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

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

Missing: Where Are the Migrants in Pandemic Influenza Preparedness Plans?

Influenza pandemics are perennial global health security threats, with novel and seasonal influenza affecting a large proportion of the world’s population, causing enormous economic and social destruction. Novel viruses such as influenza A(H7N9) continue to emerge, posing zoonotic and potential pandemic threats. Many countries have developed pandemic influenza preparedness plans (PIPPs) aimed at guiding actions and investments to respond to such outbreak events. Migrant and mobile population groups—such as migrant workers, cross-border frontier workers, refugees, asylum seekers, and other non-citizen categories residing within national boundaries—may be disproportionately affected in the event of health emergencies, with irregular/undocumented migrants experiencing even greater vulnerabilities. Because of a combination of political, sociocultural, economic, and legal barriers, many migrants have limited access to and awareness of health and welfare services, as well as their legal rights. The conditions in which migrants travel, live, and work often carry exceptional risks to their physical and mental well-being. Even if certain migrant groups have access to health services, they tend to avoid them due to fear of deportation, xenophobic and discriminatory attitudes within society, and other linguistic, cultural, and economic barriers. Evidence indicates that social stigmatization and anxieties generated by restrictive immigration policies hinder undocumented immigrants’ access to health rights and minimizes immigrants’ sense of entitlement to such rights

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

Public health practitioners’ perspectives of migrant health in an English region

Objectives: Migration is a complex and contested topic of public debate. Professionals working in public health must negotiate this politicised complexity, yet few studies examine the perspectives and practices of public health professionals in relation to migrant health. This study seeks to redress this by exploring how migrant health is conceptualised and addressed by public health professionals after a key transitional point in the reorganisation of public health in England and the public vote for the UK to leave the EU. Study design: Qualitative in-depth exploratory study Methods: Ten interviews and one focus group were conducted with 14 public health professionals’ working at Public Health England (PHE) or local authorities in an English region. Recordings were transcribed and thematic analysis was conducted. Results: Professionals viewed migrant health mainly through a health inequalities lens; migrants were considered vulnerable and their health often determined by wider social issues. This influenced public health professionals’ perceived ability to affect change. Public health professionals were greatly influenced by the societal, policy and institutional, post-Brexit vote context in England, describing a nervousness around addressing migrant health. At an institutional level, public health professionals described a sense that migrant health was not prioritised. It was considered ‘too hard’ and complex, especially with shrinking resources and highly politicised social narratives. Consequently, migrant health was often not directly addressed in current practice. The gaps identified by public health professionals were: lack of knowledge of health needs and cultural difference; lack of access to appropriate training; lack of cultural diversity within the public health workforce; and concerns about meaningful community engagement. Conclusions: These findings raise concerns about public health professionals’ ability to address the health needs of migrants living in England. The gaps highlighted require further and deeper examination across relevant organisations including the broader public health infrastructure in the UK

Opportunities and Challenges in Providing Health Care for International Retirement Migrants: A Qualitative Case Study of Canadians Travelling To Yuma, Arizona

Background Increasing numbers of older individuals opt to spend extended time abroad each year for lifestyle, health, and financial reasons. This practice is known as international retirement migration, and it is particularly popular among retirees in Global North countries such as Canada. Despite the popularity of international retirement migration, very little is known about how and why health care is accessed while abroad, nor the opportunities and challenges posed for destination hospitals. In this article we focus on addressing the latter knowledge gap. Methods This qualitative case study is focused on the only hospital in Yuma, Arizona – a popular destination for Canadian retirement migrants in the United States. We conducted focus groups with workers at this hospital to explore their experiences of treating this transnational patient group. Twenty-seven people participated in three, 90-min focus groups: twelve nurses, six physicians, and nine administrators. Thematic analysis of the focus group transcripts was conducted using a triangulated approach. Results Participants identified three care environments: practice, transnational, and community. Each environment presents specific opportunities and challenges pertaining to treating Canadian retirement migrants. Important opportunities include the creation of a strong and diverse seasonal workforce in the hospital, new transnational paths of communication and information sharing for physicians and health administrators, and informal care networks that support formal health care services within and beyond the hospital. These opportunities are balanced out by billing, practical, administrative, and lifestyle-related challenges which add complexity to treating this group of transnational patients. Conclusion Canadians represent a significant group of patients treated in Yuma, Arizona. This is contrary to long-standing, existing research that depicts older Canadians as being reluctant to access care while in the United States. Significant overlaps exist between the opportunities and challenges in the practice, transnational and community environments. More research is needed to better understand if these findings are similar to other destinations popular with Canadian international retirement migrants or if they are unique to Yuma, Arizona

The impact of rural-exposure strategies on the intention of dental students and dental graduates to practice in rural areas: a systematic review and meta-analysis

Rapeepong Suphanchaimat,1 Nisachol Cetthakrikul,1 Alexander Dalliston,2 Weerasak Putthasri1 1International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand; 2Master’s Student, School of Oriental and African Studies, University of London, London, UK Background and objectives: The objective of this study was to assess the impact of strategies on the intention of dental students/graduates to practice in rural areas. The strategies included the recruitment of dental students from rural backgrounds and clinical rotations in rural areas during the training of dental students. Materials and methods: The study undertook a systematic review and utilized meta-analysis to assess these strategies. International literature published between 2000 and 2015 was retrieved from three main search engines: Medline, Embase, and Scopus. The selected articles were scanned to extract the main content. The impact of the strategies was quantitatively assessed by meta-analysis, using the random-effect model. The pooled effect was reported in terms of odds ratios (ORs) with 95% confidence intervals. Sensitivity and subgroup analyses were performed. Publication bias was assessed by the Funnel plot and Egger’s test. Results: Seven of the initially selected 897 articles were included for the full review. The majority of the selected articles had been published in developed countries. The meta-analysis results revealed that the pooled OR of rural exposure on the intention to practice in rural areas was approximately 4.1, statistically significant. Subgroup analysis showed that clinical rotations in rural areas tended to have a slightly greater influence on rural dental practice than recruiting students from rural backgrounds (OR 4.3 versus 4.2). There was weaker evidence of publication bias, which was derived from small-study effects. Conclusion: Enrolling students with rural backgrounds and imposing compulsory clinical rotation in rural areas during their study appeared to be effective strategies in tackling the shortage and maldistribution of dentists in rural areas. Keywords: rural retention, rural background, dental students, dental graduates, systematic review, meta-analysi

Evolution and complexity of government policies to protect the health of undocumented/illegal migrants in Thailand – the unsolved challenges

Rapeepong Suphanchaimat,1,2 Weerasak Putthasri,1 Phusit Prakongsai,1,3 Viroj Tangcharoensathien1 1International Health Policy Program (IHPP), The Ministry of Public Health, Nonthaburi, 2Banphai Hospital, Khon Kaen, 3Bureau of International Health (BIH), The Ministry of Public Health, Nonthaburi, Thailand Background: Of the 65 million residents in Thailand, >1.5 million are undocumented/illegal migrants from neighboring countries. Despite several policies being launched to improve access to care for these migrants, policy implementation has always faced numerous challenges. This study aimed to investigate the policy makers’ views on the challenges of implementing policies to protect the health of undocumented/illegal migrants in light of the dynamics of all of the migrant policies in Thailand. Methods: This study used a qualitative approach. Data were collected by document review, from related laws/regulations concerning migration policy over the past 40 years, and from in-depth interviews with seven key policy-level officials. Thematic analysis was applied. Results: Three critical themes emerged, namely, national security, economic necessity, and health protection. The national security discourse played a dominant role from the early 1900s up to the 1980s as Thailand attempted to defend itself from the threats of colonialism and communism. The economic boom of the 1990s created a pronounced labor shortage, which required a large migrant labor force to drive the growing economy. The first significant attempt to protect the health of migrants materialized in the early 2000s, after Thailand achieved universal health coverage. During that period, public insurance for undocumented/illegal migrants was introduced. The insurance used premium-based financing. However, the majority of migrants remained uninsured. Recently, the government attempted to overhaul the entire migrant registry system by introducing a new measure, namely the One Stop Service. In principle, the One Stop Service aimed to integrate the functions of all responsible authorities, but several challenges still remained; these included ambiguous policy messages and the slow progress of the nationality verification process. Conclusion: The root causes of the challenges in migrant health policy are incoherent policy direction and objectives across government authorities and unclear policy messages. In addition, the health sector, especially the Ministry of Public Health, has been de facto powerless and, due to its outdated bureaucracy, has lacked the capacity to keep pace with the problems regarding human mobility. Keywords: migrant, health insurance, Thailand, policy formulation, policy proces

Impact of the health insurance scheme for stateless people on inpatient utilization in Kraburi Hospital, Thailand

Rapeepong Suphanchaimat,1,2 Phusit Prakongsai,1 Supon Limwattananon,1,3 Anne Mills2 1International Health Policy Program (IHPP), Ministry of Public Health, Faculty of Public Health and Policy, Nonthaburi, Thailand; 2London School of Hygiene and Tropical Medicine, London, UK; 3Khon Kaen University, Khon Kaen, Thailand Objectives: This study sought to investigate the impact of the Thai “Health Insurance for People with Citizenship Problems” (HI-PCP) on access to care for stateless patients, compared to Universal Coverage Scheme patients and the uninsured, using inpatient utilization as a proxy for impact.Methods: Secondary data analysis of inpatient records of Kraburi Hospital, Ranong province, between 2009 (pre-policy) and 2012 (post-policy) was employed. Descriptive statistics and multivariate analysis by difference-in-difference model were performed.Results: The volume of inpatient service utilization by stateless patients expanded after the introduction of the HI-PCP. However, this increase did not appear to stem from the HI-PCP per se. After controlling for key covariates, including patients’ characteristics, disease condition, and domicile, there was only a weak positive association between the HI-PCP and utilization. Critical factors contributing significantly to increased utilization were older age, proximity to the hospital, and presence of catastrophic illness.Conclusion: A potential explanation for the insignificant impact of the HI-PCP on access to inpatient care of stateless patients is likely to be a lack of awareness of the existence of the scheme among the stateless population and local health staff. This problem is likely to have been accentuated by operational constraints in policy implementation, including the poor performance of local offices in registering stateless people. A key limitation of this study is a lack of data on patients who did not visit the health facility at the first opportunity. Further study of health-seeking behavior of stateless people at the household level is recommended. Keywords: people with citizenship problems, difference-in-difference, double difference, impact evaluation, health servic

Equity of health workforce distribution in Thailand: an implication of concentration index

Woranan Witthayapipopsakul,1 Nisachol Cetthakrikul,2 Rapeepong Suphanchaimat,3,4 Thinakorn Noree,5 Krisada Sawaengdee5 1Health Financing Node, International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand; 2Health Promotion Policy Research Centre, International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand; 3Non-Thai population research unit, International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand; 4Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand; 5Human Resources for Health Development Office, International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand Background: Geographical maldistribution has been a critical concern of health workforce planning in Thailand for years. This study aimed to assess the equity of health workforce distribution in public hospitals affiliated to the Office of Permanent Secretary (OPS) of the Ministry of Public Health (MOPH) through the application of “concentration index” (CI). Methods: A cross sectional quantitative design was employed. The dataset comprised 1) health workforce data from the OPS, MOPH in 2016, 2) regional and provincial-level economic data from the National Economic and Social Development Board in 2015, and 3) population data from the Ministry of Interior in 2015. Descriptive statistics, Spearman’s rank correlation, and CI analysis were performed. Results: Thailand had 2.04 health professionals working in public facilities per 1,000 population. Spearman’s correlation found positive relationship in all health professionals. Yet, statistical significance was not found in most health professionals but doctors (P<0.001). Positive correlation was observed in all health cadres at regional and provincial hospitals (rs=0.348, P=0.002). In the CI analysis, the distribution of health professionals across provincial income was relatively equitable in all cadres. Significant CIs were found in doctor density (CI =0.055, P=0.001), all professionals density at district hospitals (CI =–0.049, P=0.012), and all professionals density at provincial and regional hospitals (CI =0.078, P=0.003). Conclusion: The positive CIs implied that the distribution of all health professionals, especially doctors, at provincial and regional hospitals slightly favored the richer provinces. In contrast, the distribution at district hospitals was slightly more concentrated in less well-off provinces. From a macro-view, the distribution of all health professionals in Thailand was relatively equitable across provincial economic status. This might be due to the extensive health infrastructure development and rural retention policies over the past four decades. Keywords: equity, health workforce distribution, concentration index, concentration curve, Thailan