Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia

Medical tourism is a growing phenomenon with policy implications for health systems, particularly of destination countries. Private actors and governments in Southeast Asia are promoting the medical tourist industry, but the potential impact on health systems, particularly in terms of equity in access and availability for local consumers, is unclear. This article presents a conceptual framework that outlines the policy implications of medical tourism's growth for health systems, drawing on the cases of Thailand, Singapore and Malaysia, three regional hubs for medical tourism, via an extensive review of academic and grey literature. Variables for further analysis of the potential impact of medical tourism on health systems are also identified. The framework can provide a basis for empirical, in country studies weighing the benefits and disadvantages of medical tourism for health systems. The policy implications described are of particular relevance for policymakers and industry practitioners in other Southeast Asian countries with similar health systems where governments have expressed interest in facilitating the growth of the medical tourist industry. This article calls for a universal definition of medical tourism and medical tourists to be enunciated, as well as concerted data collection efforts, to be undertaken prior to any meaningful empirical analysis of medical tourism's impact on health systems

Results from a before-and-after learning assessment of pre-migration departure training for prospective female migrants in Odisha, India

Work in Freedom (WiF) was a large multi-component intervention managed by the International Labour Organization (ILO) and funded by the Department for International Development (DFID), to prevent labour trafficking. WiF was implemented in India, Nepal and Bangladesh as source countries, and Lebanon and Jordan as destination countries, from 2013 to 2018. WiF’s community-based activities aimed to prevent labour trafficking by enhancing women’s autonomy, fostering adoption of ‘safe migration’ practices and assertion of migrant workers’ rights. The India component of WiF focussed on prospective in-country migrants only. A two-day pre-migration training event was organised for women who expressed an interest in migrating for work during WIF direct outreach sessions. The purpose of the sessions was to help women to make informed decisions about whether, and how, to migrate for work. They included modules on self-care, financial literacy, use of technology to ensure wellbeing, and safety in transit and at destination. Sessions were organised at the Gram Panchayat (village assembly) level and held once approximately 30 women had signed up per session (multiple sessions were held with different groups of approximately 30 women). The training was implemented by the Self Employed Women’s Association (SEWA) and AAINA, local NGOs with experience in gender, and labour mobilisation and organisation among women. This dataset contains data provided by 347 women who participated in pre-migration training and completed pre-training and post-training interviews. Dataset variables are listed in the accompanying questionnaire

Migrant Women's Access to Sexual and Reproductive Health Services in Malaysia: A Qualitative Study.

Providing sexual and reproductive health (SRH) services to migrant workers is key to fulfilling sustainable developmental goals. This study aims to explore key informants' views on the provision of SRH services for migrant women in Malaysia, exploring the provision of SRH education, contraception, abortion, antenatal and delivery, as well as the management of gender-based violence. In-depth interviews of 44 stakeholders were conducted from July 2018 to July 2019. Data were thematically analysed. Migrant workers that fall pregnant are unable to work legally and are subject to deportation. Despite this, we found that insufficient SRH information and contraceptive access are provided, as these are seen to encourage promiscuity. Pregnancy, rather than sexually transmitted infection prevention, is a core concern among migrant women, the latter of which is not adequately addressed by private providers. Abortions are often seen as the only option for pregnant migrants. Unsafe abortions occur which are linked to financial constraints and cultural disapproval, despite surgical abortions being legal in Malaysia. Pregnant migrants often delay care-seeking, and this may explain poor obstetric outcomes. Although health facilities for gender-based violence are available, non-citizen women face additional barriers in terms of discrimination and scrutiny by authorities. Migrant women face extremely limited options for SRH services in Malaysia and these should be expanded

Human Trafficking: Results of a 5-Year Theory-Based Evaluation of Interventions to Prevent Trafficking of Women From South Asia.

Preventing modern slavery is of global interest, but evidence on interventions remains weak. This paper presents findings from a 5-year theory-based evaluation of an empowerment and knowledge-building intervention to prevent the exploitation of South Asian female migrant workers. The evaluation used realist evaluation techniques to examine the intervention mechanisms, outcomes, and context. Findings from qualitative and quantitative data from Nepal, India, and Bangladesh indicate that the intervention mechanisms (trainings) were not well-targeted, not delivered by appropriate trainers, and did not address participants' expectations or concerns. The outcomes of empowerment and migration knowledge were not achieved due to poor integration of context-related factors, flawed assumptions about the power inequalities, including barriers preventing women from asserting their rights. Ultimately, interventions to prevent exploitation of migrant workers should be developed based on strong evidence about the social, political, and economic realities of their migration context, especially in destination settings

"Because if we talk about health issues first, it is easier to talk about human trafficking"; findings from a mixed methods study on health needs and service provision among migrant and trafficked fishermen in the Mekong.

BACKGROUND: Human trafficking in the fishing industry or "sea slavery" in the Greater Mekong Subregion is reported to involve some of the most extreme forms of exploitation and abuse. A largely unregulated sector, commercial fishing boats operate in international waters far from shore and outside of national jurisdiction, where workers are commonly subjected to life-threatening risks. Yet, research on the health needs of trafficked fishermen is sparse. This paper describes abuses, occupational hazards, physical and mental health and post-trafficking well-being among a systematic consecutive sample of 275 trafficked fishermen using post-trafficking services in Thailand and Cambodia. These findings are complemented by qualitative interview data collected with 20 key informants working with fishermen or on issues related to their welfare in Thailand. RESULTS: Men and boys trafficked for fishing (aged 12-55) were mainly from Cambodia (n = 217) and Myanmar (n = 55). Common physical health problems included dizzy spells (30.2%), exhaustion (29.5%), headaches (28.4%) and memory problems (24.0%). Nearly one-third (29.1%) reported pain in three or more areas of their body and one-quarter (26.9%) reported being in "poor" health. Physical health symptoms were strongly associated with: severe violence; injuries; engagement in long-haul fishing; immigration detention or symptoms of mental health disorders. Survivors were exposed to multiple work hazards and were perceived as disposable when disabled by illness or injuries. Employers struggled to apply internationally recommended Personal Protective Equipment (PPE) practices in Thailand. Non-governmental organizations (NGOs) encountered challenges when trying to obtain healthcare for uninsured fishermen. Challenges included fee payment, service provision in native languages and officials siding with employers in disputes over treatment costs and accident compensation. Survivors' post-trafficking concerns included: money problems (75.9%); guilt and shame (33.5%); physical health (33.5%) and mental health (15.3%). CONCLUSION: Fishermen in this region are exposed to very serious risks to their health and safety, and their illnesses and injuries often go untreated. Men who enter the fishing industry in Thailand, especially migrant workers, require safe working conditions and targeted protections from human trafficking. Survivors of the crime of sea slavery must be provided with the compensation they deserve and the care they need, especially psychological support

Evaluations of Interventions with Child Domestic Workers: A Rapid Systematic Review

Little is known about interventions to support the education, skills training, and health of female child domestic workers (CDWs). This rapid systematic literature review followed PRISMA guidelines (PROSPERO registration: CRD42019148702) and summarises peer-reviewed and grey literature on health, education, and economic interventions for CDWs and interventions targeting employers. We searched six electronic databases and purposively searched grey literature. We included observational studies, which included an intervention, quasi-experimental, and experimental studies. Two reviewers independently screened articles. Data were extracted on intervention description, inputs, activities, type of evaluation, outcomes, effect size or impact where applicable, limitations, and ethical considerations. All studies were quality appraised. We identified eight papers from five studies. Six papers reported on health-related outcomes, two on education-related outcomes, and three on economic outcomes. No evaluations of employer-related interventions were identified. Only one intervention specifically targeted CDWs. Others included CDWs in their sample but did not disaggregate data for CDWs. Findings suggest that the evaluated interventions had a limited impact on CDW's health, education, and economic outcomes. While it appears feasible to reach CDWs with outreach interventions, further work is needed to improve the consistency of their effectiveness and their ability to improve CDWs' current and future prospects

Universal health coverage in 'One ASEAN': are migrants included?

BACKGROUND: As the Association of South East Asian Nations (ASEAN) gears toward full regional integration by 2015, the cross-border mobility of workers and citizens at large is expected to further intensify in the coming years. While ASEAN member countries have already signed the Declaration on the Protection and Promotion of the Rights of Migrant Workers, the health rights of migrants still need to be addressed, especially with ongoing universal health coverage (UHC) reforms in most ASEAN countries. This paper seeks to examine the inclusion of migrants in the UHC systems of five ASEAN countries which exhibit diverse migration profiles and are currently undergoing varying stages of UHC development. DESIGN: A scoping review of current migration trends and policies as well as ongoing UHC developments and migrant inclusion in UHC in Indonesia, Malaysia, Philippines, Singapore, and Thailand was conducted. RESULTS: In general, all five countries, whether receiving or sending, have schemes that cover migrants to varying extents. Thailand even allows undocumented migrants to opt into its Compulsory Migrant Health Insurance scheme, while Malaysia and Singapore are still yet to consider including migrants in their government-run UHC systems. In terms of predominantly sending countries, the Philippines's social health insurance provides outbound migrants with portable insurance yet with limited benefits, while Indonesia still needs to strengthen the implementation of its compulsory migrant insurance which has a health insurance component. Overall, the five ASEAN countries continue to face implementation challenges, and will need to improve on their UHC design in order to ensure genuine inclusion of migrants, including undocumented migrants. However, such reforms will require strong political decisions from agencies outside the health sector that govern migration and labor policies. Furthermore, countries must engage in multilateral and bilateral dialogue as they redefine UHC beyond the basis of citizenship and reimagine UHC systems that transcend national borders. CONCLUSIONS: By enhancing migrant coverage, ASEAN countries can make UHC systems truly 'universal'. Migrant inclusion in UHC is a human rights imperative, and it is in ASEAN's best interest to protect the health of migrants as it pursues the path toward collective social progress and regional economic prosperity

Child Domestic Work, Violence, and Health Outcomes: A Rapid Systematic Review.

This rapid systematic review describes violence and health outcomes among child domestic workers (CDWs) taken from 17 studies conducted in low- and middle-income countries. Our analysis estimated the median reported rates of violence in CDWs aged 5-17-year-olds to be 56.2% (emotional; range: 13-92%), 18.9% (physical; range: 1.7-71.4%), and 2.2% (sexual; range: 0-62%). Both boys and girls reported emotional abuse and sexual violence with emotional abuse being the most common. In Ethiopia and India, violence was associated with severe physical injuries and sexual insecurity among a third to half of CDWs. CDWs in India and Togo reported lower levels of psycho-social well-being than controls. In India, physical punishment was correlated with poor psycho-social well-being of CDWs [OR: 3.6; 95% CI: 3.2-4; p < 0.0001]. Across the studies, between 7% and 68% of CDWs reported work-related illness and injuries, and one third to half had received no medical treatment. On average, children worked between 9 and 15 h per day with no rest days. Findings highlight that many CDWs are exposed to abuse and other health hazards but that conditions vary substantially by context. Because of the often-hidden nature of child domestic work, future initiatives will need to be specifically designed to reach children in private households. Young workers will also benefit from strategies to change social norms around the value and vulnerability of children in domestic work and the long-term implications of harm during childhood

Post-trafficking stressors: The influence of hopes, fears and expectations on the mental health of young trafficking survivors in the Greater Mekong Sub-region.

BACKGROUND: Human trafficking and labor exploitation are prevalent in Southeast Asia and have substantial health consequences for children and adolescents. Research on pre-departure circumstances and trafficking experiences show that gender plays a key role in shaping the experience of exploited children and adolescents. OBJECTIVE: This study estimates how youth's concerns and hopes for the future influence the mental health outcomes of male and female children and adolescents. PARTICIPANTS AND SETTING: Data were collected in face-to-face interviews with 517 children and adolescents (10-19 years old) who attended post-trafficking services between year 2010 and year 2013 in Cambodia, Thailand or Vietnam. METHODS: Multivariable logistic regression models were fitted to estimate the association of children and adolescents' post-trafficking concerns and hopes for the future with mental health outcomes, namely symptoms of depression, anxiety and Post Traumatic Stress Disorder (PTSD). The analysis was stratified by sex. RESULTS: In adjusted analysis, children and adolescents' concerns about social ostracization and maltreatment by others in their community of origin were associated with all three outcomes in males and with depression in females. Being concerned about their own mental health was associated with all outcomes, with a potentially stronger effect observed in males for depression (AOR 9.14, CI:1.21-68.68), anxiety (AOR 13.47, CI:1.70-106.48) and PTSD (AOR 8.36, CI:1.22-56.9) than in females where the odds for depression (AOR 3.24, CI:1.92-5.48), anxiety (AOR 3.05, CI:1.82-5.11) and PTSD (AOR 1.85, CI:1.08-3.14) were much lower. CONCLUSIONS: Young people's post-trafficking care needs and reintegration planning should be designed based on their current mental health, personal security, family and financial resources and age-related capacity