Focus group in Mae Sot
(Originally published in the Georgetown Journal of International Affairs)
The first refugee camp along the Thai-Myanmar border was established in 1984 in Mae La to welcome refugees from worn-torn Myanmar. Since 1984, a total of 9 camps have been created along the Thai-Myanmar border, hosting approximately 120,000 people in close quarters. These camps provide refugees with basic amenities and access to healthcare by international organizations.
Outside of refugee camps, many economic migrants have also been seeking better job and life opportunities. Legal migrants can receive free health care in public hospitals if they are enrolled in the government Migrant Health Insurance (MHI) program, but illegal immigrants are not eligible for the plan. Today, out of an estimated 3.5 million migrants living in Thailand, over 1.5 million are illegal, and 65% of them come from Myanmar (previously known as Burma).
Facing Health Access and Funding Challenges
Near Mae Sot, along the Thai-Myanmar border, the Shoklo Malaria Research Unit (SMRU) and the Mae Tao Clinic (MTC) have provided health care services for 30 years to Burmese refugees, unregistered migrants, and people living inside Myanmar. These services are supported by different institutional donor systems, and the SMRU and MTC services for migrants have been – and continue to be – fully donor-dependent. However, this support has decreased substantially over the past few years.
Most notably, migrants working along the Thai-Myanmar border lack legal status and face dire hardships such as abuse by the local police (for instance, being robbed), living on half the minimum legal wage, and having no access to healthcare. The government of Thailand is not prepared to massively legalize migrants, who could then demand access to social protection and fair salaries. They represent a cheap workforce that is welcomed in the Thai economy, but strong nationalistic positions prevail against their legalization. It is of utmost humanitarian importance that this abundant and cheap workforce stays healthy – a point the Thai government can agree on, given their reliance on these workers.
Designing the Health Micro Insurance Model
In this context, building a micro insurance program emerged as a possible new mechanism to sustain health services for illegal migrants and other underserved communities along the border in the face of declining donor support.
In 2014, the non-profit, mission-driven, social enterprise Dreamlopments conducted research to assess the interest among migrants for this model of a privately funded and low-cost health insurance. Among the 400 migrants consulted in Tak province along the Thai-Myanmar border, 74% were unregistered, 60.5% had jobs that paid on a day-to-day basis, and 93.5% of them had monthly income below 6,000 Thai Bahts (~US$180). 90.5% of those migrants had no government health insurance (which, besides the standard eligibility requirement, requires yearly premium payment and limits provision of free care to only one designated hospital), and yet 88% stressed that they would want a monthly plan that would cover services in multiple facilities.
Building on these findings, Dreamlopments and the SMRU worked together to conduct a full feasibility assessment of setting up this insurance model for people living along the Thai-Myanmar border as a mechanism for this vulnerable population to self-determine sustainable and unrestricted access to health care services through a network of partner healthcare providers on both sides of the border.
Among the main challenges foreseen as result of this study for the set-up and provision of this service were: a) obtaining the approval from the Thai authorities, b) dealing with the economic vulnerability of the target group, c) collecting the monthly premium fee in a rural context, d) addressing pre-existing conditions and chronic diseases, and e) financing initial set-up costs. Many of these challenges have been addressed – government support to operate the project and start-up funding have both been secured. The project formally started in Mae Sot on August 1st, 2017.
Deployment, Data Analysis, and Business Model Adjustment
The digital dimension is indeed an important part of the M-Fund initiative and building a strong data management system was seen as essential from the beginning. Its importance can be found in the need to have both quantitative and qualitative data to refine the model, to be able to test management costs, and to ensure model efficiency.
The M-Fund platform supports a variety of essential tasks ranging from member’s registration and payment services to claim management and personal health record access, as well as more in-depth data analysis. The platform acts as a unifying link between different actors: It runs on a secured server, is accessible via multiple devices and respects open standards and interoperability protocols. The system is adapted to the needs of the insured participants, local infrastructure, and current legislation. It is easily scalable, adaptable, replicable and able to manage information flows between the different partners and end-users.
Innovatively, the dataset analysis and feedback from insured members allow for rapid premium redesign and pricing revaluation to occur to adjust to migrants’ needs. Indeed, the model captures all indicators required to scale-up the initiative, monitor performance, define member profiles, create pricing assumptions, and determine healthcare practices and patterns, allowing it to adjust processes and services based on actual observed performance.
The plan of the Dreamlopments team is to continue working on adapting the business model to include new services such as a personal health record management tool, a claim management tool, offline access, internal communication tools and a reporting interface for deeper data analysis. These additions would only serve to further strengthen the M-Fund platform.
This initiative should be taken into consideration for a national plan and be reproduced in countries having similar issues with illegal workforce, working to provide fair healthcare access to all. Indeed, Dreamlopments pursues the goal of extending the project to other areas and migrant communities in need of health protection in Thailand and possibly even to other countries in the region in the coming future. If employed, illegal migrant workers throughout the region may finally gain stable access to healthcare and be able to contribute to both their countries’ economies and improve their livelihoods as healthy and productive workers.