By Chelsea Tao, Natalie Haleem, Amika Shah, Samrawit Lemma
Although Thailand’s medical system has been celebrated as a successful example of universal health care, extending health insurance to undocumented migrants in the country remains the final step to ensure that no one is left behind. M-Fund is a non-profit non-governmental organization (NGO) that offers a community-based health insurance program aiming to provide health insurance to undocumented migrants who are not otherwise covered under the state-sponsored Migrant Health Insurance System (MHIS).
With its aging population and continuing economic growth, Thailand has become a major hub for regional migration. Over 1.5 million migrants are currently enrolled in Thailand’s health insurance program through various channels. Despite the MHIS’s provisions, up to two-thirds of the estimated migrant population have not enrolled, and undocumented and irregular migrants report facing particular physical, cultural and legal barriers to health care, including freedom-of-movement issues, language barriers and fear of detention and deportation. Many migrants are highly mobile because of the nature of their work or deadlines imposed by work visas, which inhibits them from accessing state run insurance as the programs provided are not portable across Thai provinces. There is an estimated 811,437 irregular status non-Thais living and working in low-skilled sectors, and this number is projected to increase. The government’s focus on borders in public health creates barriers to reaching those who are at the most risk for negative health outcomes.
The COVID-19 pandemic has highlighted that while everyone is vulnerable, vulnerability is not evenly distributed among all populations. Countries have closed their borders to limit the spread of the virus, leaving transient populations isolated and trapped. In Thailand and surrounding countries, migrants living and working in high-risk congregate settings bear both the brunt and the blame when a COVID-19 outbreak occurs in underserved communities. As employers downsized their work forces during the pandemic, migrants faced wage reductions and/or unemployment and were unable to find new jobs, go back home, access government aid or meet basic needs. The Migrant Working Group, an organization that advocates for the rights of migrant workers in Thailand, received requests from over 200,000 migrant workers for masks, sanitizers and dried food between March and June of 2020.
Although the government has committed to providing free COVID-19 testing and treatment to those with symptoms, migrants have reported being turned away from government hospitals. The International Labour Organization reports that the vast majority of migrants are well-informed about COVID-19 prevention and symptoms, but many migrants face prohibitively high costs of COVID-19 testing at private hospitals that charge more than THB 4,000 (USD 133) per test. The International Organization for Migration estimates that “a migrant worker on minimum wage … contributing 100% of their salary for testing would need to work nine full days to cover the costs of a single test.” (Wongsamuth, 2020).
In early interviews with academics in the field, we heard that the impact of a global pandemic might incentivize governments to include undocumented migrants in the national healthcare system. However, despite the reach and scale of the pandemic, Prime Minister Prayut Chan-o-cha has developed exclusionary policies and increased immigration regulation, taking a “citizen first” approach to vaccination distribution. NGOs such as M-FUND — which has enrolled over 20,000 migrants in its health protection program as of August 2020 and operates in three Thai provinces as well as in Myawaddy and Myanmar — continue to fill the gaps in health care for the hardest-to-reach populations.
Human Rights Principles are the Foundation of Inclusive UHC Policy
Technically, the pathway to accessing health coverage in Thailand requires becoming documented. Many stakeholders who we spoke to referred to this as one of the major barriers to accessing health care for undocumented migrants because this process is used as a tool by the state to catch and deport. For example, the state offers work permits to undocumented migrant workers to work legally in the country for two years. However, the workers must pay out of pocket for a health check, sign up online for the permit and be registered by an employer in order to qualify. In other words, access to health care and COVID-19 testing is currently dependent on employment status within Thai borders. By contrast, a human-rights approach would uphold the principles of accountability, participation and equity. M-Fund provides health insurance to any individual regardless of work or documentation status, reducing barriers to accessing health care services. If true herd immunity to COVID-19 is to be achieved, it is imperative that the vaccine roll-out is based on human rights, not on documentation status.
Unclear Policy Direction Slows Progress
In our interview with a member of Thailand’s Ministry of Public Health, we heard that the mere existence of inclusionary healthcare policies does not always translate to implementation on the ground. There are two major reasons this gap occurs.
Policies are not uniform across the state, which creates confusion. For example, M-Fund has been successful in gaining support from provincial and local health officials. However, the Ministry of Interior is more politically driven and views undocumented migrants as a security concern. The political unpopularity of providing health care to non-Thais also acts as a barrier to implementation. The fact that MHIS is run by a separate department from the coverage program for Thai nationals leads to intra-bureaucratic conflict and difficulty coordinating strategies. All departments of the bureaucracy must harmonize systems to increase their chances of reaching the hardest to reach in the COVID-19 response.
Recently, the economic importance of migrant labour has unified the goals of the ministries and the Thai government is exploring offering the COVID-19 vaccine to migrant workers who are covered under the social security program. The employer is expected to co-pay the cost of vaccination. However, even assuming this group receives inoculation, many undocumented workers will still be left behind. A human-rights approach to vaccination would not vaccinate based on economic value, but rather on the value of vulnerability.
M-Fund’s Community Workers: Building Relationships of Trust with the Hardest to Reach
In our interviews, we heard that trust building is foundational to connecting with migrants who experience political marginalization, particularly undocumented populations who are often considered security threats by Thailand’s Ministry of the Interior.
M-Fund employs and pays full-time community workers — some of whom are former staff from the International Organization for Migration — to work directly with migrant communities including local clinics, schools, businesses and other nonprofits to enrol individuals, circulate information and manage memberships. By building these networks of trust and social capital on both sides of the border, M-Fund’s staff can engage with undocumented and irregular migrant communities without the cultural and legal challenges or fear of detention and deportation that often accompanies state-led interactions.
However, we also heard that the most formidable challenge for community-based health insurance programs like M-Fund lies in funding shortfalls that prevent long-term sustainability or expanding operations to reach a larger population. For example, M-Fund’s experience with “adverse selection” (which occurs in voluntary insurance programs when those who are sickest self-enrol while the healthy do not) presents immense financial sustainability challenges for the organization. However, as one of our interviewees pointed out, it also demonstrates that the program is reaching exactly those who are most unwell and in need of healthcare services.
NGOs As Middlemen
Because they work with populations that are beyond the reach of the state, NGOs must work with governments and together leverage each other’s strengths to reach the hardest to reach.
As we progressed in our interviews, we began to hear the sentiment that collaborative relationships between NGOs like M-Fund and local and national governments were crucial for delivering targeted interventions to hidden populations. Whereas M-Fund had built a cross-border network of social relationships with migrants and recognition among local hospitals and clinics, the Thai Ministry of Public Health has a collection of healthcare centres, trained health professionals and importantly, greater financial capital.
M-Fund has garnered a notable amount of support from regional governments and the Ministry of Public Health despite the negative public opinion and unclear policy direction surrounding undocumented migrants. While this may be a symptom of fragmented migrant policy between supportive healthcare-oriented actors in government and the more critical Ministries of the Interior and Finance, these budding NGO-government partnerships form an optimistic path forward for future collaboration and expansion.
By August 2020, M-Fund had enrolled over 20,000 migrants. While this number may seem tiny compared to the estimated population of migrants living and working in Thailand, it represents thousands of individuals whom state-sponsored programs and services would not have reached otherwise. As countries around the world move through the vaccine-rollout phase of COVID-19, leveraging the social capital and flexibility of NGOs, as well as the financial and healthcare resources available to governments, may prove to be an effective tool in providing health protection to the hardest to reach and creating a more equitable and sustainable health system for all.