"Health Insurance Card Scheme" for cross-border migrants in Thailand: Responses in policy implementation & outcome evaluation.

Abstract

The health of migrants has attracted increasing attention in the international policy dialogue in recent years. Thailand is one of many countries where migrant health is a major political issue. This is because the country is situated at the centre of the Indochinese Peninsula and its economy is fast-growing relative to its neighbouring countries, particularly Cambodia, Lao PDR, and Myanmar. As a result, Thailand has, for decades, attracted a large number of low-skilled cross-border migrants. The majority of these immigrants have passed the border without any valid travel document. However, most of the time, past governments did not impose strict deportation measures on these undocumented/illegal immigrants since they were considered a key contributor to the Thai economy. Measures often used by recent governments included granting them leniency for temporary residence, issuing work permits for certain jobs, and insuring them through public-oriented health insurance, namely, the 'Health Insurance Card Scheme' (HICS). The primary aim of this thesis is to evaluate (i) the enrolment of cross-border migrants in a public health insurance scheme, namely, the HICS, in Thailand through the viewpoints of various stakeholders, and (ii) the effects of insurance on use of services. Ranong province was selected as the study site since it had the largest proportion of migrants compared to other provinces. The main objectives are: (1) to explore how the HICS evolved over time in light of changes in surrounding policies, (2) to investigate the responses of local officers and relevant stakeholders towards the HICS and to examine how the policy affects migrants' health-seeking behaviour in practice, (3) to evaluate the outcomes of HICS in terms of utilisation numbers and financial implications for its insurees, and (4) to provide policy recommendations. A multimethods approach was employed. In-depth interviews, document review and facilitybased data analysis were undertaken. Policy makers, local healthcare providers, and migrants were interviewed. Thematic and analyses were applied. 4 The findings revealed conflicting ministerial objectives and gaps in both inter- and intraministerial policies. In addition, policy objectives were not clear from the outset. While the health sector aimed to insure ‘all’ migrants, this was constrained by the security and economic authorities where the focus was mainly only on migrant workers who registered with the government. Besides, in reality, the boundary between ‘legal’ and ‘illegal’ migrants was very fluid. Though the current government attempted to address policy gaps by overhauling the HICS and instigating a new measure, namely, 'One Stop Service', it is difficult to claim that the deep-rooted implementation problems were resolved. This situation was even more complicated at the local level as some frontline health officers adapted the policy in various ways, and occasionally made the policy diverge from its initial objectives. For users, the cost of registration was a significant barrier in obtaining the insurance card, and a reliance on private intermediaries (both legal and illegal) to help them obtain the insurance card was not uncommon. Besides, there were migrants who were neither insured, nor able to return to their home country. However, the HICS still had some merits in reducing out-of-pocket payment, and helping increase utilisation of services amongst insurees. It was noteworthy that the most important factor determining the number of visits was history of experiencing catastrophic illness, not insurance status, and this influence was even more apparent in Thai patients than in migrants. Evidence suggested that there might be insured migrants with catastrophic illness who still experienced difficulties in accessing services, let alone uninsured migrants. Unless policies to protect the health of this population are put in place, poor access to health services for the uninsured will continue being a serious public health problem, not only to migrant communities but also to Thai society as a whole. Both macro- and micro policy recommendations are provided, for example, integrating the different authorities’ information systems on migrants, amending some outdated laws and regulations, and strengthening the capacity of the insurance governing body.