Download Improving health insurance coverage and access to essential health

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, Turkey
16th October 2015
Thailand at a glance
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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)
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Size of non-Thai citizen by group
2015 estimates
Type of non-Thai citizens
1.
2.
3.
4.
People with Citizenship Problems
International Displaced Persons (Thai Myanmar border)
Registered migrants with work permits
Illegal migrant but temporary registered (Myanmar Laos
Cambodia)
5. Undocumented migrants, no work permits, dependents
Total non-Thai citizens
Approximate 6% of total Thai population
3
Million
people
0.6
0.13
1.4
1.1
1.0
4.2
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);
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Thailand
Laos PDR
Myanmar
Cambodia
Vietnam
8.86 USD
1.39 USD
2.08 USD
4.06 USD
3.28-4.73 USD
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.
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The Three Dimensions of UHC
Economics

Politics
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
contribution
For 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.
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.
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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
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
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One Stop Service (OSS) policy 22/7/14-31/10/14 (for 3 nations)
Migrants visited the
MOI local office by
themselves.
MOI
MOPH policy since 15/1/13
Note: Implementation problems after
the advent of OSS
Imported through the
government MOU (only for 3
nations and only for specific
occupations, namely, industrial
labour and maids)
informal sector
Health
insurance card:
MOPH
informal sector
or formal sector
while NV is in
process
informal sector
Work
permit
: MOL
formal sector
Legal migrants at
point of entry
Pass NV
Register with MOI as people with
citizenship problems and be insured with
MOPH (15/1/13 policy)
Work
permit
: MOL
Deadline for NV: 31/3/15
Illegal migrants at
point of entry
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)
Health screening
Employers brought
migrants to the MOI
local office.
Fail NV
Insured by social health
insurance (MOL)
Nationality
verification (NV)
MOL and MOI should
coordinate with each after
given the NV is completed.
Results of ‘One-stop-service’ in 2014
Migrant 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%)
Migrant Health Insurance Cost Allocation
• Premium collected at the registered hospitals
ARV 300 Baht
Central
Pooling 360
Baht
Central Mx cost 10 Baht
High cost care 50 Baht
Premium 1,600
Baht
+ 500 Baht
Health check up cost
Provincial
Health
Office 326
Baht
P&P cost 206 Baht
Provincial Mx 120 Baht
Hospital 914 Baht
OP visit, hospitalization, medicines, lab
investigation
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A Global Operation Framework
on Health of Migrants
Promote conducive
policy and legal
frameworks
Monitoring migrant
health
Migrant-sensitive
health service
system
Partnerships,
networks, multicountry 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
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
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Migrant Health Volunteer,
Migrant health workers,
Primary and community care,
Mitigating language and cultural barriers
4. Health Information Systems for migrants.
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Thank you
Sawasdee