Building a resilient public health system for international migrant workers: a case study and policy brief for COVID-19 and beyond

Situation analysis of COVID-19 resurgence in Thailand

Thailand was the second country to confirm a COVID-19 case after China on January 13, 2020 [4, 6]. However, the response this upper-middle-income country took to successfully manage the spread of COVID-19 was exemplary. Thailand’s success has been rooted in its participatory approach, which emphasizes engagement, inclusivity, and shared responsibility among all people – e.g. universal mask wearing in public [7–9]. Thailand's universal healthcare coverage for its citizens ensures free testing and treatment for COVID-19 to contain all cases within hospitals. This limits risk of transmission from infected individuals to their communities. Nevertheless, the country faced a new challenge. A cluster of 2,629 COVID-19 cases was identified among IMWs – many of whom are undocumented – in a large shrimp market in the province of Samut Sakhon between December 20 and 27, 2020 [4]. This cluster has been linked to the spread of disease in 44 provinces – over half the country. This outbreak provides testimony that IMWs, particularly those undocumented, are at heightened risk for COVID-19 [10, 11]. The outbreak also illustrates the need to improve care for IMWs during and long after the COVID-19 pandemic.

Unveiling challenges for COVID-19 control and prevention in IMWs

This outbreak unveils unique challenges that make IMWs more vulnerable to COVID-19 than other populations. Before becoming migrant workers, some of these individuals face deprivations including educational and economic hardship, which drive them to leave their home country [12]. Others even risk their lives to enter their host country illegally. Once employed, they experience another set of challenges. Low daily wages restrict them to living in tightly packed rooms with other occupants, which compromises social distancing and facilitates the transmission of COVID-19. With limited health literacy and income, IMWs lack an adequate understanding about the importance of personal protective equipment (PPE) and are hesitant to spend money on items like masks when resources can be used for rent, food or remittance.

While Thailand has strived to engage and include everyone in its COVID-19 control and prevention campaigns, public communication about COVID-19 is rarely in a language these workers understand. Language barriers perpetuate poor health literacy and poor COVID-19 outcomes [13]. If IMWs contract COVID-19, they continue to encounter other barriers such as reluctance to leave the job for testing or treatment due to loss of daily wage. Unlike documented IMWs, undocumented IMWs lack the right to access healthcare [14]. Undocumented workers also tend to distrust authorities due to a fear of deportation [15, 16]. As a result of these barriers, infected workers are left undetected and untreated. Since 90% of infected workers are asymptomatic, they further spread COVID-19 to their contacts at the shrimp market. This resulted in this newly emerging outbreak across Thailand.

Addressing deficiencies in COVID-19 public health services for IMWs

The deficiencies in all ten essential public health services for IMWs were identified using the EPHS framework (Table 1). The deficiencies identified can be simplified into three core functions: assessment, policy development and assurance [5].

Within the assessment, the public health system failed to address the vulnerabilities of IMWs during the COVID-19 pandemic. The system further lacked active surveillance to proactively identify cases of disease among IMWs. Once the outbreak was recognized, the system struggled with providing COVID-19 testing and treatment to IMWs. This lack of preparedness limited the effectiveness of disease containment to the local area.

Regarding policy development, the existing laws penalizing undocumented workers have created a hostile environment, which makes collaboration between IMWs and all acting authorities challenging to achieve [10]. The lack of mutual understanding and inability to effectively communicate due to language barriers further complicates cooperation between these stakeholders. This urges the need for public health systems to develop a more diverse and integrative workforce that builds trust, fosters relationships and gains cooperation among IMW communities and authorities [17]. Even after collaboration is achieved, public health systems still face challenges providing COVID-19 testing and other services to IMWs, especially those who are undocumented.

With regards to assurance, the public health system lacked preparedness in providing additional testing and health services to IMWs. Expanding these services that are available to the general population to cover IMWs, particularly those who are undocumented, would improve the public health system as a whole. Apart from the unavailability of services, public health systems need to integrate IMWs into the workforce by mobilizing existing groups – i.e. migrant worker health volunteers. To better serve IMWs, public health systems should also improve research regarding social inequities within this vulnerable population. This could further allow public health systems to better anticipate IMWs needs and social vulnerabilities to provide early interventions that improve care for IMWs [18].

Policy alternatives and recommendations

To build a more resilient public health system, existing deficiencies in public health services must be resolved through policy and system reform (Table 1). This starts with improving the assessment of health status among IMWs, the development of appropriate policies and the assurance of effective and sustainable delivery of public health services.

The assessment of vulnerabilities and factors influencing the overall health of IMWs is critical for developing a prevention-oriented health system that limits potential future outbreaks from occurring. Nonetheless, if an outbreak occurs, the surveillance system should function to timely detect the event [19]. Awareness of the outbreak etiology would further allow systems to contain the disease at an early stage. To achieve timely detection, authorities should conduct active case finding and cooperate with IMWs. To overcome potential barriers in collaboration – i.e. distrust, language barriers, and poor health literacy – between IMWs and authorities, public health systems should engage IMWs as a part of the public health workforce. The migrant worker health volunteer program recruits volunteers from IMWs to facilitate that collaboration [20]. Since migrant worker health volunteers tend to be well-integrated in IMW communities, they can participate in active case finding by reporting unusual events and diseases to health authorities. Apart from facilitating the disease surveillance, volunteers also bridge further communication and deliver health messages to improve health literacy using IMWs' native languages to encourage cooperation for further disease control measures – i.e. COVID-19 testing and quarantine [21].

Collaboration between IMWs, authorities and other stakeholders is also important for improving the development of inclusive policies. To protect IMWs, especially those who are undocumented, the system should acknowledge the vulnerabilities of IMWs and be adaptive to accommodate these vulnerabilities. Furthermore, the system should integrate individuals from multiple sectors to ensure a skilled and diverse workforce [22]. Public health systems should also be self-regulatory and provide essential services at their best, regardless of an individual's immigration status or healthcare coverage [23]. Once the policy is developed and implemented, it is necessary to assure that the policy is working as intended. To achieve quality and sustainable care for IMWs, health systems should actively engage in research, innovation, and quality assurance.

Health system reform must commence at the core ideology that IMWs are a burden on the health systems of their host country. This notion drives stigmatization and xenophobia which further creates a hostile environment for the host communities and IMWs [24–26]. To alleviate the hostile environment, the public health system should cooperate with legal authorities to be adaptive by waiving the existing law that penalizes undocumented IMWs and their employers [10]. Establishing an inclusive and empathetic environment through partnerships and public health campaigns is essential. These public health campaigns should inform and educate members of the host communities on the importance of mutual understanding and acceptance of individuals from different social backgrounds, particularly highlighting the notion that they all are members of a larger community that must work together to achieve effective control and prevention of the disease. To provide further support, IMWs must be connected with social and health authorities through the facilitation of migrant worker health volunteers [20].

Apart from accommodating existing IMWs, there is a need to prevent the incidence of illegal entry of IMWs into the host country. The poor regulation of labor trafficking laws is the root cause for becoming an undocumented IMW. Trafficked workers are imposed to human rights violations including infringements upon their right to healthcare. As a result, labor trafficking laws must be reinforced and individuals involved in importing migrant workers illegally must be prosecuted [27].

The lack of COVID-19 testing and treatment for undocumented IMWs is a key factor that heightens the transmission of disease within this vulnerable population. Therefore, providing COVID-19 testing and necessary treatment to IMWs is essential for controlling outbreaks within communities. However, in the long run, providing COVID-19 testing and treatment can consume resources within the health system of the host country. Even countries with universal healthcare coverage like Thailand face challenges in providing sustainable services to undocumented IMWs. While Thailand provides healthcare benefits to documented IMWs, these essential services do not cover undocumented IMWs. Expansion of this coverage to undocumented IMW is controversial and can further strain healthcare resources [14].

Intersectoral collaboration to engage multiple stakeholders including members of government and non-government agencies, employers and IMWs can enable a more sustainable and comprehensive care plan for IMWs. For the case of Thailand, key government agencies including the Ministry of Defense, the Ministry of Labor, the Ministry of Public health collaborate to initiate a pathway for undocumented IMWs to have essential healthcare benefits in the long run. The Ministry of Defense provides IMWs who have entered the country illegally a two-year amnesty period for them to enroll in the registration of the Ministry of Labor. The Ministry of Labor further assists IMWs by connecting those who are unemployed with employers who are willing to hire and sponsor them. Once they are sponsored and registered by the Ministry of Labor, these IMWs become documented. This allows them to utilize the copayment system and receive healthcare benefits [28].

To further assure quality care for IMWs during and after the COVID-19 pandemic, ongoing needs assessments will be necessary to address their health needs and to better serve IMWs. Providing disease prevention services to all individuals including this vulnerable population would protect the health of the population at large [4]. Research conducted to identify the social inequalities of IMWs could also identify areas that need improvements. Long-term engagement of IMWs in the public health workforce will be key in building a supportive environment, establishing mutual understanding and promoting solidarity necessary to protect the community from the existing health threats and future pandemics.