Tuesday, September 19, 2017

Re-balancing ASEAN integration: medical tourism vs. migrant health

The South East Asian region is home to major labour-exporting countries Indonesia, Philippines, Myanmar and labor-importing countries – Malaysia, Singapore, Thailand, Brunei – which also receive large numbers of migrant workers from Nepal, Bangladesh, India.

In Malaysia, about 1 in 4 employees are migrants. In Singapore, foreigners accounted for about 40% of the island’s workforce in 2012, and in Thailand, there were 2.46 million low-skilled migrant workers from the three neighbouring countries of Laos, Myanmar and Cambodia in 2010.

Host countries benefit from the enhanced economic growth that migrant labour makes possible, while migrants benefit from employment and livelihood opportunities to the extent that decent working and living conditions are ensured for migrants 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 instrument for the enforcement of the 2007 ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers.

Universal health coverage

In the South East Asian region, 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 taxes, enjoy wide-ranging health and social benefits at public expense. In Thailand, the 2002 National Health Security Act extended healthcare coverage beyond civil servants and their dependents and employees in the private sector to the majority of the population, who hitherto had limited access to healthcare. The Philippines National Health Insurance Program (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.

However, universal health coverage in a national context often translates into citizen entitlements, leaving migrant workers – documented and undocumented – refugees and asylum seekers to fall through the cracks.

Not surprisingly, labour-exporting countries favour more generous access to social benefits for migrant workers in host countries:

At the 17th ASEAN Socio-Cultural Community (ASCC) Council Meeting, held in the Philippines in March, Social Welfare Secretary Judy Taguiwalo, chair of the ASCC, said, “Our collective efforts are needed in the 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 government of their home countries, but also of the government of their host countries.” Taguiwalo also urged the 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, ASEAN’s labour-importing countries Malaysia, Singapore and Thailand appear preoccupied with a different kind 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, following its earlier public forums on regional labour migration, SEA Junction, in collaboration with the Heinrich Böll Stiftung, convened a panel to lead a discussion, “Seeking Health Across the Border”, at the Bangkok Art & Culture Centre. I was a member of the panel, along with Jiruth Sriratanaban and Rebecca Farber.

It soon became clear that a basic issue – the lack of a uniform definition of a ‘medical traveler’, which had been demonstrably operationalised by reporting sources – remained problematical, whether in Jiruth’s regional overview or my own national reports. The resulting patchy and quite ambiguous statistics allow for wildly diverging estimates and pronouncements. Citing a 2011 OECD publication by Lunt and colleagues – “We can narrow down the number of medical tourists worldwide as lying somewhere between 60,000 and 50 million” – health economist David Reisman 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 travelers with treatment-seeking 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 traveled 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 foreign passport holders treated in Malaysia was Indonesian nationals.

Migrant rights and responsibilities

Unlike the medical tourists much welcomed in 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 hospitalisation and surgical insurance scheme that costs 120 ringgit (K37,970) annually with maximum reimbursements of 10,000 ringgit.

Migrant workers in Malaysia also contribute significantly to public finances through annual levies (currently 640-1850 ringgit) paid for by the workers, along with assorted administrative charges and consumption taxes.

These levies and charges, amounting to 1121-2331 ringgit annually, translate into a de facto income tax that is quite regressive.

For example, migrants earning 1000 ringgit a month would be paying a de facto income tax rate of 9-19 percent, 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. By comparison, a Malaysian citizen earning the same minimum wage income as the migrant worker would pay 0.6pc of his or her annual salary in income taxes, and more likely zero after tax deductions.

Toward an ASEAN Social Charter?

Since regimes of taxation and social entitlements vary across ASEAN, a multilateral agreement among its 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 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 the same social benefits as are available to local citizens.

This might have better political traction among the decision-makers and general public of the host countries, rather than a narrowly rights-based discourse and approach to social benefits and entitlements for migrant workers.


 Chan Chee Khoon is a research fellow in health and social policy at the University of Malaya’s Centre for Research in International and Comparative Education in Kuala Lumpur, Malaysia.