment [9]. However, in practice, some health facilities ignored this measure as they were willing to bear the risk of high-cost treatment themselves. This situation is more pronounced in health facilities with a high density of migrant workers, while in some settings with a small number of migrants health facilities are more likely to report this number to minimize financial risk when facing high-cost patients.
“The MOPH can’t exactly analyse the number of HICS sales as they don’t know how to track this number accurately. Some hospitals feel uncomfortable with reporting HICS revenue to the MOPH as they are willing to take the risk of treatment cost for migrants. If you have about 100 migrant patients, I suppose you tend to report the revenue of HICS to the central MOPH, as it just a small number. In contrast, if you earn 5-7 million Baht from HICS, you won’t give this number to the MOPH because if you spend only 700 thousand Baht on treatment, the rest becomes your profit.”- Female participant, Public health officer