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.