1 Introduction

The COVID-19 pandemic has profoundly impacted global health, resulting in over 7 million fatalities worldwide, including 366,486 within the Association of Southeast Asian Nations (ASEAN) [1, 2]. This crisis has exacerbated the healthcare challenges faced by stateless persons in ASEAN, numbering approximately 1.4 million [3], who encounter significant barriers to accessing medical care, testing facilities, vaccination programs, and treatment [4]. These challenges arise from a lack of identification and documentation, which renders them ineligible for free health services and leaves many unable to afford consultation fees [5]. Moreover, the fear of apprehension and deportation as part of government operations further deters stateless persons from seeking healthcare, particularly during COVID-19 [6].

Many of the 1.4 million stateless persons in ASEAN lack recognized nationality. The international framework for defining and addressing statelessness is built on two key conventions: the 1954 Convention Relating to the Status of Stateless Persons and the 1961 Convention on the Reduction of Statelessness [7]. Article 1(1) of the 1954 Convention is the only international legal instrument that explicitly defines a stateless person [8]. This provision defines the term “stateless person” as ‘a person who is not considered as a national by any State under the operation of its law’ [8]. Building on the 1954 Convention’s focus on defining and protecting stateless persons, the 1961 Convention on the Reduction of Statelessness strengthens international efforts by establishing conditions under which states should grant legal status to stateless individuals, including conferring citizenship to those born within their territory who would otherwise be stateless [7, 9]. According to the United Nations High Commissioner for Refugees (UNHCR) 2014 Handbook on Protection of Stateless Persons, the 1954 Convention’s definition is recognized as customary international law, making it binding even on states that have not acceded to the Convention [10]. Moreover, it is widely regarded as the foundational basis for interpreting any reference to statelessness in other legal contexts [10].

In the aftermath of World War II, the international community recognized two categories of individuals who lacked the protection of a state and were therefore in need of international protection: refugees and stateless persons [11]. Article 1(A)(2) of the 1951 Refugee Convention defines a refugee as:

Owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it [8].

The 1951 Refugee Convention also addresses the issue of statelessness in cases where individuals, lacking a nationality, face persecution and are unable or unwilling to return to their country of habitual residence [11]. While refugees are defined by their inability to return to their country of origin due to a well-founded fear of persecution [11], stateless persons, as defined under the 1954 Convention [8], lack recognized nationality altogether. Although distinct, there is often overlap between these two categories, as some refugees are also stateless persons [8]; however, not all stateless persons are refugees.

Scholars and policymakers have identified two primary categories of statelessness: de jure stateless persons, as defined by the 1954 Convention despite the term not appearing in the Convention [7, 8], and de facto stateless persons, which the UNHCR defined as stateless persons who are ‘persons outside the country of their nationality who are unable or, for valid reasons, are unwilling to avail themselves of the protection of that country’ [12]. The 1961 Convention primarily addresses de jure statelessness [9] but includes a non-binding recommendation in its Final Act that de facto stateless persons be treated as de jure stateless persons to facilitate their acquisition of an effective nationality [9]. However, the term ‘de facto statelessness’ is not explicitly mentioned in the 1961 Convention. This article adopts a broader definition of statelessness, incorporating both de jure and de facto stateless persons, to examine the healthcare access challenges faced by both groups in ASEAN member states during COVID-19.

Importantly, ASEAN, as an intergovernmental regional organization does not have an official definition for ‘stateless person’ or ‘statelessness’ in ASEAN legal instruments [13]; the application of these terms depends on how individual member states interpret and adopt the 1954 Convention’s definition [8]. However, according to the 2014 UNHCR Handbook on Protection of Stateless Persons [10], it can be argued that ASEAN states are bound by Article 1’s definition as part of customary international law, which obligates them to recognize and apply this definition even if they have not signed or acceded to the Convention [10]. Notably, the Philippines is the only ASEAN nation to ratify the 1954 Convention Relating to the Status of Stateless Persons in May 2011 [14] and accede to the 1961 Convention on the Reduction of Statelessness in March 2022 [15].

ASEAN's absence of an established definition on stateless persons, combined with the inconsistent interpretation and application of the 1954 Convention by individual member states, creates significant disparities across the region in how stateless persons are recognized and treated during the COVID-19 pandemic. While the 1961 Convention on the Reduction of Statelessness provides additional safeguards aimed at reducing statelessness, its impact remains limited within ASEAN, as only the Philippines has acceded to both the 1954 and 1961 Conventions [14, 15]. These disparities have severely restricted stateless persons' access to essential services, including healthcare and other fundamental human rights [16]. Consequently, stateless persons face heightened vulnerabilities due to limited access to healthcare, a situation that underscores the nexus between statelessness, human rights, and health rights in ASEAN [17].

Since its establishment in 1967, ASEAN has evolved into an expansive intergovernmental regional organization comprising ten member states as of 2025—Brunei Darussalam, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam. These nations collectively represent a population of approximately 662 million [10, 18,19,20]. The ASEAN Charter, instituted during the 13th ASEAN Summit in November 2007, functions as the foundational constitution of the organization [21]. It delineates the legal framework and institutional architecture that governs the Association, aimed at enhancing ASEAN's efficacy in attaining its objectives and fostering integration within the ASEAN Community [21]. Structurally, the Charter is buttressed by three pillars—political, economic, and socio-cultural—all of which converge on the promotion and protection of human rights and fundamental freedoms as core objectives and principles [21].

ASEAN recognizes that the issue of human rights is an important problem in the region [22]. ASEAN has established a human rights mechanism and is seriously trying to find solutions to human rights problems in the region [22]. In preparing the ASEAN Charter in 2005–2008, the 42nd ASEAN Foreign Ministers' Meeting in July 2009 proposed the establishment of a regional human rights organization called “ASEAN Intergovernmental Commission on Human Rights-AICHR” [23]. During the 15th ASEAN Summit in Cha-am-Hua Hin District on 23 October 2009 and later in 2012, the AICHR prepared the “Draft ASEAN Human Rights Declaration (AHRD)” [24]. This is considered another important step for ASEAN based on the principle of gradual action by all sectors to create a strong foundation for ASEAN in human rights to move towards a stable ASEAN Community.

However, although ASEAN has established the ASEAN Intergovernmental Commission on Human Rights and has prepared the ASEAN Human Rights Declaration, the ASEAN Human Rights Declaration (AHRD) is a political document that has no legal obligations that express ASEAN's intention to promote and protect human rights and reflects the unique characteristics of ASEAN which are different in politics, society, and culture, resulting in human rights problems in ASEAN still appearing today [25]. In particular, the problem of statelessness among stateless people in ASEAN is caused by various factors such as the history and background of ASEAN member countries that affect the legal status of stateless people within the ASEAN region and ASEAN members, discriminatory policies and practices, nationality laws that create gender injustice, flaws in the civil registration system, and other external factors such as economic factors, disasters, pandemics, and war all these factors have resulted in the problem of statelessness remaining a chronic problem for a long time.

While the 2007 ASEAN Charter and the ASEAN Human Rights Declaration (AHRD) provide a framework for regional cooperation and stability, they also raise questions about how well the organization aligns with broader international mandates on human rights and healthcare [26]. The 1948 Universal Declaration of Human Rights and the International Covenant on Economic, Social, and Cultural Rights (ICESCR) highlight the fundamental right to health, emphasizing the need for an adequate standard of living and the highest attainable health standards, respectively [27,28,29]. The COVID-19 outbreak has highlighted the vulnerability of stateless persons to accessing health services in the ASEAN region. The COVID-19 outbreak emphasizes the vulnerability of non-citizens to accessing health services in the ASEAN region. Although there is currently a great deal of research about statelessness among stateless populations in ASEAN, not all research data has been compiled. This is especially true on the issue of statelessness and ASEAN's policies to ensure access to public health services during the COVID-19 pandemic.

In addition, the working characteristics of ASEAN organizations, defined by the ASEAN Charter and epitomized in the ‘ASEAN Way’, highlights ASEAN’s traditional approach to managing regional affairs [30]. This approach is focused on developing cooperation among member states maintaining regional peace and stability [31]. This decision-making process adheres to three fundamental principles: respect for national sovereignty, non-interference in the internal affairs of member states, and consensus-driven decisions [31, 32]. These principles have positioned ASEAN as the second most successful regional organizations in the world, second to the European Union, and credited with enhancing diplomatic relations and building trust among its members [33]. However, while these principles bolster diplomatic relations and trust, they also present significant challenges such as human rights protection [33]. The need for unanimous agreement can stifle proactive measures and effective resolutions in human rights issues due to the consensus-driven and non-interference policies.

Furthermore, the ASEAN Charter’s broad stipulations, while legally binding, lack the specificity necessary for practical implementation [34]. This deficiency in detailed procedural guidance often leads to failure of many ASEAN political instruments to establish enforceable mechanisms with binding outcomes at the national level [35]. Consequently, the challenge of securing heath rights and access to healthcare services for stateless individuals in ASEAN persists, illustrating the gap between policy and practice [36]. This often results in the insufficient and ineffective actualization of human rights protections, deeply rooted in the operational norms encapsulated by the ‘ASEAN Way’. The ASEAN Charter, serving a role analogous to a constitutional document, outlines the organizational structure and operational framework for ASEAN’s activities, including its commitment to promoting and protecting human rights and fundamental freedoms [37, 38]. Despite these commitments, the implementation of a robust human rights mechanisms within ASEAN is frequently hampered by the very principles that otherwise promote stability and cooperation [39]. Therefore, while the ‘ASEAN Way’ is widely praised for its role in the organization’s successes, it remains crucial to recognize and address the limitations it imposes on the advancement of securing health rights and access to healthcare services for stateless individuals in ASEAN.

We conducted a scoping review to address knowledge gaps concerning the ASEAN Framework and the ‘ASEAN Way,’ specifically evaluating their impact on healthcare policies for stateless individuals in ASEAN member states before, during, and after the COVID-19 pandemic. While the COVID-19 pandemic presented multiple crises that asked for more than just conventional responses from ASEAN, the review focuses on examining how these extraordinary challenges impacted the healthcare accessibility for the region's stateless populations, a group often overlooked in broad crisis responses. This review aims to inform the ASEAN Summit (policymakers) [40], member states, and academic researchers, urging them to prioritize human rights considerations—particularly the well-being of vulnerable stateless communities—in both emergency healthcare responses and the broader landscape of healthcare access.

2 Methods

A scoping review was conducted to explore and consolidate the existing literature on the healthcare policy challenges faced by stateless individuals in ASEAN member states during COVID-19, focusing on identifying and synthesizing relevant information. [41]. Our primary motivations included mapping the depth and features of the available literature and identifying potential gaps [42].

We adopted the Arksey and O’Malley’s methodological framework for scoping reviews, which consists of: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results [43]. The guiding research question was: “How do the ASEAN Framework and the 'ASEAN Way' influence healthcare access for stateless individuals during the COVID-19 pandemic, and to what extent do they align with international human rights and health standards?”.

A structured search strategy, derived from the SPIDER framework, was employed [44]. We used a combination of primary keywords and related terms to capture the diverse aspects of our research interest. Boolean operators refined the search, focusing on literature published from March 11, 2020, to July 15, 2023 [45]. Databases such as JSTOR, PubMed, Scopus, Web of Science, and Mae Fah Luang University's electronic library were utilized, in addition to online research networks and search engines like ResearchGate and Google Scholar. Refer to Table 1 for a visual representation of the SPIDER search strategy framework.

Table 1 SPIDER Search Framework
Full size table

Studies were systematically evaluated for relevance, quality, and contribution to the research objectives [46]. Exclusion criteria encompassed studies not focused on stateless populations within ASEAN, those not addressing health rights, publications outside the designated COVID-19 timeframe, and non-English articles. After filtering, 26 records were selected for analysis. The detailed data extracted from these records are presented in Table 4. ‘Charted Records’.

Data management involved using Microsoft Excel for initial organization, followed by a transfer to Microsoft Word for thematic analysis to identify and interpret underlying themes and patterns within the data. Additional details on thesearch strategy, study selection process, and extracted data are available in the Supplementary file 1. An inductive coding approach was adopted, allowing themes to emerge naturally from the data [47]. We ensured objectivity by adhering to principles of analytical rigor and bracketing [48].

Refer to Fig. 1 for a visual representation of our review process, modeled after the PRISMA 2020 guidelines [49].

Fig. 1
figure 1

PRISMA 2020 Flow Chart

Full size image

3 Results

In our analysis of literature addressing policy structures for stateless individuals in the Southeast Asian region, we considered healthcare service accessibility and experiences across all ten member countries of the ASEAN organization: Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam. Of the 26 publications reviewed (see Table 4. 'Charted Records'), 21 specifically employed the term(s) 'stateless' and/or 'statelessness,' and 13 made explicit references to 'COVID-19' and/or 'Coronavirus.' Ten publications explicitly linked statelessness with the pandemic. Thirteen publications had a broad focus on the ASEAN region or multiple member states, while 10 were country specific. These country-specific publications were distributed as follows: Myanmar, Singapore, Indonesia, and the Philippines were each the subject of two publications, whereas Thailand and Malaysia were each covered in one. A comprehensive list of these publications is provided in Tables 2 and 3.

Table 2 Publication Keywords and Focus
Full size table
Table 3 Publication Focus on Individual ASEAN Member States
Full size table
Table 4 Charted records
Full size table

Our review is presented in two main sections: (1) an exploration of the ASEAN Framework and policy structures affecting healthcare access for stateless individuals across different phases of the COVID-19 pandemic, and (2) an assessment focusing on the specific challenges and policy measures for stateless individuals during the pandemic. This structure allows for a chronological understanding of the impact of ASEAN policies on healthcare access for stateless individuals, while also zeroing in on the unique challenges posed by the COVID-19 crisis.

3.1 Section I: exploration of ASEAN Framework and policy structures impacting healthcare access for stateless individuals before, during, and after COVID-19

This section provides a comprehensive overview of the existing policy frameworks established by the ASEAN intergovernmental organization and its member countries, focusing on how these policies have impacted the access to healthcare for stateless individuals not only in the pre-COVID-19 era but also during and after the pandemic. Five key themes emerged from the scoping review of the literature, which hold significant relevance for the access to healthcare of stateless individuals in the ASEAN organization, both prior to, during, and in the aftermath of the COVID-19 pandemic which are: legal barriers and inconsistencies in addressing statelessness; barriers to healthcare access and increased vulnerability of stateless individuals; regional inconsistencies and systemic challenges in addressing statelessness; international efforts and recommendations for inclusive healthcare policies; and the importance of social protection and financial assistance for stateless individuals.

3.2 Pre-COVID-19 ASEAN policies for stateless individuals

From the review carried out, 5 publications detailed the pre-COVID-19 ASEAN policies for stateless individuals and how these frameworks leave stateless persons at a greater risk of inadequate healthcare access due to the absence of explicit healthcare policies in most ASEAN countries, complexities in defining and quantifying stateless populations, significant obstacles arising from a lack of legal nationality, inconsistencies in addressing statelessness at a regional level, barriers created by lack of recognition and domestic legal status, and systemic challenges related to identification and discrimination.

3.2.1 Legal barriers and inconsistencies

The lack of explicit healthcare policies for stateless individuals across ASEAN countries has led to disparities in healthcare access. This section examines the legal landscape and inconsistencies in addressing statelessness in the pre-COVID era. The lack of explicit healthcare policies for stateless individuals across ASEAN countries, except for Thailand, is examined by Barua et al. (2020) [50]. The authors emphasize the absence of uniform definitions, types, and statistics on stateless populations, reflecting the complexity and inconsistency in addressing statelessness at a regional level [50]. Furthermore, Wahyuningrum (2021) discusses the significant milestone marked by the adoption of the Terms of Reference (TOR) for the ASEAN Intergovernmental Commission on Human Rights (AICHR) but emphasizes the lack of a protection mandate in AICHR's TOR, highlighting the critical gaps in legal protections for stateless individuals [51].

3.2.2 Healthcare access and vulnerability

Access to healthcare is a fundamental human right, yet stateless individuals in the ASEAN region face significant barriers. This section explores these barriers and the increased vulnerability of specific groups. Kitchanapaibul et al. (2022) investigate the role of Thai IDs in accessing medical services in Thailand, highlighting the barriers faced by stateless individuals [52]. They reveal that the lack of Thai IDs leads to various perceptions of stigma and barriers to healthcare access [52]. Domino et al. (2020) presents the limited access to COVID-19 testing and treatment for stateless individuals in Thailand and Malaysia, emphasizing the increased vulnerability of these populations during the pandemic [53].

3.2.3 Regional inconsistencies and systemic challenges

The ASEAN region faces complexities and inconsistencies in addressing statelessness, leading to significant obstacles in policy formulation due to the lack of an official definition of stateless in the ASEAN legal instruments. The complexity and inconsistency in addressing statelessness at a regional level across ASEAN countries are reflected in the findings of Barua et al. [50]. They emphasize the lack of uniformity in defining and quantifying stateless populations, leading to significant obstacles in policy formulation and implementation [50]. Kitchanapaibul et al. focus on the systemic challenges and barriers faced by stateless individuals in Thailand, such as the lack of Thai IDs, which leads to discrimination and a lack of financial support from the government [52]. These findings shed light on the regional inconsistencies and systemic challenges that worsen the vulnerabilities of stateless persons.

3.2.4 International efforts and recommendations

International efforts and recommendations play a vital role in guiding policies and interventions for stateless individuals in the ASEAN region. Aligning with international efforts to protect the rights and health of refugees, migrants, and stateless persons, Domino et al. (2020) calls for equal access to health services and inclusion in national responses to COVID-19 [53]. They emphasize the global call for inclusivity and equality in healthcare provision, reflecting a broader international consensus [53]. Lord & Anderson (2023) provide comprehensive insights into the impact of a lack of domestic legal status on stateless children in Thailand, offering recommendations for policy reforms, including increasing awareness of resolutions among operational officers and considering the expansion of reduced fees to all children under 18 years old [54]. These findings offer a detailed understanding of the international efforts and recommendations that can guide future policies and interventions for stateless individuals in the ASEAN region.

3.3 Policy responses during COVID-19

From the review carried out, 8 publications provided comprehensive insights into the ASEAN policy responses aimed at ensuring healthcare access for stateless individuals during the COVID-19 pandemic. The publications illustrated a multifaceted approach to addressing the unique challenges faced by stateless individuals, emphasizing principles of equality, non-discrimination, inclusivity, and regional collaboration.

3.3.1 Regional cooperation and cohesive strategies

Cardenas (2022) examined the policy responses during COVID-19 for stateless individuals and healthcare access in the ASEAN region, emphasizing the vital role of regional cooperation and the need for cohesive strategies [55]. The research highlights that the ASEAN Health Cooperation on Epidemic Preparedness played a significant role in addressing the pandemic but lacked cohesiveness in using existing regional health frameworks to develop a coherent response [55]. While ASEAN has established regional frameworks for health cooperation, the implementation of these frameworks often varies significantly among individual member states. For instance, while ASEAN's overarching policies advocate for inclusivity, individual member states, such as the Philippines with its Republic Act No.11469 or ‘Bayanihan to Heal as One Act,’ have initiated specific legislative measures to provide economic relief to vulnerable populations, including stateless individuals [55]. Furthermore, the study emphasizes the urgent need for strategic international partnerships, such as the US-ASEAN Dialogue, which provided $112 million in emergency health and humanitarian assistance, to expand financial capability and enhance relief responses [55].

3.3.2 Barriers to healthcare access and birth registration

Cheong and Mary Anne (2021) investigated the barriers to maternal health care and birth registration among stateless persons and irregular migrants in Malaysia, providing a comprehensive framework to understand the challenges faced by these populations [56]. The study identified three phases of delay that hinder access to healthcare and registration services, emphasizing the role of state policies in creating unequal access [56]. During the COVID-19 pandemic, the fear of apprehension further discouraged stateless individuals from seeking healthcare, with over 7,000 immigrants rounded up for deportation as part of a government operation [56]. The authors also highlighted the importance of community networks in disseminating information about healthcare access and legal requirements and provided actionable recommendations for policy interventions [56].

3.3.3 International efforts and inclusivity in healthcare

Domino et al. (2020) explored the policy responses during COVID-19 for stateless individuals and healthcare access, aligning with international efforts to ensure inclusivity in healthcare [53]. On 31 March 2020, global organizations such as the OHCHR, IOM, UNHCR, and WHO issued a joint statement emphasizing that the rights and health of refugees, migrants, and stateless individuals must be protected in COVID-19 responses, ensuring equal access to health services including prevention, testing, and treatment [53]. This global stance is further supported by international human rights law, which mandates that non-citizens, including stateless persons, have the right to access health facilities, goods, and services without discrimination, and states must refrain from denying or limiting equal access [53]. Specific policy recommendations have also been outlined, such as guaranteeing all persons, including non-citizens, access to COVID-19 prevention, treatment, and screening services without prohibitive documentary requirements or the threat of arrest, and training healthcare workers to ensure non-discrimination [53].

3.3.4 Policy implementation and practical barriers

The ICJ (2021) examined the policy responses during COVID-19 for stateless individuals and healthcare access in Thailand, uncovering a complex landscape of both policy initiatives and practical barriers [57]. The ICJ's report highlights that non-citizen, including stateless persons, continue to face barriers in accessing necessary healthcare services specific to COVID-19, despite the Thai Ministry of Public Health's announcement that testing, and treatment are available free-of-charge for those deemed “high risk individuals” [57]. However, the report emphasizes that this policy has not been effectively implemented in practice, with urban refugees, asylum seekers, and stateless persons experiencing barriers such as fear of high costs, lack of information, and fear of arrest due to their undocumented legal status in Thailand [57]. Furthermore, the ICJ's findings align with a joint statement issued by OHCHR, IOM, UNHCR, and WHO in March 2020, emphasizing that migrants and refugees, including stateless individuals, should be ensured equal access to health services and be “effectively included in national responses to COVID-19, including prevention, testing, and treatment” [57].

3.3.5 Significance of identification and stigma

Kitchanapaibul et al. (2022) investigated the status of the stateless population in Thailand, focusing on the significant role of Thai IDs in accessing healthcare services and the barriers faced during the COVID-19 pandemic [52]. The study revealed that having a Thai ID is a crucial factor affecting the likelihood of a good future for the stateless population, as these IDs are used to access medical services and education [52]. However, the stateless population, lacking Thai IDs, remained invisible to policymakers during the COVID-19 epidemic, facing charges at public or private hospitals and being excluded from free medical and healthcare services [52]. The research also highlighted the stigma perceptions among the stateless population, including feeling unequal, unable to qualify for healthcare services, and being ranked below others with IDs [52].

3.3.6 Public health preparedness and responses

Sarkar et al. (2020) explored the public health preparedness and responses to the COVID-19 pandemic in South Asia, shedding light on the unique challenges faced by vulnerable communities, including stateless individuals [58]. The research emphasized the need for a comprehensive and context-specific approach to COVID-19 in South Asia, considering the region's population density, limited resources, and inadequate public investment in health systems [58]. The socioeconomic context of the region, marked by poverty and inequality, has aggravated pressure on medical resources, highlighting the need for targeted interventions and investments to ensure equitable access to healthcare [58]. The study also noted that the pandemic has exposed the challenges faced by stateless persons, who often lack access to health services and are left out of formal policy measures [58]. In response, several countries, including Cambodia, Malaysia, Singapore, and Thailand, have extended free COVID-19 testing and treatment to all non-citizens, including stateless individuals, and provided information on containment measures in various languages [58].

3.3.7 UN's comprehensive overview

The UN (2020) presented a comprehensive overview of the policy responses during COVID-19 for stateless individuals and healthcare access, particularly in Southeast Asia including ASEAN member states [59]. The pandemic exposed the challenges faced by vulnerable communities, including stateless persons, who often lack access to health services and are left out of formal policy measures [59]. Several countries, recognizing the systemic vulnerability for disease control, extended free COVID-19 testing and treatment to all non-citizens, including stateless individuals, and provided information on containment measures in various languages [59]. The UN emphasized the need for immediate crisis response to be sensitive to existing vulnerabilities, recommending targeted measures to ensure access to prevention, testing, and treatment for all, and even suggesting a moratorium on arrest and immigration detention of migrants [59]. Additionally, the document highlighted the multifaceted health challenges faced by migrants, including increased susceptibility to COVID-19, greater risks of abuse, and language barriers limiting access to health information [59].

3.3.8 Inclusive healthcare provisions in the Asia–Pacific region

The UN.ESCAP (2020) investigated the policy responses during COVID-19 for stateless individuals and healthcare access in the Asia–Pacific region, revealing a concerted effort by several governments to ensure inclusivity in healthcare provisions [60]. Recognizing that excluding anyone from COVID-19 prevention and treatment puts everyone at risk, countries such as Malaysia and Thailand ensured that refugees and asylum-seekers, including stateless individuals, have free access to COVID-related treatment without negative repercussions [60]. Specific measures were also taken by Indonesia and Thailand to expand access to testing and treatment, such as reimbursing the cost of testing, providing free medical treatment regardless of insurance registration, and extending financial protection for health expenses to both nationals and foreign residents [60]. The report also highlighted the broader context of informal employment in the region, with an estimated seven in ten workers in informal employment, and lower coverage among women, emphasizing the unique challenges faced by stateless individuals and the need for targeted policy interventions [60].

3.4 Post-COVID-19 policy considerations and future directions

From the review carried out, 6 publications provided comprehensive insights into the post-COVID-19 policy considerations and future directions for stateless individuals and their healthcare access, focusing on legal, administrative, intersectional challenges, inclusive policies, universal coverage, financial protection, social protection, and targeted support. The publications emphasized the need for comprehensive and non-discriminatory policies that recognize the rights and needs of stateless individuals, providing a blueprint for future pandemics and post-COVID-19 recovery that ensures no one is left behind.

3.4.1 Universal healthcare access and inclusive policies

In the aftermath of the COVID-19 pandemic, the importance of universal healthcare access for stateless individuals has been emphasized by various publications. Arundhati, Ulum, and Afera highlighted the role of the ASEAN Intergovernmental Commission on Human Rights (AICHR) in advocating for universal healthcare access for stateless individuals [61]. They also underscored the need for comprehensive policies that address the healthcare needs of marginalized populations, including stateless individuals [61]. Similarly, Chua et al. (2020) discussed Singapore's targeted interventions to protect vulnerable populations during the pandemic [62]. They emphasized the importance of inclusive policies, reducing financial barriers to healthcare, and ensuring resilient healthcare systems that prioritize inclusivity [62]. Domino et al. (2020) further emphasized the need for comprehensive and non-discriminatory policies that recognize the rights and needs of stateless individuals, aligning with international efforts to protect the rights and health of this vulnerable population [53].

3.4.2 Legal and administrative barriers

Legal and administrative barriers continue to hinder access to healthcare for stateless individuals. Cheong and Mary Anne (2021) investigated the interrelated barriers to maternal health care and birth registration among stateless persons and irregular migrants in Malaysia [56]. They focused on the legal, administrative, and intersectional challenges faced by these populations and extended Thaddeus and Maine's "three delays" framework to model the legal marginalization and stratification of access to rights and benefits, including healthcare [56]. Their study emphasizes the need for targeted interventions that address each phase of delay and highlights the importance of considering access to healthcare through an intersectional lens.

3.4.3 Social protection and financial assistance

Social protection and financial assistance are crucial for ensuring healthcare access for stateless individuals. UN.ESCAP (2020) emphasized the importance of inclusive healthcare policies and social protection measures, highlighting the challenges faced by informal workers, including stateless persons, who often lack access to social protections [60]. The UN (2020) further emphasized the need for inclusive policies that consider the unique needs of refugees and stateless persons [59]. They advocated for targeted support and financial assistance that aligns with the support provided to nationals, emphasizing the importance of universal access to prevention, testing, and treatment [59].

3.4.4 Regional cooperation and international support for stateless healthcare

Regional cooperation and international support play a vital role in addressing the healthcare needs of stateless individuals. Arundhati, Ulum, and Afera (2022) highlighted the role of regional cooperation and international support in addressing the healthcare needs of stateless individuals [61]. They emphasized the interconnectedness of regional and global initiatives and the importance of leveraging these efforts to include stateless populations in post-COVID-19 recovery plans [61]. Domino et al. (2020) further emphasized the need for comprehensive and non-discriminatory policies that align with international efforts to protect the rights and health of stateless individuals [53]. They provided a blueprint for future pandemics and post-COVID-19 recovery, emphasizing the principles of equality, non-discrimination, and inclusivity [53].

3.5 Section II: strategies and recommendations for enhancing healthcare access for stateless individuals in the ASEAN region

This section offers a comprehensive exploration of strategies and recommendations for enhancing healthcare access for stateless individuals in the ASEAN region. Building on the findings from Section I, which examined the existing policy frameworks and their impact on healthcare access for stateless individuals before, during, and after the COVID-19 pandemic, this section delves into actionable solutions to address the identified gaps and disparities. Five key themes emerged from the scoping review of the literature, which hold significant relevance for the strategies and recommendations for enhancing healthcare access for stateless individuals in the ASEAN region. These themes are policy standardization and legal reforms, inclusive healthcare policies and social protection measures, community engagement and awareness, regional cooperation, and international support coupled with monitoring and accountability.

3.6 Policy standardization and legal reforms

From the review carried out, 3 publications provided comprehensive insights into the role of policy standardization and legal reforms in enhancing healthcare access for stateless individuals, focusing on three key themes: the need for standardized definitions and policies to identify and protect stateless individuals, the significance of legal reforms to address statelessness and extending healthcare protection to those without legal status, and the implementation of protection mandates to guarantee healthcare access and uphold the health rights of stateless individuals.

3.6.1 Standardization of definitions and policies

The standardization of definitions and policies is crucial for addressing the challenges faced by stateless individuals. Stateless individuals face significant challenges due to a lack of legal identity, which adversely impacts their living conditions and access to rights and services [63]. The need for identifying affected individuals and groups, improving civil registration, law reforms, facilitating naturalization, and building new digital identification systems is emphasized in the article by Lord & Anderson [54]. The importance of having adequate legal safeguards to prevent legal identity problems or statelessness is highlighted [54]. Barua et al. (2020) further emphasizes the importance of explicit healthcare policies for stateless populations, noting that only Thailand has such policies among ASEAN countries [50].

3.6.2 Legal reforms to address statelessness

Legal reforms are essential for addressing statelessness and improving healthcare access for stateless individuals. Recent legal and policy developments in Thailand demonstrate a commitment to providing greater protection to persons without legal status, including the 'Nationality Verification' process that allows undocumented migrants to register and regularize their status in-country [54]. Barua et al. (2020) recommends that countries with recognized prevalence of stateless populations reform their nationality and/or naturalization laws to reduce statelessness [50]. Sperfeldt (2021) identifies common causes of statelessness in Southeast Asia, including colonial legacies, discrimination, weaknesses in civil registration systems, lack of protections for migrants, mobile lifestyles, and inadequate legal frameworks [63].

3.6.3 Protection mandates for stateless individuals

Stateless individuals face practical barriers to accessing services, including language barriers, limited knowledge of formal systems and services, and cost of services [54]. Community-based assistance programs can help overcome fears among affected populations about government registration schemes [63]. Barua et al. (2020) emphasizes that while having legal nationality is not sufficient to guarantee the right to healthcare, not having legal nationality is almost certainly an obstacle for stateless and undocumented people [50]. They recommend interim decentralized healthcare policies for stateless populations, similar to those in Thailand, as a potential solution [50].

3.6.4 Implications and research gaps

The findings highlight the urgent need for the ASEAN policymakers to standardize policies on statelessness, enact legal reforms, and implement protection mandates to improve healthcare access for stateless individuals. While our review comprehensively assessed the current landscape, the existing literature and data we could include often lacked detail, particularly regarding the adaptation of these policies to the socio-political contexts of individual ASEAN countries. Furthermore, there is a notable absence of empirical evaluations that assess the effectiveness of these mandates in practice.

3.7 Inclusive healthcare policies and social protection measures

From the review carried out, five publications provided comprehensive insights into the importance of inclusive healthcare policies and social protection measures for enhancing access to healthcare for stateless individuals in the ASEAN region. The publications highlighted three central themes: the pressing need for universal healthcare access for stateless individuals during the COVID-19 pandemic, the importance of social protection measures and comprehensive health insurance for non-citizens, and the value of community engagement in bridging healthcare resource gaps and informing stateless communities.

3.7.1 Universal healthcare access

The importance of universal access to healthcare for stateless individuals has been emphasized by multiple authors. Domino et al. (2020) highlighted the joint statement by OHCHR, IOM, UNHCR, and WHO that stressed the need for equal access to health services for this group, especially during the COVID-19 pandemic [53]. UN.ESCAP (2020), Barua et al. (2020), and Lim et al. (2023) also underscored the critical importance of universal access to healthcare during the pandemic [50, 60, 64]. Lord and Anderson (2023) pointed out the marginalization of stateless people due to fragmented health insurance schemes, emphasizing the need for a unifying and non-discriminatory scheme to ensure their right to access healthcare [54]. The findings emphasize the urgent need for ASEAN policymakers and healthcare providers to prioritize universal healthcare access for stateless individuals, particularly during health crises like the COVID-19 pandemic, while also revealing a research gap in evaluating the effectiveness of unified, non-discriminatory health insurance schemes in addressing the healthcare needs of this marginalized group.

3.7.2 Social protection measures

Social protection measures are crucial for ensuring access to healthcare services for non-citizens, including stateless individuals. Domino et al. (2020) highlighted the need for social protection measures that ensure access to healthcare services for non-citizens without the risk of arrest or immigration control procedures [53]. UN. ESCAP emphasized the role of social protection measures in responding to the impacts of the COVID-19 crisis [60]. Barua et al. (2020) noted the lack of explicit healthcare policies for stateless people in most ASEAN countries, except Thailand [50]. Lim et al. (2023) highlighted the limitations of existing health insurance coverage, which excludes certain services and treatments [64]. Lord and Anderson (2023) emphasized the need for implementing resolutions that ensure access to healthcare for registered stateless children and migrant workers [54]. The findings urgently call for ASEAN policymakers to enact social protection measures for healthcare access among stateless individuals, especially during COVID-19, while highlighting a research gap in the practical implementation and effectiveness of these measures across ASEAN countries.

3.7.3 Community engagement and awareness

Community engagement and awareness efforts are essential for addressing the gaps in social protection systems and ensuring that stateless individuals and other vulnerable populations are not left behind. Domino et al. (2020) emphasized the importance of providing information about COVID-19 and government responses in languages that are accessible to all individuals, including non-citizens [53]. UN. ESCAP (2020) highlighted the gaps in existing social protection systems and the increased visibility of those left behind [60]. Barua et al. (2020) also emphasized the need for community engagement and awareness efforts to address the gaps in social protection systems [50]. Lim et al. (2023) highlighted the inequitable distribution of resources in healthcare, which can impact the ability of hospitals to meet the needs of patients [64]. Lord and Anderson (2023) highlighted the importance of raising awareness among stateless and migrant communities about the protective services available to them [54]. The findings highlight the need for ASEAN policymakers and healthcare providers to focus on community engagement and multilingual outreach for stateless individuals, while also revealing a research gap in evaluating the effectiveness of such strategies across ASEAN's diverse socio-political landscapes.

3.8 Regional cooperation and international support

From the review carried out, 7 publications provided comprehensive insights into the importance of international support and regional cooperation for enhancing access to healthcare for stateless individuals in the ASEAN region, focusing on three key themes. First, the significance of international support in addressing healthcare needs. Second, the role of ASEAN in fostering regional collaboration. Third, the criticality of monitoring and accountability in ensuring stateless-inclusive policies and civil society involvement.

3.8.1 International support

Legido-Quigley, Chuah, & Howard (2020) highlight the need for responsibility-sharing arrangements across actors and a framework that allows states to contribute and receive support based on their capacities and needs [65]. Barua et al. (2020) emphasizes the importance of international human rights obligations and health policies in addressing the vulnerability to health emergencies amongst stateless populations [50]. Cardenas (2022) highlights the support provided by the U.S. government and the UK government to ASEAN in addressing the COVID-19 pandemic [55], and the international support should be strategically allocated to prioritize healthcare assistance for stateless individuals during the COVID-19 crisis, leveraging ASEAN's regional cooperation framework. Arundhati, Ulum, & Afera (2022) emphasize the importance of international support in addressing the healthcare needs of stateless individuals in the ASEAN region [61]. They highlight the role of the ASEAN COVID-19 Response Fund in providing financial resources to support the ASEAN Member States in detecting, controlling, and preventing the transmission of COVID-19 [61]. Lim, Kamaruzaman, Wu, & Geue (2023) emphasize the importance of international support in addressing institutional conflicts of interest in establishing a sustainable health insurance system [64] focused on stateless populations.

3.8.2 Regional cooperation

Legido-Quigley, Chuah, and Howard emphasize the need for a different perspective in responding to vulnerable populations, such as refugees and asylum seekers, who can contribute significantly to host-country economies [65]. They suggest that regional platforms like ASEAN can be used more effectively to address the health-related issues of forced migration and statelessness [65]. Barua et al. highlights the role of ASEAN as a regional grouping that promotes cooperation among its member countries [50]. Cardenas emphasizes the role of ASEAN in addressing the COVID-19 pandemic response in the region through joint efforts and cooperation [55], as opposed to adhering to the “ASEAN Way” principles of non-interference. Arundhati, Ulum, & Afera also highlight the role of ASEAN in addressing the COVID-19 pandemic response in the region through joint efforts and cooperation [61]. Lim, Kamaruzaman, Wu, & Geue emphasize the importance of regional cooperation in creating a unified and non-discriminatory health insurance scheme for stateless individuals in the ASEAN region [64]. Htun strongly advocates for ASEAN countries to endorse the two conventions on statelessness—the 1954 Convention relating to the Status of Stateless Persons and the 1961 Convention on the Reduction of Statelessness—and to establish minimum standards in their nationality laws for the treatment of stateless individuals [66].

3.8.3 Monitoring and accountability

Legido-Quigley, Chuah, and Howard emphasize the need for migrant-inclusive policies and services that are responsive, financially sustainable, and sensitive to the rights and needs of refugees and asylum seekers [65]. Barua et al. highlights the importance of summarizing existing health policies for stateless populations in the ASEAN region, a step that contributes to enhanced monitoring and accountability in addressing their healthcare needs [50]. Cardenas emphasizes the role of the government in providing economic stimulus and relief response to the poor and vulnerable populations [55], a measure that could potentially improve healthcare access for stateless individuals. Arundhati, Ulum, & Afera emphasize the role of civil society in responding to the COVID-19 pandemic and the need for a legal framework to provide recognition and freedom for civil society to participate more effectively [61]. Lim, Kamaruzaman, Wu, & Geue emphasize the role of civil society in responding to the COVID-19 pandemic and the need for a legal framework to provide recognition and freedom for civil society to participate more effectively [64]. Abil, Shaka, Penan, & Deligöz emphasize the need for measured and systematic humanitarian action to accommodate stateless persons and prevent harm to state sovereignty [67]. They also highlight the need for detection and coordination with the country of origin and assistance from UNHCR [67].

3.9 Implications and research gaps

The findings emphasize the imperative for ASEAN policymakers to prioritize universal healthcare, enact robust social protection measures, and leverage community engagement to improve healthcare access for stateless individuals. Despite these identified needs, the literature reveals a significant gap in empirical studies assessing the effectiveness of existing policies and community engagement strategies across diverse socio-political contexts in ASEAN member states. Additionally, there is a critical need for research evaluating the impact of regional cooperation and international support on healthcare access for stateless populations. Studies should explore barriers created by legal and administrative frameworks and propose targeted interventions to overcome these obstacles. Furthermore, the role of inclusive healthcare policies and social protection measures in mitigating health disparities for stateless individuals requires further investigation. Future research must address practical implementation challenges of these policies and assess their adaptability in varying national contexts. By addressing these gaps, researchers can provide a comprehensive understanding that informs policymakers and enhances the well-being of stateless individuals in the ASEAN region.

4 Discussion

In this scoping review, we explored the nexus between existing ASEAN policy structures, the 'ASEAN Way' decision-making principle, and the framework on statelessness and health within ASEAN member states before, during, and after the COVID-19 pandemic. It is important to distinguish between ASEAN's regional frameworks and the specific policies of individual member states, as the implementation of these frameworks can vary significantly. Our aim goal was to provide a comprehensive overview of the available literature for researchers, academics, policymakers, healthcare providers, and other stakeholders in the ASEAN region, serving as a foundation for further inquiry into this critical connection.

We examined the nexus between ASEAN policy structures, the 'ASEAN Way' decision-making principle, and the framework on statelessness and health within ASEAN member states before, during, and after the COVID-19 pandemic. Our analysis identified five key themes that significantly impact the access to healthcare for stateless individuals in the ASEAN region: legal barriers and inconsistencies in addressing statelessness; barriers to healthcare access and increased vulnerability of stateless individuals; regional inconsistencies and systemic challenges in addressing statelessness; international efforts and recommendations for inclusive healthcare policies; and the importance of social protection and financial assistance for stateless individuals. The findings emphasize the urgent need for reforms to address the legal barriers, healthcare access disparities, regional inconsistencies, and systemic challenges faced by stateless individuals. Interpreting these findings, it is evident that international efforts and recommendations provide valuable guidance for future policies and interventions to ensure the rights and health of stateless individuals in the ASEAN region. However, our review highlights a critical gap in the protection mandates and consistent healthcare policies for stateless individuals across ASEAN, leading to disparities in healthcare access and increased vulnerability, especially in the context of the COVID-19 pandemic. The right to health, recognized as a fundamental right for stateless persons in ASEAN, is inconsistently advocated and implemented across the region. This inconsistency underscores the need for further inquiry into the nexus between ASEAN policy structures, the 'ASEAN Way' decision-making principle, and the framework on statelessness and health in ASEAN member states during the COVID-19 pandemic. The insights from this review provide a foundation for future research and policy development to address the healthcare needs of stateless individuals in the ASEAN region.

The study's findings have significant implications for both policy and practice in the ASEAN region. The identification of legal barriers, healthcare access disparities, regional inconsistencies, and systemic challenges faced by stateless individuals highlights the need for comprehensive reforms. The findings also emphasize the importance of social protection and financial assistance for stateless individuals, which can help mitigate their increased vulnerability, especially during crises like the COVID-19 pandemic.

5 Limitations

This scoping review is first, limited by the lack of comprehensive research on ASEAN policies concerning COVID-19 and statelessness, affecting the depth and applicability of our analysis because of how recent the COVID-19 pandemic was. Secondly, the study's reliance on international guidelines may not fully capture the unique dynamics within the ASEAN region. Thirdly, the invisibility of stateless individuals to governmental data centers complicates the assessment of their healthcare needs. Finally, the use of Arksey and O'Malley's framework restricts the study to a descriptive analysis, highlighting the need for more in-depth, context-specific research. To address these limitations, a follow-up scoping review should be conducted in the coming years, incorporating newly published research on ASEAN policies related to COVID-19 for stateless populations.

6 Conclusion

This study is the first scoping review examining the ASEAN Framework, ‘ASEAN Way’ decision principle, current policy structures, and the frameworks of the 10 ASEAN member states as a nexus concerning statelessness, healthcare access, and the right to health during COVID-19. However, it is crucial to distinguish between ASEAN's regional frameworks and the policies implemented by individual member states, as these can vary significantly in practice. Although the right to health is a fundamental human right, universally applicable and ensuring access to healthcare services for all individuals irrespective of race, religion, or other criteria, including nationality status [68, 69] the review emphasizes that this principle is not fully upheld for groups significantly impacted by statelessness in ASEAN before, during, and after COVID-19. Per “Article 2 Principles” letter (j) of the ASEAN Charter, member states are expressly bound to “upholding the United Nations Charter and international law, including international humanitarian law”, and in tandem, “Article 1 Purposes” number 7 emphasizes the objective “To strengthen democracy, enhance good governance and the rule of law, and to promote and protect human rights and fundamental freedoms” [27]. These policies highlight ASEAN's firm commitment to recognizing healthcare access as a fundamental human right. Yet, the stipulation in “Article 2 Principles” letter (e) that “ASEAN and its Member States shall act in accordance with… (e) non-interference in the internal affairs of ASEAN Member States” [27] introduces challenges to the consistent realization of these rights, particularly access to healthcare, within ASEAN. However, non-interference does not preclude regional or international cooperation, as demonstrated by ASEAN's collaborative efforts in various sectors. The 'ASEAN Way', characterized by its non-interference principle, poses a significant barrier to ensuring healthcare access for stateless individuals, as illuminated by our scoping review. The evident absence of explicit healthcare policies for stateless individuals in ASEAN member states further emphasizes this insufficiency. Despite these challenges, ASEAN has shown capacity for cooperation, such as through the ASEAN Coordinating Centre for Humanitarian Assistance, highlighting that collaboration is possible even within the framework of non-interference. Notably, even if an ASEAN member state ratifies international human rights treaties recognizing the universal right to health, it doesn't necessarily lead to the development or implementation of specific policies ensuring healthcare access for stateless groups. Our review highlights the gaps in the ASEAN policies and its ramifications for stateless populations, particularly in the context of the COVID-19 pandemic. The diversity among ASEAN member states, in terms of political, economic, and cultural contexts, adds complexity to forming a unified regional policy response. Addressing these issues requires not only regional cooperation but also policies that are politically, economically, socially, and culturally sensitive, acknowledging the unique contexts of each member state. It is also crucial to establish frameworks that specifically consider the needs of stateless individuals, ensuring that healthcare access and protections are adequately addressed in future health crises.