Southeast Asia is home to major labour-sending countries (Indonesia, the Philippines, Myanmar) as well as labour-receiving countries (Malaysia, Singapore, Thailand and Brunei, some of which also receive large numbers of labour migrants from Nepal, Bangladesh and India).
In Malaysia, migrants make up one quarter of all employed people, and in Singapore, foreigners account for about 40% of the total workforce. In Thailand, official figures for 2010 showed 2.46 million low-skilled migrants from three neighbouring countries: Laos, Myanmar and Cambodia. Unofficial estimates suggest the migrant worker population could be as high as 4 million.
Host countries benefit from the enhanced economic growth that migrant labour makes possible (which may entail winners as well as losers), while migrants benefit from employment and livelihood opportunities (to the extent that decent working and living conditions are ensured for migrant as well as local workers).
The social dimension of Asean's regional integration, however, seems to have taken a back seat to trade liberalisation and regional economic integration, judging by the glacial pace of progress toward a mandate and mechanism for the enforcement of the Asean Declaration on the Protection and Promotion of the Rights of Migrant Workers (2007).
UNIVERSAL HEALTH COVERAGE
In Southeast Asia, citizens of Malaysia and Singapore have long benefited from widely accessible tax-funded or subsidised government healthcare, and Brunei nationals (who do not pay personal income tax) enjoy wide-ranging health and social benefits at public expense. In Thailand, the National Health Security Act (2002) extended 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.
The Philippines National Health Insurance Programme (PhilHealth), established in 1995, reported that 79% of Filipinos were covered by 2013. 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.
But universal health coverage (UHC), 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 healthcare.
Not surprisingly, labour-sending countries favour more generous "quasi-citizen" access to social benefits for migrant workers in their host countries:
"Our collective efforts are needed in Asean to support reforms that will enable migrant workers to find safe, legal, and decent work and to work in dignity and with the support, not only of the governments of their home countries, but also of the governments of their host countries," Philippine Social Welfare Secretary Judy Taguiwalo told a recent meeting on the Asean Socio-Cultural Community (ASSC). She urged delegates to work together to protect all migrant workers and treat them as they would their own citizens when they are in need.
TRICKLE-DOWN REGIONALISM?
However, the three labour-receiving Asean countries -- Malaysia, Singapore and 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. 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 harmonised social policy.
On June 24 this year, following its earlier public forums on regional labour migration, SEA Junction, in collaboration with the Heinrich Boll Stiftung, convened a panel (of which I was a member, along with Jiruth Sriratanaban and Rebecca Farber) to discuss "Seeking Health Across the Border", at the Bangkok Art and Culture Centre.
It soon became clear that a very basic issue -- the lack of a uniform definition of a "medical traveller" -- remained a problem, whether in a regional overview or in national reports. The resulting patchy and quite ambiguous statistics allow for wildly diverging estimates and pronouncements.
Citing an OECD publication from 2011, "we can narrow down the number of medical tourists worldwide as lying somewhere between 60,000 and 50 million", health economist David Reisman observed. He acknowledged that "speculation abounds … it is not even certain that the market is growing".
The reasons for this state of affairs are well known: the conflation, in reported statistics, of treatment-seeking travellers with treatment seeking episodes by migrant labourers, resident expatriates, foreign retirees, foreign students, vacationing tourists, multiple counting (and sometimes, under-counting), on top of the elastic boundaries of the category "healthcare" as notions of etiology (causation of ill health, determinants of well-being) become more encompassing.
In 2011 for instance, the state of Penang, which accounted for 60-70% of foreign patients who travelled to Malaysia expressly for the purpose of seeking treatment, reported that 95% of Penang-bound patients were from Indonesia. By contrast, only 57% of the more encompassing category of all foreign passport holders treated in Malaysia were Indonesian nationals.
RIGHTS AND RESPONSIBILITIES
Unlike the medical tourists avidly courted by Asean member states, migrant workers are often perceived as an added imposition on overburdened public services, if not as freeloaders. In fact, migrants in Malaysia pay about four times the user charges levied on Malaysians at government hospitals, under a mandatory hospital care and surgical insurance scheme that costs 120 ringgit (US$28) annually with maximum reimbursements of 10,000 ringgit.
Migrant workers in Malaysia also contribute significantly to public finances through annual levies (currently 640 to 1,850 ringgit) paid for by the workers, along with assorted administrative charges (and consumption taxes). These levies and charges, amounting to between 1,121 and 2,331 ringgit per head annually, translate into de facto income taxes that are quite regressive.
For example, migrants earning 1,000 ringgit per month would be paying a de facto income tax rate of 9-19%, which would put them in the same tax bracket as that of a mid-career academic in Malaysia, without the citizen entitlements of the latter.
So are we any closer to an Asean social charter that will address issues such as migrant healthcare? Since regimes of taxation and social entitlements vary across countries, a multilateral agreement among Asean member states on contributory options for migrants, which would entitle them and their dependents to designated "citizen-equivalent" social benefits in their host country, should perhaps avoid a one-size-fits-all approach.
An approach customised to the (evolving) taxation and social entitlement regimes of respective Asean member states may better accommodate, and build upon, the diversity of such regimes in the region.
The envisaged multilateral agreement, for instance, might adopt the generic principle that mandatory contributory regimes of the host country (including income taxes) could be extended to migrant workers, who in return would be entitled to social benefits, which could be specifically designated or even on the same terms as are available to local citizens.
This, arguably, might have better political traction among the decision-makers and general public of the host countries, than a narrowly rights-based discourse and approach to social benefits and entitlements for labour migrants.
Chan Chee Khoon, ScD (Epidemiology) is a visiting scholar at the Centre for Research in International and Comparative Education, Faculty of Education, University of Malaya.