Implementing health insurance for migrants, Thailand

Abstract Problem Undocumented migrant workers are generally ineligible for state social security schemes, and either forego needed health services or pay out of pocket. Approach In 2001, the Thai Ministry of Public Health introduced a policy on migrant health. Migrant health insurance is a voluntary scheme, funded by an annual premium paid by workers. It enables access to health care at public facilities and reduces catastrophic health expenditures for undocumented migrants and their dependants. A range of migrant-friendly services, including trained community health volunteers, was introduced in the community and workplace. In 2014, the government introduced a multisectoral policy on migrants, coordinated across the interior, labour, public health and immigration ministries. Local setting In 2011, around 0.3 million workers, less than 9% of the estimated migrant labour force of 3.5 million, were covered by Thailand’s social security scheme. Relevant changes A review of the latest data showed that from April to July 2016, 1 146 979 people (33.7% of the total estimated migrant labourers of 3 400 787) applied, were screened and were enrolled in the migrant health insurance scheme. Health volunteers, recruited from migrant communities and workplaces are appreciated by local communities and are effective in promoting health and increasing uptake of health services by migrants. Lessons learnt The capacity of the health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for undocumented migrants. Continued policy support will be needed to increase recruitment to the insurance scheme and to scale-up migrant-friendly services.


Introduction
Migrants, especially those who are unskilled and undocumented, often work under limited social protection, with poor access to health and other social services, and at risk of exploitation. The International Convention on the Protection of the Rights of All Migrant Workers and the Members of Their Families 1 was adopted by the United Nations (UN) General Assembly in 1990. However, as of 2016, it was ratified by only 48 UN Member States, most of whom are source countries of international migration. Article 25 of the Convention -which indicates that migrant workers shall enjoy treatment (health) not less favourable than that which applies to nationals -has yet to be fully implemented by States parties to the Convention.
Many countries worldwide face difficulties in meeting the health service needs of migrant workers. Despite regulations on minimum wage and employment benefits, legislation is often not enforced effectively, thus compounding migrants' vulnerable status. France's efforts in 1999 to regularize undocumented migrants, by providing limited residence permits and access to state medical aid through means testing, have failed because subsidies were judged to be unaffordable by the government. 2 The 2012 debt crisis in Europe and the subsequent austerity measures have had a negative impact on social protection for national and non-national labourers. 3 In Thailand, the growing cost of subsidizing migrant workers' health care, through exemption of user fees on a humanitarian basis, prompted the government to initiate a health insurance scheme for migrant workers.

Local setting
According to the most recent figures, the proportion of migrant workers in the total labour force in Thailand grew from 2.2% (0.8 of 34 million) in 1995 to 5.0% (1.8 of 36 million) in 2005. 4 Mostly coming from Myanmar, migrants are employed in the agriculture and fisheries, construction, manufacturing and service industries, often earning piecerate wages. Although there are no accurate statistics, around three quarters are estimated to be undocumented migrants (i.e. non-nationals who enter and stay in a country without appropriate legal documentation or, after legally entering, stay beyond the authorized time). 5 Migrant labour contributed an estimated 6.2% of the Thai gross domestic product of 189.3 billion United States dollars (US$) in 2005, yet the migrant workforce, in particular undocumented workers, were not eligible for tax-supported social benefits.
Migrants who have work permits are fully covered by the Thai social security scheme. This is a mandatory scheme financed by payroll taxes, to which employers, employees and the government contribute equal parts. Thai nationals and migrants who contribute to the social security system have equal rights of access to social security benefits, including health services. In 2011, around 0.3 million workers, less than 9% of Thailand's estimated migrant labour force of 3.5 million, were covered by the social health insurance scheme. According to the law, a self-employed worker can voluntarily join the social security scheme. However, migrants without legal documents face barriers to enrolling in social health insurance and therefore must resort to paying for health services out of pocket. Undocumented migrants were sometimes exempted Problem Undocumented migrant workers are generally ineligible for state social security schemes, and either forego needed health services or pay out of pocket. Approach In 2001, the Thai Ministry of Public Health introduced a policy on migrant health. Migrant health insurance is a voluntary scheme, funded by an annual premium paid by workers. It enables access to health care at public facilities and reduces catastrophic health expenditures for undocumented migrants and their dependants. A range of migrant-friendly services, including trained community health volunteers, was introduced in the community and workplace. In 2014, the government introduced a multisectoral policy on migrants, coordinated across the interior, labour, public health and immigration ministries. Local setting In 2011, around 0.3 million workers, less than 9% of the estimated migrant labour force of 3.5 million, were covered by Thailand's social security scheme. Relevant changes A review of the latest data showed that from April to July 2016, 1 146 979 people (33.7% of the total estimated migrant labourers of 3 400 787) applied, were screened and were enrolled in the migrant health insurance scheme. Health volunteers, recruited from migrant communities and workplaces are appreciated by local communities and are effective in promoting health and increasing uptake of health services by migrants. Lessons learnt The capacity of the health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for undocumented migrants. Continued policy support will be needed to increase recruitment to the insurance scheme and to scale-up migrant-friendly services.
Lessons from the field Health coverage for migrant workers, Thailand Viroj Tangcharoensathien et al.
from health-care charges, subsidized by hospital revenue, but only at the discretion of hospital staff.

Approach
Two strands of policy action on migrant health have been introduced in Thailand: (i) extending financial risk protection for migrants and (ii) strengthening the provision of migrant-friendly services.

Financial risk protection
In 2001 the Thai Ministry of Public Health set up the migrant health insurance scheme for all migrants (documented and undocumented) who are not covered by social health insurance. This was later extended to migrants' dependants including spouses and children in 2005. Migrant health insurance is a voluntary prepayment scheme financed by an annual premium paid by the migrant worker (2200 baht in 2015, equivalent to US$ 73), with no employer or state contribution, as it is not technically feasible to enforce mandatory participation.
The scheme has two policy goals: screening for and treatment of certain communicable diseases; and enabling access to health care for migrants. Applying for migrant health insurance requires the migrant to register at a specific hospital where they receive health screening (costing 500 baht in 2005). The screening includes chest X-ray and sputum confirmation for tuberculosis, and tests for syphilis, microfilaria, malaria and leprosy, for which a full course of treatment is offered. The benefit package covers comprehensive curative services, including antiretroviral therapy, and a range of prevention and health promotion services, similar to the Thai universal health coverage scheme. The migrant health insurance excludes some services, such as aesthetic surgery and renal replacement therapy. A full schedule of immunization is provided to child dependants of all migrants.

Migrant-friendly services
A second strand of policy action on migrant health was the establishment by the public health ministry in 2003 of innovative, migrant-friendly services with the aim of improving access to health care for all migrants, whether covered by insurance or not. These included the use of volunteer community health workers, mobile clinics for migrant communities, bilingual (mostly Thai and Burmese) signposts and information in health facilities, and outreach services in the workplace. 6 A pilot programme in seven provinces with large numbers of migrants was set up in 2003 by the public health ministry and the International Organization for Migration with support from the United States Agency for International Development. Volunteer health educators were recruited from migrant communities and workplaces to provide health education and advice about how to access health services. One volunteer for every 50 households was proposed and approved by migrant communities. In manufacturing areas, there were 5-10 volunteers per factory. They received an initial two days' training by staff at district hospitals, with refresher trainings twice a year. 7 The training content included personal hygiene, maternal and child health and safe water and sanitation.

Relevant changes
Opening up the migrant health insurance scheme to all documented and undocumented migrants and their dependants led to greatly increased enrolment. In the most recent data, between April and July 2016, a total 1 147 889 migrants applied to enrol in the scheme and were screened (33.7% of the total migrant health insurance estimate target of 3 400 787). 8 Of these, 1 146 979 people were enrolled; 8913 (0.8%) were treated for infectious diseases (4929 of them for pulmonary tuberculosis). A further 910 migrants (0.1%) were assessed as not fit for work (due to substance abuse, syphilis stage 3, symptomatic leprosy or lymphatic filariasis) and returned to their country of origin without treatment (Table 1). All children, not only members of the migrant health insurance scheme, were eligible for full immunization coverage through the same schedule for the expanded programme on immunization as Thai nationals. By 2015, migrant health insurance covered 1.3 million members, including 50 000 children who are targets of immunization. Despite this achievement, the health-service utilization rate among health insurance members was low. 8 A study in 2008 assessed the migrant health volunteer programme in two provinces having high concentrations of migrant workers. 7 Interviews with 260 volunteers and 446 migrants showed that community attitudes towards the programme were positive, and the migrants recognized the benefit of these volunteers who spoke the same dialect and shared the same culture. Training of and support to volunteer health communicators had been effective in promoting migrants' health awareness and improving service uptake through advice and help with navigating through services. 7 The model was expanded to cover 27 districts in seven provinces with high concentration of migrants, but due to lack of policy support it has yet to be scaled up further.
Alongside these initiatives were external pressures on the government Health coverage for migrant workers, Thailand Viroj Tangcharoensathien et al.
to take further multisectoral policy on migrants (Fig. 1). When Thailand was listed in the tier 2 watch list of the 2012 Trafficking in Persons Report, 10 international pressure pushed the government to introduce new initiatives to combat human trafficking. 11 The Cabinet Resolution on 15 January 2013 endorsed the Ministry of Public Health as the lead agency in providing comprehensive health insurance and service provision to migrant workers and their dependants not covered by the social health insurance. In 2014, a multisectoral policy was introduced and managed by the immigration bureaux of the interior, commerce, labour and public health ministries, encouraging illegal workers to register for temporary permission to stay so that all migrants are screened and covered by health insurance. A national policy committee on international migration of labour and human trafficking was appointed.

Lessons learnt
Migrant health insurance for undocumented workers in Thailand contributes to health security through screening and treatment of communicable diseases, improved access to health services and reduced risk of catastrophic out-ofpocket expenditure for this vulnerable group. The capacity of the health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for migrants (Box 1).
Migrant health volunteers acting as communicators in migrant communities and workplaces are important for supporting the scheme by linking with primary health-care facilities and encouraging health-care uptake by migrants. Scaling up migrant-friendly services and recruitment of volunteers will require continued policy support.
Political pressure from outside the country pushed the government to take action in support of better health care for migrant populations. Recognition

Box 1. Summary of main lessons learnt
• The capacity of the public health ministry to innovate and manage migrant health insurance was a crucial factor enabling expanded health insurance coverage for undocumented migrants. • Continued policy support will be needed to increase recruitment to the migrant health insurance scheme and to scale-up migrant-friendly services. • External political pressure can push governments to take action in support of better health care for migrant populations.
Lessons from the field Health coverage for migrant workers, Thailand Viroj Tangcharoensathien et al.
of labour shortages in some sectors, and migrants' contribution to the Thai economy, contributed to better intersectoral action among the labour, social welfare and health ministries to address these challenges in a holistic way, focusing not only on health concerns (Fig. 1).
Challenges remain, however. Migrants' experiences of poorly responsive services and fear of litigation by the authorities result in low utilization rates for outpatient and inpatient services. 12 Health ministry hospitals have a dual role as insurer and provider, and linking the scheme members to a single provider for the whole year is problematic when migrants change employers or move to another province. Portability of insurance coverage has not yet been developed. The voluntary nature of migrant health insurance encourages sick members to participate and healthy persons to self-exclude. Migrants' illegal status is another key barrier to enrolment. The low enrolment of migrants to migrant health insurance, with limited population coverage, inhibits large pooling of risks, which adversely affects the financial viability of the scheme. ■