CHAN Chee Khoon
In recent years, WHO Member States have been urged to speed up reforms to ensure that all persons can have timely access to quality health services without falling into financial hardship.1 In the Southeast Asian region, citizens of Malaysia and Singapore have long benefited from widely accessible tax-funded or subsidized government healthcare, and Brunei nationals (who do not pay personal income taxes) enjoy wide-ranging health and social benefits at no cost to the individual. In Thailand, the National Health Security Act (2002) extended healthcare coverage beyond civil servants and their dependents, and employees in the formal (private) sector, to the majority of the population who hitherto had limited access to healthcare.2 The Philippines National Health Insurance Program (PhilHealth), established in 1995, reported that 79% of Filipinos were covered by 2013.3 Indonesia established a national health insurance scheme (Jaminan Kesehatan Nasional) in November 2014 with the ambitious target of enrolling 121.6 million citizens in the first year and achieving universal coverage for a projected 250 million citizens by 2019.4
Universal Health Coverage (UHC), however, in a national context often translates into citizen entitlements, leaving migrant workers (documented and undocumented), refugees, and asylum seekers without adequate cover for access to health care. This has given rise to urgent labor and human rights concerns for the Association of South East Asian Nations (ASEAN) whose Member States include major labor-exporting countries (Indonesia, Philippines, Myanmar) as well as labor-receiving countries (Malaysia, Singapore, Thailand).5
The presence of sizeable populations of undocumented migrants also presents distinctive public health challenges. As an example, the severe acute respiratory syndrome (SARS) pandemic erupted, and subsided, over an eight-month period in 2002-03 in the absence of therapeutics, clinically-useful diagnostics, and vaccines. One of the key control measures—quarantine and meticulous contact tracing—which helped to break the chains of transmission and extinguish the pandemic, would be difficult to implement when large populations of undocumented migrants have a strong incentive to avoid contact with government agencies. The Bangkok office of the International Organization for Migration estimated that in 2009-2010 there were 2.46 million low-skilled migrants from three neighboring countries (Laos, Myanmar, Cambodia) of whom 1.4 million were unregistered.6 A World Bank report estimated about 1.8 million registered foreign workers, and another one to two million unregistered workers were in Malaysia in 2010.7
In his preliminary observations and recommendations following his country visit to Malaysia (19 November-2 December 2014), Dainius Pūras (UN Special Rapporteur on the Right to Health) noted that undocumented migrants are “considered illegal in the country and face criminal penalties for being undocumented, ranging from fines to imprisonment and caning. During my visit, I learned about the establishment of immigration counters inside public hospitals to facilitate the referrals of undocumented migrants and asylum seekers to the police when they come seeking medical attention. I consider that this practice goes against public health interests and the code of ethics of doctors. The establishment of these counters will deter undocumented migrants from seeking health care for fear of being reported, which among other things could cause the spread of communicable diseases.”8
The pandemic potential of the Middle East respiratory syndrome (MERS) coronavirus, a more lethal but less transmissible relative of the SARS coronavirus, is amplified in the region by the annual flow of 250,000 Haj pilgrims traveling between Southeast Asia and the Saudi epicentre.
The disturbing but plausible scenarios, if SARS or MERS became established in the large undocumented migrant populations, can trigger health policy responses that reinforce xenophobic sentiments towards migrants. This would be regrettable and counter-productive. A pragmatic and rights-based public health approach, coupled with deterrent penalties for human trafficking and illicit employment of vulnerable and compliant undocumented migrants, would be more effective in the control of communicable diseases and the protection of migrants’ well-being.
The ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers (2007) expresses its essential tension in clause 3:
The receiving states and the sending states shall take into account the fundamental rights and dignity of migrant workers and family members already residing with them without undermining the application by the receiving states of their laws, regulations and policies
followed by the disclaimer that
Nothing in the present Declaration shall be interpreted as implying the regularisation of the situation of migrant workers who are undocumented.9
The ASEAN Socio-Cultural Community Blueprint (2009) and the 5th ASEAN Forum on Migrant Labour (2012) likewise deploy the language of migrant rights, welfare and human dignity, but the main receiving countries (Malaysia, Singapore, Thailand) appear more preoccupied with a different category of health-seeking foreigner, namely, ‘medical tourists’ which in Malaysia and Singapore may also include migrant workers with private insurance coverage.10 The Malaysian federal government, for instance, which controls the second largest listed healthcare provider in the world, IHH Healthcare, focuses more on an integrated regional health market than on regionally harmonized social policy.11
Even if there is political will to tackle human trafficking, dubious labor brokering practices, and jurisdictional irregularities along the labor ‘supply chain’ for undocumented migrants, it is clear that both sending and receiving countries are wary about enforceable binding commitments that comply with international human rights and migrant rights conventions.12
Thailand, in 2001, introduced a government-run Compulsory Migrant Health Insurance scheme (CMHI) for migrant workers, documented or undocumented. But this scheme has differential benefits compared to the Universal Coverage Scheme for Thai citizens. To date only about 60,000 out of a targeted one million migrant enrollees have registered with the scheme. The barriers to its uptake include the restricted portability of the coverage, annual medical examinations for policy renewal, and reluctance of undocumented migrants to identify themselves. The Philippines, with nearly 11% of its population living or working outside the country, requires its outward-bound migrant workers to enroll with PhilHealth. However, PhilHealth’s reimbursable benefits are often inadequate for the medical costs incurred abroad. To address this, bilateral labor agreements negotiated by Filipino authorities must comply with the Migrant Workers and Overseas Filipinos Act (1995) which requires overseas employers to provide the same health insurance benefits to Filipino migrant workers as are provided for their locally-hired employees. The Indonesian government is likewise negotiating on a bilateral basis for minimum standards in wages and benefits for Indonesians working overseas.13
Beyond these bilateral initiatives, a regional initiative which perhaps could find some traction is a multilateral binding agreement among ASEAN Member States on taxation options for migrants and their dependents, which would entitle them to ‘citizen-equivalent’ social benefits in their host country. This would not be a one-size-fits-all solution, but would be customized to evolving taxation and social entitlement regimes of respective ASEAN Member States. Such regional agreements might be better received in the host countries through expanding the notion of ‘adoptive’ citizen rights and responsibilities.
CHAN Chee Khoon, ScD (Epidemiology) is a health policy analyst at the Center for Poverty & Development Studies, Faculty of Economics & Administration, University of Malaya. Email: firstname.lastname@example.org
1 World Health Assembly resolutions on sustainable health financing, universal coverage and social health insurance: WHA 58.33 (2005). Available at http://apps.who.int/iris/bitstream/10665/20383/1/WHA58_33-en.pdf?ua=1, WHA 64.9 (2011). Available at http://apps.who.int/medicinedocs/documents/s21474en/s21474en.pdf (Geneva: World Health Organization).
2 T.G. Evans, A.M.R. Chowdhury, D.B. Evans, et. al., Thailand’s Universal Coverage Scheme: Achievements and Challenges. An independent assessment of the first 10 years, 2001-2010 (Nonthaburi, Thailand: Health Insurance System Research Office, 2010). Available at http://www.jointlearningnetwork.org/uploads/files/resources/book018.pdf
3 Philippines National Health Insurance Program (PhilHealth), Stats & Charts 2013. Available at http://www.philhealth.gov.ph/about_us/statsncharts/snc2013.pdf
4 R. Sciortino, “Indonesia health cards and the ‘missing middle’,” Jakarta Post (November 29, 2014). Available at http://www.thejakartapost.com/news/2014/11/29/indonesia-health-cards-and-missing-middle.html
5 R.L.L.R Guinto, U.Z. Curran, R. Suphanchaimat, and N.S.Pocock, “Universal health coverage in ‘One ASEAN’: are migrants included?” Global Health Action 8 (2015). Available at http://dx.doi.org/10.3402/gha.v8.25749
6 J.W. Huguet and A. Chamratrithirong (eds.), Thailand Migration Report, 2011 (Bangkok: International Organization for Migration), p.9. Available at http://publications.iom.int/bookstore/free/TMR_2011.pdf
7 X. Del Carpio, R. Karupiah, M.A. Marouani, C. Ozden, M. Testaverde, and M Wagner, Immigration in Malaysia: Assessment of its Economic Effects, and a Review of the Policy and System (Washington, DC: World Bank, Social Protection & Labor Unit, East Asia and Pacific Region, 2013).
8 Dainius Pūras, Preliminary observations and recommendations by the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Country Visit to Malaysia, 19 November-2 December 2014 (Geneva: Office of the United Nations High Commissioner for Human Rights). Available at http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=15370&LangID=E
9 Association of Southeast Asian Nations (ASEAN), ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers (Jakarta: Asean Secretariat, 2007). Available at http://www.asean.org/communities/asean-political-security-community/item/asean-declaration-on-the-protection-and-promotion-of-the-rights-of-migrant-workers-3
10 See Association of Southeast Asian Nations (ASEAN), ASEAN Socio-Cultural Community Blueprint, section C.2. Protection and promotion of the rights of migrant workers (Jakarta: Asean Secretariat, 2009). Available at http://www.asean.org/archive/5187-19.pdf and Protection and Promotion of the Rights of Migrant Workers: Towards Effective Recruitment Practices and Regulations – Recommendations, 5th ASEAN Forum on Migrant Labour, October 9-10, 2012, Siem Reap, Cambodia (Jakarta: Asean Secretariat, 2012). Available at http://www.ilo.org/asia/whatwedo/projects/WCMS_193024/lang–en/index.htm; M. Ormond, K.M. Wong, and C.K. Chan, “Medical tourism in Malaysia: How can we better identify and manage its advantages and disadvantages?” Global Health Action 7 (2014). Available at http://dx.doi.org/10.3402/gha.v7.25201
11 Y. Ngui and C. Kok, “Malaysia’s IHH jumps 14 percent as world’s No.3 IPO debuts,” Reuters (July 24, 2012). Available at http://www.reuters.com/article/2012/07/25/us-malaysia-ihh-ipo-idUSBRE86O03J20120725; Association of Southeast Asian Nations (ASEAN), Appendix I – Roadmap for integration of healthcare sector (Jakarta: Asean Secretariat, 2009). Available at http://www.asean.org/archive/19429.pdf
12 See for example J. Szep and S. Grudgings, “Authorities implicated in Rohingya smuggling networks,” Reuters (July 17, 2013). Available at http://www.pulitzer.org/files/2014/international-reporting/reuters/01reuters2014.pdf; S.Z. Al-Mahmood, “Palm-Oil Migrant Workers Tell of Abuses on Malaysian Plantations,” Wall Street Journal (July 26, 2015). Available at http://www.wsj.com/articles/palm-oil-migrant-workers-tell-of-abuses-on-malaysian-plantations-1437933321; S. Chao, “Malaysia’s Unwanted,” Al Jazeera documentary (November 21, 2014). Available at https://www.youtube.com/watch?v=qdV3sj76vnA ; J. Yeow, “Malaysia must do more to prosecute human traffickers, says top US diplomat,” The Malaysian Insider (April 17, 2015). Available at http://www.themalaysianinsider.com/malaysia/article/malaysia-must-do-more-to-prosecute-human-traffickers-says-top-us-diplomat
13 Guinto et al, (see note 5), pp.6-8