Migrant health care a critical issue

       In Tak province, caring for migrant workers and their families is straining the provincial hospital toits limits, while in some border provinces many apparently go without needed treatment By Erika Fry
       When Mae Sot General Hospital first ran out of space a few years ago,hospital staff pitched tents and dragged out old beds. Since then, the problem hasn't improved - the crowded conditions have become more frequent and new beds have been permanently stationed in the hospital corridors. They are seldom empty.
       But beds are hardly the extent of the hospital's resource problems. The hospital has a skeleton staff of five Burmese migrants serving as health workers and translators who assist Thai health personnel, but because of labour regulations they are technically employed as domestic workers. The Ministry of Labour limits migrant workers to low-skill work in the agricultural, manufacturing, fisheries or domestic sectors.
       The waiting room is invariably crowded,and hospital personnel are overworked. Last year the hospital ran a 50 million baht deficit.
       The reason for this debt is well known,and a subject on the minds of hospital administrators, public health officials, NGO staff and a number of Thai patients who ask their doctors why they must treat patients from Burma - the rising cost of providing health care to Mae Sot's migrant population.
       Dr Patjuban Hemhongsa, chief medical officer for Tak province, home to Mae Sot and 30 formal points of entry on the ThaiBurma border, looked exasperated when asked about the issue. He called Tak "a perfect place for so many problems we can't solve refugees, stateless, displaced persons and a continuous flow of illegal migrants. There is no budget or system to care for them".
       Dr Supakit Sirilak, director of the Bureau of Policy and Strategy for the Ministry of Public Health (Moph), agrees that migration has increased the burden on Thailand's health services and manpower, and added challenges to the disease surveillance and outbreak control system. He also acknowledges that the burden is one that can't be ignored.
       Under his nine-year watch in Tak province,the public health system has initiated a number of programmes to target migrant populations and increase their access to medical services.
       These included a migrant health worker and volunteer programme, as well as an ini-tiative targeting malaria."The security of the country is security in the health of the people living in it, no matter if they are Thai or not,"said Dr Supakit.
       Indeed, these migrant populations, who tend to live in cramped and unsanitary conditions, are often those most vulnerable to disease outbreaks and severe medical problems. Yet because of their mobility, they are also the most difficult to treat.
       Dr Supakit spoke of concerns over outbreaks of cholera and emerging diseases like meningococcal meningitis in the border areas.
       Tuberculosis, a disease once thought to have been largely conquered in Thailand,now has a strong and increasingly threatening presence in the form of drug-resistant strains along the border. Handfuls of cases of multidrug resistant and extremely drug-resistant forms of the disease have been detected in recent years.
       Tuberculosis is a special concern among migrant populations because of the intensive six-month regimen needed to treat the disease.
       Health workers speak of challenges in getting migrant patients to complete treatment - often they will begin to feel better and stop coming while at other times, they simply disappear.
       In one case a worker being treated was learned to have been arrested and placed in the Immigration Detention Centre. Because of bureaucratic obstacles, it took the NGO nearly two weeks to get him the drugs he needed.
       Yet, while many public health workers and officers at Moph agree with Dr Supakit's sentiments, there remains a disconnect between ideology and financing.
       "Moph allocates money according to provincial headcounts, which exclude migrant populations. Hospitals cannot request extra budgets, and the government cannot allocate it. You can't spend money you don't have,"Dr Patjuban said.
       The reasons for the rising costs are not as clear-cut as they might seem. While there have long been migrants in the border province - in Mae Sot and surrounding districts the Burmese population is estimated at more than 400,000- there hasn't always been hospital debt.
       In 2005 and 2006, Mae Sot General Hospital actually earned enough revenue through the Compulsory Migrant Health Insurance (CMHI)scheme to cover the medical costs of both registered and unregistered migrant patients,said Dr Ronnatrai Ruangweerayut, the hospital's deputy director.
       He blames the shortfalls that have arisen since largely on the decreasing number of registered workers, a problem which is as much the making of policy makers as it is of Mae Sot's migrants.
       According to statistics from the Ministry of Labour,85% of migrant workers living in Thailand in 2004 were registered and insured.Workers pay an annal fee of 1,900 baht for a health screening and insurance that entitles them to health care similar to that available to Thai citizens.
       The registration rate has fallen precipitously ever since - only 30% of migrant workers were registered in 2007- because of the restrictive nature (it had been closed to new workers) of the registration programme. Dr Ronnatrai estimates that only 20% of Mae Sot's migrant population is now registered.This figure is bound to increase, as the government opened registration to new migrants earlier this year.
       However, the Thai government's recent promise to permanently close the border suggests a likely continuation in the pattern of decline in terms of registration.
       As the number of registered migrants has fallen, so too has revenue from CMHI. Hospitals now have a fraction of the income generated through the insurance programme to care for a growing, or at least equal, number of migrants. Revenue collected from CMHI fell from 800 million baht in 2005 to 500 million baht in 2006. At the same time, fewer migrants are entitled to care and more are likely to face out-of-pocket health expenses they cannot afford.
       The amount of health services provided free of charge to Burmese rose from nearly 44 million baht in 2006 to 49 million baht in 2008.
       Before the advent of universal healthcare coverage in Thailand in 2001, hospitals used the income generated from out-of-pocket payments to fund care for those who could not afford it. With that income no longer available, hospitals and provinces are on their own. Dr Ronnatrai said his hospital has already burned through its past savings and has appealed, along with the Moph, to the government to allocate an additional budget to provinces with large stateless and migrant populations. Their requests have been denied.PROVINCIAL DIFFERENCES While Tak struggles with swelling health care costs, many provinces - some also with large migrant populations - continue to generate significant income through CMHI. Samut Sakhon and Rayong provinces, hubs for migrants working in the Thai fishing and manufacturing sectors, both generated nearly 10 million baht in revenue in 2006 through the insurance scheme, even after covering the costs of services that uninsured and unregistered workers could not afford.
       Dr Supakit says the discrepancies are due to the particularities of each province. Tak has far more unregistered workers than registered ones, while that gap is not as great in Samut Sakhon and Rayong. Uninsured workers in these provinces, where wages are higher,may also be more able to pay out-of-pocket medical costs than those in Tak.
       Just as hospital exemption payments for unregistered migrants have increased over the years, so too have out-of-pocket health payments made by migrants. Nationally, hospital exemptions in 2006 cost 170 million baht, while out-of-pocket costs by unregistered migrants totaled 120 million baht. In addition,registered migrants contributed 493 million baht through the CMHI scheme. This data includes only 47 provinces.
       Any surplus income earned through the system is used, at the discretion of individual hospitals or provinces, to subsidise the costs of providing care to unregistered migrants and stateless people. In most cases, this income exceeds the costs of exempted payments and theoretically is intended for outreach to migrants in the community.
       Though this is the expectation, it's hard to know what becomes of this surplus funding. Reports of populations covered and revenue collected through the CMHI scheme have been incomplete and inadequate, despite the fact that the Moph requests all provinces to report their data to the central office.
       In 2007, only nine provinces submitted data - four of these are sites of IOM-Moph migrant health projects - down from 65 in 2004 and 46 and 47 in 2005 and 2006, respectively.
       "There is no real enforcement of the penalty for those that don't do it," said Dr Nigoon Jitthai, programme manager of International Organisation of Migration's (IOM) Thailand Health programme, which since 2003 has collaborated with the Moph on a Migrant Health Program.
       Meanwhile, figures which have been reported vary widely and attract questions on their own.
       "The governance and management of the funds is being questioned by everybody, as it seems that it lacks transparency. Many NGOs have tried to find out how the funds are managed and how exactly the funds are spent,without success. To be honest, no one knows how the surplus is used," said Dr Nigoon.
       Dr Supakit agrees that reporting has been a problem, and has for several years been working to establish a Migrant Health Management Information System to better monitor migrant health financing and population data.
       The surplus funds in many provinces suggest to Dr Nigoon that the public health services - even those in Mae Sot - to which registered workers are entitled through CMHI,are vastly underused. Data from the Moph show that from 2004-2006, registered migrant workers were half as likely to visit public health centres as other insured patients insured migrant workers averaged less than one visit per year, while Thais under the universal coverage plan seek services an average of 2.5 times per year.
       Dr Nigoon says this under-utilisation is due to several factors, including fear of local authorities - even those that are registered tend to feel this way - a lack of awareness of their coverage, long working hours, long journeys to health care facilities, restrictive employers, and perhaps, as a consequence of all of these, the preference to self-medicate.
       She says the self-medication is unfortunate as migrants may lose money for inappropriate treatment, health providers may miss health developments within migrant populations,and in cases of infectious diseases, the chronic misuse of antibiotics etc can cause drug resistance.
       Available data continues to show that migrants under the CMHI scheme are most likely to seek treatment when health cases are quite severe and require in-patient care.
       While Dr Supakit calls CMHI an effective system for those it covers, he acknowledges there are some locations where there may not be adequate translators or cultural help for migrant workers to feel comfortable in accessing it. Those who are not covered by CMHI - stateless persons and illegal migrants - present the complications.
       Accordingly, he recommends that policy makers adopt a system that will facilitate migrant workers into insurance schemes."The more they are insured, the better health insurance can survive."
       While this year's influx of one million migrants into the registration system should buoy, or further bloat, hospitals' CMHI accounts, the increase will not resolve the disparities and gaps within the funding system.
       A handful of NGOs and international organisations like IOM continue to pitch in, in areas where service is most patchy. These efforts are often specifically targetted to provide TB services or HIV/Aids prevention, though others more broadly address the migrant community's health needs. IOM, for example,funds several community health posts and the training and service of migrant health workers.
       A health worker in a post in Tak's Thasong Yang district - a young Karen woman whose family has lived in Thailand for more than 40 years, but lacks Thai citizenship - attends the health needs of her village's 884 members,sometimes around-the-clock as her home is next to the health post, providing basic care.
       Much relief also comes from Mae Sot's Mae Tao Clinic, an internationally-funded operation that in 2006 had a caseload of 80,000 and expended 55 million baht in health services to Burmese patients. Half of these came from Burma for treatment.
       While the Moph and provincial health offices have recently absorbed some programmes once supported by IOM, in a nod for sustainability, much of the external assistance comes with an expiration date, and provides neither a complete nor permanent fix.
       Dr Patjuban grapples with how to keep the population of Tak healthy, and his public health services financially solvent."The shortages impact the whole system. We need more human resources, more equipment.It's an insufficient budget."
       While Tak province receives assistance for funding migrant health care from a handful of NGOs, the inequalities of the migrant health care system and lack of assistance from the government get to him.
       "For education, its not a problem. The resources are allocated," he says, referencing the Education for All programme that, at least theoretically, provides education to Thais and non-Thais."Why more funding for education, but none for health?" he asks.
       He sees no light at the end of the tunnel,and having given up on on his own government turns to another."The strain on our system is great. We need Burma to improve."