Introduction

In March 2005, following an emergency response to the Tsunami, Médecins Sans Frontières Belgium (MSF-B) discovered a group of Burmese migrants living in Phang Nga province, near the area of great devastation, who were vulnerable and in significant need of health care. A project was begun to address their needs in cooperation with the Thai Ministry of Public Health (MoPH).

In the course of providing medical care, Médecins Sans Frontières (MSF) gained experience with the migrants’ difficulties in accessing health care services. For both humanitarian and economic reasons MSF believes that providing health care for migrants is in Thailand’s best interests. We could find no published literature describing the barriers to health care for Burmese migrants in Thailand. This field report describes MSF’s program of support to Phang Nga’s migrants and the barriers to health care access that were encountered. Suggestions to improve access are made, based on this experience.

Migrant Workers in Thailand

It is estimated that over two million migrant workers are currently living and working in Thailand, with over 70% from Burma [1]. Of these, only 501,500 [2] are currently registered, while the majority remain unregistered and therefore “illegal”. The Burmese are fleeing forced labor, extortion, land confiscation, agricultural quotas and access limitations according to a report from the Thai Burma Border Consortium [3]. However, research from the International Rescue Committee suggests that political persecution is the main reason for many migrants leaving Burma [4]. Once in Thailand, the migrants carry out the so-called “3D” jobs: “dangerous, dirty or difficult”, ones that most Thai citizens avoid, such as deep sea fishing, fish processing, rubber-tapping, housekeeping and construction work. Without the migrants, many Thai employers would find it impossible to fill the labor gap. At the end of 2008 there were only 570,000 underemployed persons in Thailand [5] as compared to an estimated two million migrant workers [1]. Despite the fact that they are an essential part of the Thai economy, they remain a marginalized [4] group. One of the reasons for this is the negative attitude of Thai citizens towards them. Migrants are often portrayed by the Thai press as stealing jobs from Thai citizens [6], even though these are jobs that are frequently spurned by Thai workers [7].

Health Issues for Migrants

Migrants come from a difficult situation in Burma, a country with some of the worst health indicators in the world. The under-5 mortality rate in Burma in 2008 was 122 per 1,000 live births versus medians of 23 and 63 per 1,000 live births for the whole world and south–east Asia, respectively [8]. After arrival in Thailand many migrants see their health deteriorating due to heavy work, poor living conditions and lack of access to care. Construction workers are required to perform heavy manual labor for more than 12 h a day, 7 days a week. Fishermen remain on their boats for weeks in a row without a break. Housing is over-crowded and lacking proper sanitation [9]. A study by the International Labor Organization found that 60% of young domestic workers were not allowed to leave their employer’s house to meet others [10]. These conditions encourage the transmission of TB.

Although accurate figures for prevalence for HIV are unknown for Burmese migrants in Thailand, data from MSF’s project in Phang Nga suggest a high HIV prevalence among Burmese migrants. In 2007–2008 the prevalence among pregnant women attending to the clinics was 4.8% [11] compared to a 2007 HIV prevalence of 1.4% for Thailand according to WHO statistics [12].

Conditions in Phang Nga Province

Phang Nga province, in the south west of Thailand, is currently home to an estimated 50,000 migrants of whom only about 14,000 are officially registered [13]. Almost all in Phang Nga are of Burmese origin and work in fisheries, on construction sites or in rubber plantations.

Living and working conditions of these migrants in Phang Nga, as elsewhere in Thailand, remain difficult with constant fear of being arrested and deported [14]. MSF staff witnessed the police regularly setting-up road blocks in front of the main hospital of Phang Nga province in Takuapa and arresting migrants on their way out after they had attended medical services. This situation deteriorated significantly in Phang Nga in June 2007 when a provincial decree applied increased restrictions to their movements and strengthened the implementation of the arrest and deportation policy. It included a curfew between 8 PM and 6 AM, a ban on the use of mobile phones, strict enforcement of the policy forbidding migrants to drive cars or motorbikes and a ban on gatherings of more than five migrants outside their living compounds.

Médecins Sans Frontières’ Activities in Phang Nga

MSF began treatment and health education activities in three sub districts of Phang Nga province, covering a population of approximately 10,000 migrants. These areas were chosen because of the high concentration of migrants working in fishing, rubber-tapping and construction. Basic health care (outpatient care, vaccinations, under-5s and antenatal clinics) was provided in two Primary Health Care Units. MSF-supported community health volunteers offered translation services and counseling in Ministry of Public Health (MoPH) hospitals and in three health stations. In addition, MSF organized mobile clinics that provided primary health consultations, health education and referrals to hospital. In total, 620 women received antenatal care of whom 46 were sent for cesarean section [11].

In addition to providing financial support for referrals to MoPH hospitals, MSF provided health insurance cards for the most vulnerable groups among the migrants, children, pregnant women and HIV positive people. Unfortunately, this was not possible for undocumented migrants, only for those registered (even if they were not working at the time). In 2008 MSF provided health insurance cards for 423 patients. Of these, 354 were children under 12 years old, 60 were patients positive for HIV or TB or co-infected and 39 were pregnant women. To reduce the chance of patients being stopped by roadblocks, MSF transported patients directly to hospital, negotiated with police or provided referral letters to legitimize the visit.

Barriers to Accessing Health Care

Based on its experience, MSF came to understand the barriers to accessing health care experienced by Burmese migrants and registration for health care is one of the most difficult.

The registration process is very cumbersome and expensive. To use the Thai public health system, migrants must obtain work permits and purchase health insurance cards. Before they can be obtained, however, their employers must request approval to hire migrant workers from the Provincial Employment Office. This approval requires workers to have a health exam and, if pronounced fit, they receive a valid medical certificate. Then, employers can secure work permits and health insurance cards from the Provincial Employment Office. A 1 year work permit costs 1,900 baht (US$ 58 or € 38) and a health card, including the obligatory health exam, is another 1,900 baht per annum. Given these requirements, many employers don’t even bother starting the process since unregistered workers can be paid less than registered workers.

In addition, the regulations change almost annually, reducing the likelihood of being followed. To cope with this situation, some migrants hire a broker to help with the necessary paperwork and to make contacts with the authorities on their behalf. However, this is expensive and hardly feasible for the majority.

Without health cards, migrant workers must pay the full cost of treatment, which is usually impossible. For example, a caesarean delivery in the hospital costs more than 10,000 baht (US$ 300 or € 200) which, for the average migrant, is more than 3 month’s wages.

Even for those migrant workers who can pay for treatment, there is the added barrier of fear of being stopped at a police check-point on their journey to the hospital leading to arrest and deportation or fear of being reported to the police by hospital staff.

In addition, having a health card is not always a solution for diseases like TB or HIV/AIDS since their treatment medications and those used for prevention of mother to child transmission are not included in the insurance package for migrants.

MSF observed several other barriers preventing migrants from seeking adequate care: language, transportation costs and lack of knowledge about important health problems. Being unable to speak or read Thai is compounded by the unwelcoming attitude of some MoPH staff. MSF teams have witnessed that Burmese migrants had much longer waiting times before receiving treatment as compared to Thai citizens. And in a few cases, MSF observed MoPH health staff notifying the immigration police when an undocumented migrant couldn’t pay a hospital bill. The negative attitude of both MoPH staff and the general public was identified by the Prevention of HIV/AIDS Among Migrant Workers in Thailand (PHAMIT) migrant health project that has been operating in 22 provinces between 2003 and 2008. During that period, more than 13,000 government officials, employers and journalists were enrolled in sensitization sessions to improve relations between the two nationalities [15]. All these factors lead many migrants to seek treatment only when they have an advanced stage of disease.

In response to these conditions, the Thai MoPH recognized the barriers to health care for undocumented migrants and drafted in 2008 a policy to provide care and treatment. However, at this time the policy has not been formally approved by the cabinet and as a result, the decision to provide health care to undocumented migrants is made at a decentralized level and differs markedly from province to province [4, 16].

MSF’s Suggestions

We recognize that our experience in migrant health care in Thailand is limited to one project, but based on that experience, we offer some suggestions that could improve access to health care for migrants:

  • The registration process could be made simpler, cheaper and available to all migrants. For instance, the requirement for a medical exam could be dropped and the fee reduced or removed so that employers would be more likely to register workers. This, together with lifting the restrictions laid down in some provincial decrees, would reduce their constant fear of deportation.

  • Alternatively, the purchase of health insurance cards could be made independent of the registration process, to allow all migrants, with or without registration, to have access to an adequate level of health care.

  • The MoPH could ensure that current policies such as free HIV/AID and TB treatment for Thai citizens are available for migrants in all public health facilities. To reduce spread of communicable diseases like these, it is in Thailand’s best interests to treat them aggressively in the same manner as their own citizens.

  • Specific outreach services, like translation services, home visits, targeted health education and counseling, could be provided by health facilities in areas with large migrant populations. For this purpose the health facilities should be allowed to hire migrant workers as interpreters or community health volunteers, something that is not currently allowed under Ministry of Labor regulations.

  • Employers could be encouraged, by legal means if necessary, to take more responsibility for the health of their migrant workers, especially if the above suggestions are followed. This is in the employers’ best financial interests since keeping the workers healthy reduces time lost for illness and loss of productivity. This is an important economic consideration, given the large number of migrant workers who fill jobs Thais won’t accept.

  • Positive public education about the value of migrants and their health needs may improve Thai citizens’ and health workers’ attitudes towards migrant workers.

Conclusion

Migrant workers are numerous in Thailand and are an important part of the economy but, based on our experience, there are many barriers to access adequate health care. MSF has demonstrated that this access can be improved and encourages the Thai government to implement policies that provide for migrants’ basic right to adequate health services.