Strategies & Activities
Health Referral
Barriers to Accessing Appropriate Health Services Although registered migrants in Thailand are held out the promise of equal rights and access to the same services as the Thai public, the reality is that there are numerous structural and practical barriers to realizing this. Migrants registered with a work permit, for example, can receive a subsidized rate for treatment of a list of basic conditions equivalent to what the general Thai population receives, with the exception of anti-retroviral drugs. Yet, migrants’ ability to avail their health insurance benefits is frustrated in numerous ways To receive their health benefits, registered migrants must seek services at a designated hospital that is assigned to them. If they go to any other provider, they must pay full price, which can be substantially higher. Not many migrants are even aware that they are assigned a health provider as this is not clearly explained in their language duringregistration, and the name of the hospital is written in Thai. Moreover, migrants’ work places are usually in remote areas far from hospitals, requiring a considerable sacrifice of time and money for transportation and loss of a day’s wages in order to avail their health benefits. Fear of arrest or harassment by police, regardless of whether a migrant is registered or not, is also an obstacle. In many cases, employers withhold migrants’ ID cards, making even registered migrants vulnerable to arrest. For those who are unregistered, a visit to the hospital is even more unlikely unless they have a dire health condition, due to fear of being arrested and conflict with health officials over the high cost of payment. As a result, many registered and unregistered migrants will choose to go to afriend; or if available, they will use traditional remedies or healers. In the worst cases, migrants will simply remain untreated until their condition becomes severe. Migrantsworking in refrigerated units in Mahachai, for example, have a reportedly high instance of respiratory problems, which, when left untreated, have developed into TB. The danger of untreated STIs among fishermen not only affects their health, it endangers their partners’ health and increases both partners’ risk of HIV transmission. Many fishermen have also engaged in the alarming trend of penile insertion. While on the boat, fishermen are known to insert glass beads or inject hair oil under the foreskin to enlarge their penises. This unintentionally increases their and their partners’ vulnerability to sexually transmitted infections, HIV and results in other sexual health problems for the men. When left untreated, infection has set in as well as penile erectile dysfunction. Those migrants who do make it to the hospital face language barriers and negative attitudes of health staff: two factors that contribute to migrants’ belief that they are discriminated against and that public health providers give poor service. Although there are some migrants who have been in Thailand for years and are able to speak Thai, there are many others who need to bring a translator, or who are left to their own devices. The greatest problem associated with language barriers is in explaining symptoms to doctors. For example, in Chiang Mai, a hill-tribe woman was having problems with her uterus, but the doctor misunderstood that she had a stomach ache Increasing Access to Health Services Since Thailand’s policies and laws do not explicitly exclude migrants from receiving basic services or rights, the overall strategy that PHAMIT partners use to reduce migrants’ vulnerability to HIV and other health problems can be described as “increasing access to services.” PHAMIT partners increase migrants’ access to health services through two main strategies, namely - referral and the development of Migrant Friendly Services. Referral The core element of PHAMIT’s strategy to increase migrants’ access to health services is referral. Put simply, referral assists migrants in overcoming the numerous barriers that stand in the way of their receiving proper treatment, and reinforces Public Health’s duty to provide health to all. Referral may include any or all of the following services: transportation, translation, peer counseling and negotiation for payment with the medical facility depending on the registration status of the individual. Drop-in centers and migrant volunteers provide migrant workers and their families two main ways to access PHAMIT’s referral services. Drop-in Centers Drop-in centers act as a central point for migrants to easily access referral assistance to health services, making the drop-in centers’ location essential. For example, drop-in centers in port areas receive fishermen coming off of boats. Since many fishermen are undocumented, it is difficult for them to go beyond the docks. Having services available or being able to receive referral assistance in the immediate proximity of the docks is essential for these men. Fishermen are also hard to reach, as they are highly mobile, making it important to have a fixed contact point – as in the case of fishermen who have approached PHAMIT drop-in centers requesting assistance in removing penile insertions. The convenience of being located close to the docks is also important for urgent situations, such as fishermen coming off of boats in a weakened state from HIV or other health conditions (e.g. malnutrition or chronic diarrhea) and in need of immediate health assistance. Proximity is also important for fishermen who have a short amount of time on land but need treatment, such as those with STI symptoms. Although all drop-in centers provide general health referral, some PHAMIT partners also provide referral for specialized services. For example, at Rayong, CAR organizes a mother-child health referral day from its drop-in center while EMPOWER’s center in Chiang Mai provides full assistance with STI referral for sex workers. Some drop-in centers have specialized periodic clinics through cooperation with health providers such as Raks Thai’s drop-ins at Mahachai where the Red Cross provides a mobile dental clinic. Other drop-in centers, notably World Vision Foundation of Thailand’s sites in Ranong and Phuket, are clinics and have Burmese medical practitioners who provide basic health services, symptomatic treatment of STIs or family planning consultations to migrant communities from Burma. Migrant Volunteers On the other hand, migrants working in other occupations may have their mobility limited to their place of employment or may be undocumented, making it unrealistic to expect them to seek out referral at drop-in centers. To reach these people, PHAMIT partners have developed networks of migrant volunteers to act as a linkage between migrant communities, local health providers and PHAMIT partners. These volunteers, who can communicate in Thai, and are trained on HIV, health and the health system, play a crucial role in supporting migrants’ health. Volunteers play a basic role in referral. Being located in migrant communities and work places, they are often the first to encounter migrants in need of health services. When a migrant approaches them for assistance in accessing health services, the volunteer will arrange transportation and assist with translation at the health facility if possible, and the related expenses are reimbursed by the local PHAMIT implementer. If the volunteer is unavailable or unable to assist directly, the volunteer will contact a PHAMIT field officer to assist. In Chiang Mai, for example, MAP Foundation has a hot-line that migrants can call to dispatch the nearest volunteer or field officer for health referral. Volunteers also assist in promoting health events when a mobile clinic is scheduled to enter a migrant community on a certain day. Migrant Health Workers One of PHAMIT’s core objectives is “To make the health system favorable for migrant workers to receive suitable health prevention and treatment services.” Contributing to this, a pilot model for “migrant-friendly” health systems is currently being implemented in ten provinces (Chiang Mai, Chonburi, Pattani, Phuket, Ranong, Rayong, Samut Prakarn, Samut Sakorn, Songkla, Tak). The central focus of the model is developing and integrating Migrant Health Workers (MHW) into Government Hospitals located in areas where there are significant populations of migrants. The rationale is that having MHW assist with translation in the provision of general services and counseling at hospitals will lift the major barrier of inadequate communication between health staff and migrants. This will improve the quality of services for migrants and increase migrants’ trust in Government hospitals, which, in turn, will result in greater usage of public health services by migrants. PHAMIT partners have facilitated the development of Migrant Health Workers by assisting in the recruitment and training of these people. Through a collaboration of PATH, the MOPH Department of Health Services Support and PHAMIT implementing partners, PHAMIT has developed a set of training materials for MHW and health personnel. The training curriculum developed and now in use, mainly focuses on preparing MHW to provide counseling for HIV, antenatal care, TB and STIs, as well as provide home-based care and referral for more intensive health services. To overcome hospitals’ reluctance in utilizing migrant personnel, initially, MHWs have been hired on a trial basis as “volunteers” with their wages and work permits supported by PHAMIT. Local hospitals have started using MHWs as translators on days when there is the antenatal clinic or on an on-call basis. Providing counseling for pregnant migrant women in the antenatal clinic has been emphasized as an essential role for MHWs, as this is a highly utilized service by migrants. It is also especially significant for those who test positive for HIV. PHAMIT partners hope to see these MHW eventually give counseling directly to migrants coming to government hospitals for VCT, TB and other conditions that are related to HIV, beyond just the antenatal clinic. Hospitals in all ten PHAMIT pilot-project provinces now have active Migrant Health Workers. In locations with these MHW, such as Chonburi and Tak, the increase in numbers of migrants using public health services is noticeable. In Trad, the Klong Yai Hospital has hired MHW using its own resources. Word of mouth has spread quickly among the migrant community there, resulting in a considerable increase in the number of Cambodian migrants seeking services Although the hospitals using MHW have shown increased usage by migrants and are generally pleased with the assistance MHW provide, there are some lingering issues as to whether this system will fully develop and become sustainable • The Ministry of Labor has been reluctant to provide official registration status for migrants in this capacity because it is considered a skilled job; • MOPH pilot hospitals have not yet demonstrated that they will use their own budgets to hire and train these people; and • The RTG central health authorities have not issued any directives or conducted planning to support the expanded use of MHWs into other hospitals around the country. Another barrier is that some local doctors reject the idea of MHWs directly providing HIV counseling because the MHW are not professionally trained. This has currently relegated MHWs to simply providing translation for HIV counselors who are Thai. While recognizing that issues of confidentiality and use of objective language in counseling are realistic concerns, PHAMIT believes that these issues can be overcome through on-going training and mentoring, and that MHWs should have an official role in responding to the psychological and emotional needs of migrants living with HIV. As it is now, PHAMIT Migrant Field Officers supplement counseling provided in hospitals by providing pre-pre-test counseling and post-post-test counseling to migrants who PHAMIT refers for voluntary HIV testing.
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