Evolution and complexity of government policies to protect the health of undocumented/illegal migrants in Thailand – the unsolved challenges

Abstract

BackgroundOf the 65 million residents in Thailand, >1.5 million are undocumented/illegal migrants from neighboring countries. Despite several policies being launched to improve access to care for these migrants, policy implementation has always faced numerous challenges. This study aimed to investigate the policy makers’ views on the challenges of implementing policies to protect the health of undocumented/illegal migrants in light of the dynamics of all of the migrant policies in Thailand.MethodsThis study used a qualitative approach. Data were collected by document review, from related laws/regulations concerning migration policy over the past 40 years, and from in-depth interviews with seven key policy-level officials. Thematic analysis was applied.ResultsThree critical themes emerged, namely, national security, economic necessity, and health protection. The national security discourse played a dominant role from the early 1900s up to the 1980s as Thailand attempted to defend itself from the threats of colonialism and communism. The economic boom of the 1990s created a pronounced labor shortage, which required a large migrant labor force to drive the growing economy. The first significant attempt to protect the health of migrants materialized in the early 2000s, after Thailand achieved universal health coverage. During that period, public insurance for undocumented/illegal migrants was introduced. The insurance used premium-based financing. However, the majority of migrants remained uninsured. Recently, the government attempted to overhaul the entire migrant registry system by introducing a new measure, namely the One Stop Service. In principle, the One Stop Service aimed to integrate the functions of all responsible authorities, but several challenges still remained; these included ambiguous policy messages and the slow progress of the nationality verification process.ConclusionThe root causes of the challenges in migrant health policy are incoherent policy direction and objectives across government authorities and unclear policy messages. In addition, the health sector, especially the Ministry of Public Health, has been de facto powerless and, due to its outdated bureaucracy, has lacked the capacity to keep pace with the problems regarding human mobility.

Understanding the problem of access to public health insurance schemes among cross-border migrants in Thailand through systems thinking

“…It is clear that the high demand for, in particular, the '3D' jobs (dangerous, dirty, and demeaning) to address economic necessity is the main factor that drives a high influx of migrant workers [9,21,23]. Migrants with illegal status might opt to enter Thailand first then undertake the NV later in order to obtain a legalized work permit [9] (as shown in the cloud symbol on the left hand-side of the Fig. 1).…”

“…The dynamics of migrants in the labour market is remarkable [9]. Not all registered migrants are in the labour market all the time.…”

“…The second scheme is the Health Insurance Card Scheme (HICS), regulated by the Division of Health Economics and Health Security (DHEHS) at the Thai Ministry of Public Health (MOPH). The HICS covers migrant workers in the informal sector from CLM nations [9].…”

“…In reality, there remain migrants (an unknown figure) that have not joined the NV process as intended by the government. Suphanchaimat et al [9] describe these challenges in relation to numerous factors such as ignorance of policies among migrants and employers, a swift change of policies due to both international and domestic pressures, and incoherence of policy direction among concerned authorities. However, none of the work has been addressed the problem of migrant workers accessing the public health insurance schemes.…”

Moving towards culturally competent health systems for migrants? Applying systems thinking in a qualitative study in Malaysia and Thailand

“…Among migrant workers using hospitals in Kuala Lumpur, 79% paid out-of-pocket payments for health treatments [32], with 87% of Bangladeshi migrants in another study not receiving any financial support from employers for treatment [33]. In Thailand, migrants (including undocumented migrants) can enrol in public health insurance schemes with comprehensive benefits packages operated by the Ministry of Public Health (MOPH) and the Social Security Scheme for those who work in the formal sector [34,35]. While the Health Insurance Card Scheme (HICS) has improved migrant workers' access to services and reduced out-of-pocket payments (OPPs), outpatient utilization rates have remained low.…”