Centre for Epidemiology and Evidence-based Practice, Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia.
United Nations University-International Institute for Global Health (UNU-IIGH), Kuala Lumpur, Malaysia.
PLoS One. 2020 Dec 9;15(12):e0243629. doi: 10.1371/journal.pone.0243629. eCollection 2020.
For Malaysia, a nation highly dependent on migrant labour, the large non-citizen workforce presents a unique health system challenge. Although documented migrant workers are covered by mandatory healthcare insurance (SPIKPA), financial constraints remain a major barrier for non-citizen healthcare access. Malaysia recently extended protection for migrant workers under the national social security scheme (SOCSO), previously exclusive to citizens. This study aims to evaluate healthcare financing and social security policies for migrant workers to identify policy gaps and opportunities for intervention.
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.
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.
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.
马来西亚高度依赖外来劳务移民，庞大的非公民劳动力群体给其医疗体系带来了独特的挑战。虽然有文件记录的移民工人已被强制医疗保险（SPIKPA）覆盖，但经济限制仍然是他们获得医疗服务的主要障碍。马来西亚最近将国家社会保障计划（SOCSO）的保护范围扩大到了移民工人，此前该计划仅对公民开放。本研究旨在评估移民工人的医疗融资和社会保障政策，以发现政策空白和干预机会。
本研究于 2018 年 7 月至 2019 年 7 月期间对 44 位利益相关者进行了总共 37 次深入访谈。对定性访谈的主要主题与政策文件审查进行了混合方法分析。对政府医疗机构收取的收入等公开可得的次要数据进行了描述性分析，以对政策审查和定性结果进行背景分析。
我们发现，移民工人和雇主并不了解 SPIKPA 的参保和权益。非公民需要支付更高的费用，导致他们延迟寻求医疗服务。尽管马来西亚政府在 2014 年至 2018 年期间将非公民医疗费用收入从 1.04 亿林吉特增加到 1.82 亿林吉特（2600 万至 4500 万美元），但同期未付费用收入却翻了三倍，从 1600 万林吉特增加到 5000 万林吉特（400 万至 1200 万美元）。SPIKPA 覆盖范围可能不足以对移民工人提供财务风险保护，尤其是在公立医院提高非公民费用的情况下。SPIKPA 缴费的无记录工人和其他移民群体的未付费用收入尚不清楚。理论上，外国工人赔偿计划（FWCS）的问题可以部分通过 SOCSO 来解决。然而，SOCSO 的实施元素，如向工人及其海外亲属定期付款，仍存在可行性问题。
马来西亚正在通过为有文件记录的移民工人提供 SOCSO 来实现移民融入，但还需要做更多的工作。在这里，我们建议扩大 SPIKPA 保险计划的覆盖范围，将所有移民群体纳入其中，同时扩大其范围，纳入更全面的保障，包括基本的初级保健。
