At the present age, health of migrants is an issue on a spotlight in
many countries. This is due to a rapid economic growth and a swift
change in communication and transportation technology around the
globe. Thailand also has a huge demand on migrant labour, and the
recent governments always paid much attention on this matter. In 2004,
the government introduced 'Health Insurance Card' for cross policy for
cross-border migrants, who were not covered by the Social Health
Insurance (SHI). The insurance was regulated by the Health Insurance
Group (HIG) under the Ministry of Public Health (MOPH), and was tied with
the nationality verification process (managed by the Ministry of Interior
(MOI)) and the registration for legitimate work permit (managed by the
Ministry of Labour (MOL)). So far, there has been very few studies
exploring the management and performance of the insurance. The
aforementioned reason thus becomes the objectives of this study.
Study objectives
The study ahas 4 main objectives: (1) to systematically review
evidence of the management of health insurance and the attitudes of
healthcare providers in healthcare practice for migrants from international
literature, (2) to explore attitudes of local healthcare providers and
migrant patients on the operation of health insurance policy for migrants
in the real setting, (3) to assess the effect of the insurance on volume of
use and out of pocket payment (OOP) of migrants, relative to the
uninsured migrants and Thai beneficiaries, and (4) to synthesise policy
recommendations for better management of the health insurance policy
for migrants in the future. Methodology
Ranong province was served as study site. The study employed
both qualitative and quantitative methods. Data collection techniques
were composed of: (1) a systematic review, (2) in-depth interviews with 24
local healthcare providers and 11 migrant patients, and (3) the
investigation of routine faciliy-based data. Thematic analysis was used for
qualitative data analysis and econometric models were used for
quantitative data analysis.
Results
The management of health insurance policy for cross-border
migrants in Thailand was quite complex. The policy was also open to all
types of migrants.
However, there has been a number of operational problems and
challenges because: (1) In theory, the process of buying the insurance
card is tightly linked with the acquisition of legitimate residence permit,
managed by the MOI, and the registration of work permit, regulated by
the MOL. In fact, the enforcement of such regulation is ineffective. A large
number of migrants were not registered for the work permit. In addition,
the registration policies (by the three ministries) were inconsistent and
frequently changed over time, (2) The policy does not fir the local
context of Ranong province since the province has a long border
connecting to Myanmar, which renders the cross-border control difficult.
Many migrants enter the country for various purposes rather than seeking
for jobs. Thus, some migrants relied on "brokers" to make them accessible
to the registration process (in order to acquire the work permit and then
be eligible to buy the insurance card), (3) The MOPH does not have
sufficient institutional capacity in regulating, and monitoring the
performance of each facility in implementing the insurance scheme. This problem is intermingled with inadequate communication between the
MOPH and the local authorities, (4) Many healthcare providers viewed
that the insurance is always running deficit. This is because the healthy
migrants are not willing to buy the card, and the pooling size is too small
(the card revenue is collected at each individual facility). Accordingly,
some health facilities adapt the policy by various means, such as allowing
only healthy migrants to buy the card, andimposing a lag time between
the starting valid day and the time of buying the card, (5) One of adaptive
measures of health facility is hiring migrants to work as 'migrant health
workers (MHW)', serving as bridging personnel between migrants in nearby
communities and the local providers. However, the sustainability of this
measure is questionable due to the limitation of law on the work of
migrants, which still disallows official authorities to hire migrants as official
employees. Many healthcare providers hence finds a way out by hiring
migrants as their house maids, but in fact these migrant employees are
still working as MHWs.
The quantitative analysis shows that the utilisation rate of
migrants was about 3-4 folds was low as the Thai beneficiaries, covered
by the Universal Coverage (UC) scheme. The absolute effect of having the
card (after adjusting all covariates) did not significantly increase the
volume of use of the patients, who ever visited a facility. The key factor
of increasing the use is clinical factor that is a patient's disease status per
se. Moreover, the card was proved to reduce the OOP of migrants at
point of care by 157-756 Baht per outpatient visit and 2,706 Baht per
inpatient visit.