Improving health insurance coverage and access to essential health care for migrants: Experiences from Thailand Supakit Sirilak , MD, MPHM. Phusit Prakongsai, MD, Ph.D. Ministry of Public Health, Thailand Presentation to Platform for Partnership (PFP), The 8th Global Forum on Migration and Development Summit Meeting Istanbul, Turkey 16th October 2015

Thailand at a glance Population – 67.2 million (July 2014) GDP (2014) US$ 5,519 per capita, Gini 39.3 (2013) Fiscal space: Tax to GDP 17.6 (2011), Revenue to GDP 21.3 (2011) Total Health Expenditure (2010NHA) US$ 194 per capita, 3.9% GDP Sources of finance: Public 65%, SHI 8%, Private 25%, OOPs 14% of THE, GGHE 13.1% GGE Health status Total fertility rate 1.5 (2013) Life expectancy at birth 74.2 years (2014) Infant mortality rate 11/1000 liver birth (2014) MMR 28/100,000 live birth (2014) Physicians per capita 5/10,000 pop (2014) ANC & hospital delivery 99-100% (2014)

Size of non-Thai citizen by group 2015 estimates

Push and pull factors for migrants in Thailand Push factors: Civil war and violence against ethnic minority groups; Lower economic development and minimum daily wage; Lower social welfare and public services, lack of access to quality health services. Pull factors: Changes in demographic patterns of Thai population  complete ageing society leads to the requirements for migrants’ labour, Gaps in minimum daily wage between Thailand and neighboring countries (in USD); Thailand 8.86 USD Laos PDR 1.39 USD Myanmar 2.08 USD Cambodia 4.06 USD Vietnam 3.28-4.73 USD

Contributions to Thai economy ILO 2007 estimate: Migrant labour size: 5% of total Thai labour Contribution to Thai economy, US$ 2 billion per annum, or 6.2% of GDP in 2006, Migrant workers contributed to 7-10% of industrial sector, and 4-5% in agricultural sector.

World Health Organization 27 May 2018 The Three Dimensions of UHC Economics Health Politics 6

Health Financing and health insurance schemes in Thailand after achieving UHC in 2002 Source of Finance Population Coverage Civil Servant Medical Benefit Scheme (CSMBS) General Tax For Civil servants :about 6 million beneficiaries (plus their parents, spouses and kids) Social Security Scheme (SSS) Tri-partite payroll contribution For workers in the formal sector: approximately 11 million beneficiaries Universal Coverage of Health Care Scheme or Previous 30 Baht Program Around 48 million beneficiaries in the informal sector

Health Financing for Migrants Health insurance schemes for Migrants in Thailand: Social Security Scheme (SSS) same as Thai Workers in the formal sector responsible by Social Security Office, Ministry of Labor Eligible only for Imported Migrant under MOU or those who had completed nationality’s verification process and working in the formal sector, Migrant Health Insurance Scheme (MHIS) responsible by Ministry of Public Health.

1. Social Health Insurance Voluntary SHI, low population coverage Implemented by the Social Security Office, through MOU with 3 neighboring countries In 2012, of total 0.5 million eligible migrants (from Laos, Cambodia and Myanmar), only 0.2 million covered Limitations Employee contribution only, neither from employers nor government, Migrants not aware of their rights and which is the contractor hospital, hence low use rate, Inefficient management: delay in certification of eligibility to receive health services, Benefit package not response to their real health needs.

Registration of migrants under Social Health Insurance (SHI) Registered migrants in 2014 – total 445,040 Myanmar 280,648 (63.1%) Laos PDR 11,243 (2.5%) Cambodia 79,874 (17.9%) Registered migrants in 2015 – total 490,100 Myanmar 304,835 (62.2%) Laos PDR 11,845 (2.4%) Cambodia 86,228 (17.6%) Source: Social Security Office of Thailand, 31 July 2015

2. Compulsory Migrant Health Insurance (CMHI) First launched 1994 as MOPH pilot project: 500 Baht premium per worker per year: Implemented by MOPH targeting workers not covered by social health insurance (SHI), 2001, cabinet resolution formalized CMHI: Registered migrants paid 300 Baht for annual health screening and 1,200 Baht for curative services, Required copayment 30 Baht per visit. 2004, annual premium increased Health screening 600 Baht, services 1,300 Baht 2013, CMHI for undocumented migrants and children <7 yrs old: ARV for PLHIV were included into the benefit package, Launch targeting children, premium 365 Baht per annum One Baht a day premium campaign with low uptake

One Stop Service (OSS) policy 22/7/14-31/10/14 (for 3 nations) Employers brought migrants to the MOI local office. Ad hoc Policies on temporary permission (but renewed very often); Migrants applied for legitimate residence permit (Tor-ror 38/1) and national ID (13 digits) Health screening Illegal migrants at point of entry Facilitating the NV process Work permit: MOL Migrants visited the MOI local office by themselves. MOI Deadline for NV: 31/3/15 MOPH policy since 15/1/13 Note: Implementation problems after the advent of OSS informal sector informal sector or formal sector while NV is in process Health insurance card: MOPH informal sector Imported through the government MOU (only for 3 nations and only for specific occupations, namely, industrial labour and maids) Work permit: MOL Insured by social health insurance (MOL) formal sector Legal migrants at point of entry Nationality verification (NV) Pass NV Register with MOI as people with citizenship problems and be insured with MOPH (15/1/13 policy) Fail NV MOL and MOI should coordinate with each after given the NV is completed.

Results of ‘One-stop-service’ in 2014 Migrant Registration During NCPO Policy 1,626,235 cards issued MWs= 1,533,675 (94%), Dependents= 92,560 (6%) Myanmar 623,648 (40.6%) Cambodia 696,338 (45.4%) Lao PDR 213,689 (13.9%)

Migrant Health Insurance Cost Allocation Premium collected at the registered hospitals Premium 1,600 Baht Central Pooling 360 Baht ARV 300 Baht Central Mx cost 10 Baht High cost care 50 Baht Provincial Health Office 326 Baht P&P cost 206 Baht Provincial Mx 120 Baht Hospital 914 Baht OP visit, hospitalization, medicines, lab investigation + 500 Baht Health check up cost

A Global Operation Framework on Health of Migrants Promote conducive policy and legal frameworks Monitoring migrant health Migrant-sensitive health service system Partnerships, networks, multi-country framework

1) Promote conducive policy and legal frameworks

2) On going Monitoring Migrant Health Trend In TB Cases Notification, 2006-2012 ( non Thais) Source: Bureau of Tuberculosis Tend in treatment outcomes of new smear positive cases 2006-2011 (Non-Thai) Source: Bureau of Tuberculosis Annual Check-up + MHI and Friendly Service to keep good accessibility to health care = Good Surveillance

3) Develop Migrant-sensitive health service system

4) Develop Partnerships, networks, multi- country framework Regular review key internal and external stakeholders and develop partnership through various forums

Mandalay Statement in March 2014 'Improving Access to Health Services by Migrants in Mekong Region'  Cambodia, Lao PDR, Myanmar,  Thailand and Vietnam  26 March 2014      Delegations from Cambodia, Lao PDR, Myanmar, Thailand and Vietnam met in Mandalay  during 23-26 March 2014 to discuss policy, financing, and service delivery issues on migrants’ health.    We recognize that migrants in the Mekong Region, a large majority being undocumented, are  vulnerable to ill health and exploitation due to poor work and employment conditions, as well as  inadequate legal and labour protection. Despite their contributions to host‐country economies, they  have limited access to health and other social services due to legal, financial and cultural barriers.  When they do access services, the resulting expenditure is a major burden. There are inconsistent  policies across  sectors such as labour, immigration and health.       There are rich experiences and innovation in managing and improving the health of migrants in the  Mekong Region, though these are often financed by out of pocket payment, a prepayment scheme,  or donors.  Various cross border collaborations have gone through many years of trial and error,  from  which  a  lot  was  learned,  though  much  remains  to  be  improved  in  order  to  translate  commitment and MOUs into actual implementation at scale.  We pledge our firm commitment to improving access to health services by migrants.  This requires  multi‐sectoral actions by public security, immigration, health, labour, social security, civil  society and  private employer constituencies. Close collaboration among agencies responsible for  migrants’  health in host and sending countries is essential.  The main bottleneck is financing health  services for  migrants and their dependents. The upcoming ASEAN Economics Community requires closer  collaboration across countries, recognizing private sector as an indispensable partner. 

Reform strategies 1. Expand the size of registered migrants to 100% 2. Establish migrant health insurance for all registered migrants sources of finance, management of schemes: premium collection, benefit package design, provider payment methods, M&E by purchaser organization 3. Migrant friendly services Migrant Health Volunteer, Migrant health workers, Primary and community care, Mitigating language and cultural barriers 4. Health Information Systems for migrants.

Thank you Sawasdee