Tuberculosis among migrants is increasingly becoming one of the largest public health problems in Thailand. Despite the widespread belief that migrants import the disease into Thailand, the reality is that when they first arrive in the country, migrants are often healthy. Many migrant health problems stem from their impoverished and unsanitary living conditions within Thailand.
An estimated 1.3 million migrants are unregistered. Being illegal means having no access to basic health services or to legal and social protection, as well as travel restrictions. Hiding and keeping a low profile are key to the survival of these individuals. This phenomenon has put migrants at particular risk to tuberculosis (TB).
The highly transient nature of such migrants, their poor working and living conditions and lack of access to health care for fear of deportation increase their chances of getting sick and dying of TB. As they are often on the move, it is difficult for them to complete the required minimum six-month TB treatment regimen. This failure to complete treatment makes them susceptible to drug-resistant strains of TB. As of 2011, there are estimated 1.7% new multi-drug resistant TB cases in the country, treatment of which can cost upward of US$5,000 per case.
Many migrants themselves are keen to assist their communities. One of them is 56-year-old Khin, a Myanmar tailor living in Thailand and one of the many migrant health volunteers who works with World Vision to assist migrants with suspected cases of TB.
Khin tells her account of one patient she assisted: "He moved to seven places within two months since the neighbours forced him to move out; they could neither eat nor sleep [because of] his disturbing cough. With tears in his eyes, he begged me to allow him to stay in our home for two months and to take treatment ... his trembling voice makes that day unforgettable for me." Khin and other volunteers help enable vulnerable individuals to receive information about TB, and receive examination and treatment when needed.
Migrant workers' contribution to Thailand's economy should not be underestimated. According to the 2011 Thailand Migration Report by the International Organisation for Migration (IOM), the availability and low wages of migrants in labour-intensive industries has contributed to the country's GDP growth and increased profits for many businesses, helped employers and producers to keep prices of their goods low, and filled low-skilled jobs involving work in difficult conditions unwanted by Thais.
The Thai government has also acknowledged the need for migrant workers to maintain its labour-intensive, export-oriented economy. Inevitably, migrants will be a permanent feature of Thai society for the foreseeable future. For these labour-intensive industries, such as fishing, manufacturing, construction, and agriculture, to thrive and maintain their economic prosperity, a healthy workforce must be in place. But do the migrants have access to the needed and deserved healthcare?
One key strategy of the Thai government to improve migrant workers' access to health services is to allow regular labour migrants to join the Compulsory Migrant Health Insurance Scheme (CMHIS). For an annual fee of 1,300 baht, they would be able seek health care services either in a Thai government clinic or hospital for little or no cost.
However, most migrants are irregular or undocumented, making them ineligible for health insurance coverage. They can still access the public health services but they must to pay for each service, which they cannot afford.
Interestingly, various reports have noted that among registered migrants under the health insurance scheme, there is still low usage of its benefits. According to an IOM report, "During 2004-2006 more than half of the regular migrants did not collect their health cards which would have entitled them access to the health system". This is in part because migrants do not understand the benefits of the cards, do not know how to use them or how to access hospital services. Worse still, some employers keep migrants' cards to prevent them from changing jobs. It seems that being a registered migrant is no guarantee to accessing public health services in Thailand.
The situation is bleaker for undocumented migrants.
Even though they are allowed to access public healthcare facilities, most are hesitant to do so due to language barriers, perceived and real discrimination, fear of arrest for not having proper documents, and an inability to pay the fees. Consequently, labour migrants, whether registered or undocumented, would prefer to self-medicate and will often not seek healthcare until their illness is already in the critical stage.
For those who may have acquired TB without knowing it, this poses serious risk of transmission to both Thais and migrants. A sickly migrant workforce would also entail a fast turnover of workers at high cost for employers and businessmen to recruit, train, and maintain migrant workers.
A recent World Vision report proposed several alternative solutions including the following:
- Establish a local mutual or trust fund to support migrants' healthcare costs, either by securing resources from the private sector or a combined contribution from the local health facilities, migrant employers and migrants themselves.
- Encourage employers to buy CMHIS on behalf of their migrant workers who cannot afford the premiums.
- Create a campaign targeting migrants, actively promoting the benefits of the health care coverage scheme and how to use it.
- Enable easier follow-up of mobile migrant TB patients under treatment by creating service provider networks among government health facilities and NGOs.
- Use part of the CMHIS budget to hire migrant health workers so that migrants can access healthcare with the support of someone speaking their language.
The more migrants that are brought into the public health system, the more sustainable the health development of migrants would be. Migrant workers are here to stay to fill the jobs available in labour-intensive industries that are pumping in profits for Thailand. A paradigm shift must occur. It is about time that ensuring the health needs of migrants is seen by the country as an investment rather than as an expense.
Dr Nang Sarm Phong works at World Vision Foundation of Thailand (WVFT) with The Global Fund To Fight AIDS, Tuberculosis and Malaria. WVFT is one of the driving forces behind a network including government, NGOs, hospitals and migrant volunteers that aims to curb the spread of TB in Thailand.