Re-balancing ASEAN Integration: Medical Tourism vs Migrants’ Health?

The Southeast Asian region is home to major labor-sending countries (Indonesia, Philippines, Myanmar) as well as labor-receiving countries (Malaysia, Singapore, Thailand, Brunei, which also receive large numbers of labor migrants from Nepal, Bangladesh, India). 
In Malaysia, about 1 in 4 employed persons are migrants. In Singapore, foreigners account for about 40% of the island’s total workforce (2012), while in Thailand (2010), there were 2.46 million low-skilled migrants from three neighbouring countries (Laos, Myanmar, Cambodia).
 
Host countries benefit from the enhanced economic growth that migrant labor makes possible (which may entail winners as well as losers), while migrants benefit from employment and livelihood opportunities (to the extent that decent working and living conditions are ensured for migrant 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 towards a mandate (and instrument) for the enforcement of the ASEAN Declaration on the Protection and Promotion of the Rights of Migrant Workers (2007).1
 
Universal Health Coverage
In the Southeast Asian region, citizens of Malaysia and Singapore have long benefited from widely accessible tax-funded or subsidized 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 National Health Security Act (2002) extended healthcare coverage beyond civil servants and their dependents, and employees in the formal (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.
 
Universal Health Coverage (UHC), in a national context, often translates however into citizen entitlements, leaving migrant workers (documented and undocumented), refugees, and asylum seekers to fall through the cracks.
 
Not surprisingly, labor-sending countries favor more generous ‘quasi-citizen’ access to social benefits for migrant workers in their host countries:
“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,” said Social Welfare Secretary Judy Taguiwalo, chair of the ASCC pillar.  During the meeting, 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”.2
 
Trickle Down Regionalism?
The three labor-receiving ASEAN countries however (Malaysia, Singapore, Thailand) appear more preoccupied with a different category 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 harmonized social policy.
On June 24,  2017, following its earlier public forums on regional labor migration, SEA Junction, in collaboration with the Heinrich Böll Stiftung, convened a panel (Jiruth SRIRATANABAN, CHAN Chee Khoon, Rebecca FARBER) to lead a discussion on Seeking Health Across the Border, at the Bangkok Art & Culture Centre.
 
It soon became clear that a very basic issue, viz. the lack of a uniform definition of a ‘medical traveler’ which had been demonstrably operationalised by reporting sources, remained problematical, whether in a regional overview (JS), or in national reports (CCK).  The resulting patchy and quite ambiguous statistics allow for wildly diverging estimates and pronouncements.  Citing an OECD publication by Lunt and colleagues (2011, “we can narrow down the number of medical tourists worldwide as lying somewhere between 60,000 and 50 million”)3, health economist David Reisman acknowledged that “speculation abounds… it is not even certain that the market is growing”.4 
 
The reasons for this state of affairs are well known: the conflation, in reported statistics, of treatment-seeking travelers with treatment seeking episodes by 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 these Penang-bound patients, were from Indonesia.  By contrast, only 57% of the more encompassing category of foreign passport holders treated in Malaysia in toto, were Indonesian nationals.
 
Migrant Rights & 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 RM 120 annually with maximum reimbursements of RM 10,000 (USD 1 = RM 4.29).
 
Migrant workers in Malaysia also contribute significantly to public finances through annual levies (currently RM 640-1850) paid for by the workers, along with assorted administrative charges (and consumption taxes).
 
These levies and charges, amounting to RM 1121-2331 annually, translate into de facto income taxes which are quite regressive.
For example, migrants earning RM 1000/month would be paying a de facto income tax rate of 9-19%, which would put them in the same tax bracket as that of a mid-career academician in Malaysia, without the citizen entitlements of the latter.  A Malaysian citizen earning the same minimum wage income as the migrant worker would be paying 0.6% of his or her annual salary as income taxes (more likely zero after tax deductibles).
 
Towards an ASEAN Social Charter?
Since regimes of taxation and social entitlements vary across ASEAN countries, a multilateral agreement among ASEAN 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 envisaged 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 (designated?) social benefits (on the same terms?) as are available to local citizens.
 
This, arguably, might have better political traction among the decision makers and general public of the host countries, than a narrowly rights-based discourse and approach to social benefits and entitlements for labor migrants.
This article is written as part of the “ASEAN People in FLux” etc.

Endnotes

1              Moe Thuzar. ASEAN’s long road to protect migrant workers The Myanmar Times 29 June 2017 http://www.mmtimes.com/index.php/opinion/26599-asean-s-long-road-to-protect-migrant-workers.html
2              ASCC chair urges ASEAN leaders to set up reforms for migrant workers  http://www.asean2017.ph/ascc-chair-urges-asean-leaders-set-reforms-migrant-workers/
3              Lunt, N, Smith, R, Exworthy, M, Green, ST, Horsfall, D and Mannion, R (2011) Medical Tourism: Treatments, markets and health system implications: A scoping review.  Paris: OECD
4              David Reisman (2014) Trade in Health: Economics, Ethics and Public Policy (p.6) Cheltenham: Edward Elgar
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