Abstract
Although the Thai Government shows a clear intention towards improving the health care of migrant workers and dependants, healthcare measures for urban refugees and asylum seekers (URAS) have not materialised. At present, approximately 5,000 URASs live in Greater Bangkok. The main authority responsible for the registration and the screening of URASs is the Office of the United Nations High Commissioner for Refugees (UNHCR). The objectives of this study are to: (i) review policies related to the health care and well-being of URASs; (ii) analyse views of stakeholders related to the health care and well-being of URASs in Thailand; and (iii) explore the health status and health access of URASs through the perspective of unmet need for health services. This study employed both qualitative and quantitative methods. Data collection comprised a review of academic documents from both domestic and international sources, multi-lateral agreements or international covenants, and domestic laws related to human rights and health of URASs; in-depth interviews with 30 stakeholders and 7 URASs; a Delphi survey among 13 experts and key informants; and a primary survey on unmet need among 181 URASs. Data from the unmet-need survey were collated with data from the previous Health and Welfare Survey (HWS) in 2019 with 2,941 Thai participants. The findings revealed that academic literature concerning the health care of URASs in Thailand was extremetly sparse, relative to the same kind of literature on refugees in other settings. In terms of international covenants, Thailand is not yet a party of the 1951 Refugee Convention. However, the Thai Government always allows UNHCR to implement screening measures and take action for the well-being of URASs in Thai territory. Recently in 2019, the Government endorsed the ‘Regulation of the Office of the Prime Minister: Screening process for aliens entering the Kingdom of Thailand and incapable of returning to their home country’. However, there has not been any tangible change of healthcare policies for URASs after this Regulation was promulgated. The interviews and Delphi-survey suggested that the ideology of national security and international relations influenced the concept of human rights for URASs. The ambiguity of the policy direction from central authorities to take care of URASs causes varying legal interpretations and incoherence of practice among frontline officers regarding the care for URASs. Nevertheless, the majority of the key informants agreed that URASs should be granted the right to work in the country lawfully and should be able to acquire health insurance. The quantitative survey on unmet need for health services demonstrated that the prevalence of unmet need in URASs was significantly greater than in Thais. Factors that were significantly associated with greater odds of unmet need were increasing age, below-bachelor educational background, and the lack of health insurance. Being uninsured tended to yield the largest degree of association with unmet need in both outpatient and inpatient care. URASs from Arab countries were found to face a greater degree of unmet need, compared with URASs from other nations. Policy recommendations include the following proposals. Firstly, as grantingURASs rights to work lawfully in Thailand is the most agreeable issue in the perspective of many stakeholders involved in this study and there exists legal mechanisms to push this agenda forward (for instance, Article 17 of the 1979 Immigration Act and Article 63 of the 2017 Royal Ordinance Concerning the Management of Employment of Foreign Workers), the Ministry of Labour should work closely with relevant authorities to advocate a Cabinet Resolution to permit URASs to acquire a work permit. Such a proposal will not only increase the stock of labour to boost the Thai economy, but also reduce the financial burden of the state that is used to take care of this population. Secondly, theThai Government should demonstrate a clear strategic direction to ensure the wellbeing of URASs in all related areas, especially health, education, and employment. The clear policy direction of the Government will translate into concrete actions at the operational level in respective agencies. Thirdly, though at present URASs are still uninsured, the Ministry of Public Health (MOPH) should launch a clear policy message to guarantee URASs the right to enjoy basic healthcare for diseases that may cause public health threats and the related right to acquire necessary health promotion and disease prevention services without excessive personal expense burdens. Fourthly, as the MOPH has already introduced health insurance for non-Thais who are not yet covered by the Social Security Scheme (SSS), the MOPH should ratify rights to access this insurance scheme for URASs as well. The MOPH should officially issue a letter to notify all affiliated facilities about this right. In terms of insurance management, the MOPH should consult with UNHCR and relevant agencies to come up with solutions that are acceptable for all parties. The consultative points should include who should pay for the insurance and mechanism to ensure that all URASs will be enrolled in the insurance, not just the unhealthy ones. Fifthly all authorities in the health sector, particularly the MOPH and the National Health Security Office (NHSO), should actively take part in the screening process of URASs as specified by the 2019 Regulation of the Office of the Prime Minister on ‘Screening process for aliens entering the Kingdom of Thailand and incapable of returning to their home country’. Though representatives from the MOPH or the NHSO are not enlisted as the screening committees, the committees may set up sub-committees or working groups to work on specific issues if necessary. Hence, an early discussion with the committees is indispensible. Lastly, to take a clear stance to promote wellbeing of URASs, the Thai Government should consider becoming a party of the 1951 Refugee Convention and withdrawing a reservation to ratify Article 22 of the 1989 Convention on the Rights of the Child. However, additionals studies to gauge benefits, drawbacks, and limitations, should be conducted if the Government decides to ratify these agreements. This would complement the progress og the abovementioned recommendationsand help demonstrate a long-term commitment to the wellbeing of URAS.
