METHODS: A total of 37 in-depth interviews were conducted of 44 stakeholders from July 2018 to July 2019. A mixed-methods analysis combining major themes from qualitative interviews with policy document reviews was conducted. Descriptive analysis of publicly available secondary data, namely revenues collected at government healthcare facilities, was conducted to contextualise the policy review and qualitative findings.
RESULTS: We found that migrant workers and employers were unaware of SPIKPA enrolment and entitlements. Higher fees for non-citizens result in delayed care-seeking. While the Malaysian government nearly doubled non-citizen healthcare fees revenues from RM 104 to 182 million (USD 26 to 45 million) between 2014 to 2018, outstanding revenues tripled from RM 16 to 50 million (USD 4 to 12 million) in the same period. SPIKPA coverage is likely inadequate in providing financial risk protection to migrant workers, especially with increased non-citizens fees at public hospitals. Undocumented workers and other migrant populations excluded from SPIKPA contribution to unpaid fees revenues are unknown. Problems described with the previous Foreign Workers Compensation Scheme (FWCS), could be partially addressed by SOCSO, in theory. Nevertheless, questions remain on the feasibility of implementing elements of SOCSO, such as recurring payments to workers and next-of-kin overseas.
CONCLUSION: Malaysia is moving towards migrant inclusion with the provision of SOCSO for documented migrant workers, but more needs to be done. Here we suggest the expansion of the SPIKPA insurance scheme to include all migrant populations, while broadening its scope towards more comprehensive coverage, including essential primary care.
DESIGN: Qualitative interviews were conducted in Rui Li City and Tenchong County in Yunnan Province, China (n=23) and Kuala Lumpur, Malaysia (n=44), along with review of policy documents. Data were thematically analysed.
PARTICIPANTS: Participants were migrant workers and key stakeholders with expertise in migrant issues including representatives from international organisations, local civil society organisations, government agencies, medical professionals, academia and trade unions.
RESULTS: Migrant health policies at destination countries were predominantly protectionist, concerned with preventing transmission of communicable disease and the excessive burden on health systems. In China, foreign wives were entitled to state-provided maternal health services while female migrant workers had to pay out-of-pocket and often returned to Myanmar for deliveries. In Malaysia, immigration policies prohibit migrant workers from pregnancy, however, women do deliver at healthcare facilities. Mandatory HIV testing was imposed on migrants in both countries, where it was unclear whether and how informed consent was obtained from migrants. Migrants who did not pass mandatory health screenings in Malaysia would runaway rather than be deported and become undocumented in the process. Excessive attention on migrant workers with communicable disease control campaigns in China resulted in inadvertent stigmatisation. Language and financial barriers frustrated access to care in both countries. Reported conditions of overcrowding and inadequate healthcare access at immigration detention centres raise public health concern.
CONCLUSIONS: This study's findings inform suggestions to mainstream the protection of migrant workers' health within national health policies in two middle-income destination countries, to ensure that health systems are responsive to migrants' needs as well as to strengthen bilateral and regional cooperation towards ensuring better migration management.