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Patinya Srisai,1 Mathudara Phaiyarom,1 Rapeepong Suphanchaimat1,2 1International Health Policy Program (IHPP), The Ministry of Public Health, Nonthaburi 11000, Thailand; 2Division of Epidemiology, Department of Disease Control, The Ministry of Public Health, Nonthaburi 11000, ThailandCorrespondence: Patinya SrisaiInternational Health Policy Program (IHPP), The Ministry of Public Health, 88/20 Satharanasuk 6 Alley, Tambon Bang Khen, Mueang Nonthaburi District, Nonthaburi 11000, ThailandTel +66-2-590-2366Fax +66-2-590-2385Email patinya@ihpp.thaigov.netBackground and Purposes: Thailand has implemented a nationwide insurance policy for migrants, namely the Health Insurance Card Scheme (HICS), for a long time. However, numerous implementation challenges remain and migrant perspectives on the policy are rarely known. The aim of this study was to examine migrant service users’ perspectives and their consequent response towards the HICS.Methods: A qualitative case-study approach was employed. In-depth interviews with ten local migrants and four employers were conducted in one of the most densely migrant-populated provinces in Thailand. Document review was used as a means for data triangulation. Inductive thematic analysis was exercised on interview data.Results: The findings revealed that most migrants were not aware of the benefit, they are entitled to receive from the HICS due to unclear communication and inadequate announcements about the policy. The registration costs needed for legalising migrants’ precarious status were a major concern. Adequate support from employers was a key determining factor that encouraged migrants to participate in the registration process and purchase the insurance card. Some employers sought assistance from private intermediaries or brokers to facilitate the registration process for migrants.Conclusion: Proper communication and promotion regarding the benefits of the HICS and local authorities taking action to expedite the registration process for migrants are recommended. The policy should also establish a mechanism to receive feedback from migrants. This will help resolve implementation challenges and lead to further improvement of the policy.Keywords: migrants, health insurance, health policy, health service user, policy implementation, Thailand

Rapeepong Suphanchaimat,1,2 Watinee Kunpeuk,1 Mathudara Phaiyarom,1 Sirinard Nipaporn3 1International Health Policy Program, Ministry of Public Health, Nonthaburi 11000, Thailand; 2Division of Epidemiology, Department of Disease Control, Ministry of Public Health, Nonthaburi 11000, Thailand; 3National Health Security Office, Bangkok 10210, ThailandCorrespondence: Rapeepong Suphanchaimat Tel +66-2-590-2366Fax +66-2-590-2385Email rapeepong@ihpp.thaigov.netIntroduction: Although Thailand achieved Universal Health Coverage since 2002, there remained gaps in the insurance coverage as undocumented migrants were ineligible to be enrolled in the national public insurance. In 2004 the Thai Ministry of Public Health implemented the Health Insurance Card Scheme (HICS) to cover undocumented migrants. The objective of this study was to investigate the effect of the HICS on out-of-pocket payments (OOP) made by migrant patients at point of care.Methods: The study applied quantitative methods, using individual patient records from one provincial hospital, one district hospital and two health centers between 2011 and 2015. Ranong province was chosen as a study site as it had the largest proportion of migrants to Thai residents compared with other provinces. Descriptive and inferential statistics were employed. In descriptive statistics, mean and median were used. In inferential statistics, the two-part model (TPM) was applied to examine the relationship between the HICS and OOP for both outpatient (OP) and inpatient (IP) care.Results: The HICS reduced IP and OP OOP expenditures by 2471 Baht (US$ 75) and 293 Baht (US$ 9) respectively. The attributes contributed to the reduction of IP and OP OOP included insurance status, residential address close to the facilities, and a history of visiting health facilities after 2013 (the year that the HICS expanded its benefit package). In contrast, severe illness, and advanced age were expected to increase IP and OP OOP.Conclusion: The HICS appeared to reduce the financial burden from accessing care among its beneficiaries. Future studies to explore supply-side financing and equity aspects of the impact of HICS on OOP are recommended.Keywords: migrants, out-of-pocket expenditure, two-part model, health insurance

Rapeepong Suphanchaimat,1,2 Weerasak Putthasri,1 Phusit Prakongsai,1,3 Viroj Tangcharoensathien1 1International Health Policy Program (IHPP), The Ministry of Public Health, Nonthaburi, 2Banphai Hospital, Khon Kaen, 3Bureau of International Health (BIH), The Ministry of Public Health, Nonthaburi, Thailand Background: Of the 65 million residents in Thailand, >1.5 million are undocumented/illegal migrants from neighboring countries. Despite several policies being launched to improve access to care for these migrants, policy implementation has always faced numerous challenges. This study aimed to investigate the policy makers’ views on the challenges of implementing policies to protect the health of undocumented/illegal migrants in light of the dynamics of all of the migrant policies in Thailand. Methods: This study used a qualitative approach. Data were collected by document review, from related laws/regulations concerning migration policy over the past 40 years, and from in-depth interviews with seven key policy-level officials. Thematic analysis was applied. Results: Three critical themes emerged, namely, national security, economic necessity, and health protection. The national security discourse played a dominant role from the early 1900s up to the 1980s as Thailand attempted to defend itself from the threats of colonialism and communism. The economic boom of the 1990s created a pronounced labor shortage, which required a large migrant labor force to drive the growing economy. The first significant attempt to protect the health of migrants materialized in the early 2000s, after Thailand achieved universal health coverage. During that period, public insurance for undocumented/illegal migrants was introduced. The insurance used premium-based financing. However, the majority of migrants remained uninsured. Recently, the government attempted to overhaul the entire migrant registry system by introducing a new measure, namely the One Stop Service. In principle, the One Stop Service aimed to integrate the functions of all responsible authorities, but several challenges still remained; these included ambiguous policy messages and the slow progress of the nationality verification process. Conclusion: The root causes of the challenges in migrant health policy are incoherent policy direction and objectives across government authorities and unclear policy messages. In addition, the health sector, especially the Ministry of Public Health, has been de facto powerless and, due to its outdated bureaucracy, has lacked the capacity to keep pace with the problems regarding human mobility. Keywords: migrant, health insurance, Thailand, policy formulation, policy process

Rapeepong Suphanchaimat,1,2 Phusit Prakongsai,1 Supon Limwattananon,1,3 Anne Mills2 1International Health Policy Program (IHPP), Ministry of Public Health, Faculty of Public Health and Policy, Nonthaburi, Thailand; 2London School of Hygiene and Tropical Medicine, London, UK; 3Khon Kaen University, Khon Kaen, Thailand Objectives: This study sought to investigate the impact of the Thai “Health Insurance for People with Citizenship Problems” (HI-PCP) on access to care for stateless patients, compared to Universal Coverage Scheme patients and the uninsured, using inpatient utilization as a proxy for impact.Methods: Secondary data analysis of inpatient records of Kraburi Hospital, Ranong province, between 2009 (pre-policy) and 2012 (post-policy) was employed. Descriptive statistics and multivariate analysis by difference-in-difference model were performed.Results: The volume of inpatient service utilization by stateless patients expanded after the introduction of the HI-PCP. However, this increase did not appear to stem from the HI-PCP per se. After controlling for key covariates, including patients’ characteristics, disease condition, and domicile, there was only a weak positive association between the HI-PCP and utilization. Critical factors contributing significantly to increased utilization were older age, proximity to the hospital, and presence of catastrophic illness.Conclusion: A potential explanation for the insignificant impact of the HI-PCP on access to inpatient care of stateless patients is likely to be a lack of awareness of the existence of the scheme among the stateless population and local health staff. This problem is likely to have been accentuated by operational constraints in policy implementation, including the poor performance of local offices in registering stateless people. A key limitation of this study is a lack of data on patients who did not visit the health facility at the first opportunity. Further study of health-seeking behavior of stateless people at the household level is recommended. Keywords: people with citizenship problems, difference-in-difference, double difference, impact evaluation, health service