As many as five million migrants live and work in Thailand, mostly entering across porous borders from Laos, Cambodia and Myanmar. Many are currently facing a government crackdown because of dubious legal status. But in one respect Thailand’s treatment of its immigrants is world-leading: their healthcare.
For countries in tropical south-east Asia, fighting the spread of diseases like malaria and tuberculosis is a major public health priority. But the number of immigrant workers in the region means infectious diseases cross borders easily — making it all but impossible to tackle them without special attention to migrant health.
To address that challenge, the Thai government has developed a special health insurance scheme for migrants which allows them to access treatment even if they aren’t in the country legally — the only scheme of its kind in the world.
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But in a country known for high rates of trafficking and exploitation, helping irregular immigrants is no simple matter.
Migration is key to public health
The Thai government has been fairly successful at combating tuberculosis in recent years, reducing its incidence to 13 deaths per 100,000 people in 2016. But in neighbouring Laos and Myanmar, significant sources of migrant workers to Thailand, the rate is nearly four times as high — meaning the disease could easily return to prevalence.
The intersection of public health issues and migration affects many countries. Sri Lanka was on the verge of achieving malaria-free certification from the World Health Organization (WHO) in 2012 when 32 cases were diagnosed among refugees returning to the country.
Because many migrants were returning to areas where health infrastructure had been ravaged by the civil war that ended in 2009, there was a serious risk of the disease regaining a foothold on the island.
“A country that’s reaching elimination needs to look at the last bastion of migration”
“For a country trying to eliminate malaria, importation through inbound migration routes forms a key strategy, the last bastion of defence if you will,” said Kol Wickramage, coordinator of global migration health research at the International Organization for Migration (IOM).
It’s even possible that, since disease patterns are very different between countries, doctors can simply misdiagnose people if they’re not alert to the migration-health connection.
In one of the Sri Lankan cases, physicians were unable to correctly diagnose malaria — the burden of cases had fallen by more than 99% since 1999, making many unfamiliar with managing the disease — and instead started treatment for dengue fever. Only the intervention of a more experienced doctor, whose questions about travel history revealed the patient had recently returned from a malaria-endemic part of Africa, ensured the right treatment was delivered.
In response to the 2012 cases, the Sri Lankan government successfully partnered with the IOM, WHO and other partners to address the importation of malaria through migration routes. The WHO certified Sri Lanka as malaria-free in 2016.
One step further
Sri Lanka’s experience shows the possible gains from taking migration health seriously — but the Thai government has pushed that approach even further.
Thailand is a relatively rich country for the region and has a robust health system, according to Wickramage. “But they rely on these migrant workers coming in from poorer countries,” he said.
Rather than simply trying to screen incoming migrants for disease, the public health ministry launched a new healthcare scheme in 2003 — the first in the world to offer equal coverage to both documented and undocumented migrants.
As of 2015, migrants pay an annual premium of 2200 baht ($63 USD), and undergo a 600 baht ($15 USD) annual health screening for TB, malaria and AIDS. They then receive a health care card that entitles them to treatment.
An accompanying scheme, launched in collaboration with the WHO and IOM, focuses on bilingual outreach to migrant communities and workplaces to educate migrants on the health services at their disposal. In some regions, volunteers proposed by migrants themselves also educate communities on available health resources.
The program is not the project of a government that is generally pro-immigration. But bringing irregular migrants out of the shadows and into the health system enables more targeted medical interventions and allows the spread of diseases to be properly tracked.
The reality on the ground, however, is not so straightforward.
While all migrants are legally entitled to Thailand’s health care services, as of 2009, only about 9% of migrant workers were covered.
As in many voluntary insurance schemes, healthy individuals shy away from enrolment, leaving hospitals with the burden of costlier, sicker patients. Hospitals can also wait as long as four months for reimbursement from the national health service.
That means many hospitals, especially in remote areas, face difficulties covering costs. Although the scheme itself doesn’t require a work permit or proof of residence to qualify, struggling hospitals often insist on legal documentation before they issue cards.
Thailand’s generally difficult conditions for migrants create further challenges. The US State Department says the country’s efforts to combat human trafficking don’t meet minimum standards, and growing numbers of immigrants are employed on precarious 30-day work permits. That means many don’t feel secure enough to apply for health insurance, or are prevented from doing so by exploitative employers.
But even with these practical limitations, the principle of the Thai program far exceeds what many rich countries offer. EU countries’ services for illegal immigrants — many only allow access to emergency care, and two-thirds don’t even provide treatment for highly-infectious HIV — pale in comparison.
“There remain many challenges to the many low-paid migrant workers in terms of health needs,” Wickramage said. “But adopting such approaches provide a win-win scenario for public health of host communities and migrants themselves.” —Fergus Peace & Alia Shahzad
This piece has been updated to more accurately reflect the IOM’s position and the purpose of the Thai healthcare scheme.
(Picture credit: Flickr/Solidarity Center)