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, Turkey16th October 2015

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• 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)

Thailand at a glance

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Size of non-Thai citizen by group2015 estimates

Type of non-Thai citizens Million people

1. People with Citizenship Problems 0.6 2. International Displaced Persons (Thai Myanmar border) 0.13 3. Registered migrants with work permits 1.4 4. Illegal migrant but temporary registered (Myanmar Laos

Cambodia) 1.1

5. Undocumented migrants, no work permits, dependents 1.0 Total non-Thai citizens 4.2 Approximate 6% of total Thai population

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

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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.

The Three Dimensions of UHCThe Three Dimensions of UHC

Politics

Economics

Health

Health Financing and health insurance schemes in Thailand after achieving UHC in 2002

Scheme 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

contributionFor workers in the formal sector: approximately 11 million beneficiaries

Universal Coverage of Health Care Scheme or Previous 30 Baht Program

General Tax 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.

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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

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2. Compulsory Migrant Health Insurance (CMHI)

• First launch 1994 as MOPH 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 migrant pays 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: • + 900 Baht for ARV• Launch targeting children, premium 365 Baht per annum• One Baht a day premium campaign with low uptake

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)

Illegal migrants at point of entry

Legal migrants at point of entry

MOIWork

permit: MOL

Health insurance card:

MOPH

Hea

lth s

cree

ning

informal sector

One Stop Service (OSS) policy 22/7/14-31/10/14 (for 3 nations)

MOPH policy since 15/1/13Note: Implementation problems after

the advent of OSS

Insured by social health insurance (MOL)

Nationality verification (NV)

Work permit: MOL

Pass NV

informal sector or formal sector while NV is in process

formal sector

Imported through the government MOU (only for 3 nations and only for specific occupations, namely, industrial labour and maids)

Dea

dlin

e fo

r NV:

31/

3/15

Employers brought migrants to the MOI local office.

Migrants visited the MOI local office by themselves.

Facilitating the NV

process

MOL and MOI should coordinate with each after given the NV is completed.

informal sector

Fail NVRegister with MOI as people with

citizenship problems and be insured with MOPH (15/1/13 policy)

Results of ‘One-stop-service’ in 2014Migrant 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%)

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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 BahtProvin

cial 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

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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.

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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.

SawasdeeThank you