Dreamlopments (DLP) has set up the first insurance system for unregistered migrants living on the border between Burma and Thailand, and Cambodia and Thailand. Dr. Nicolas Durier, its founder, explains the concept and the challenges.

1. Dr Durier, tell us a little about yourself

I am a physician from Lille, France, who first visited Thailand in 2001 as part of a project to treat people living with HIV with antiretrovirals (ARV) funded and implemented by Doctors Without Borders. I then went on to work for seven years in ARV access projects in China and Malawi. I have also worked for other organizations such as Family Health International, the Foundation for AIDS Research (amfAR) and PATH.

2. How did this micro-insurance project for migrants come about?

We established the non-profit social enterprise Dreamlopments in 2015 to provide the Migrant Fund (M-Fund). It all started with our collaboration with SMRU, the research and care unit linked to the Oxford-Mahidol Universities alliance based in northern Thailand which for several years has been developing projects with migrant populations, particularly in the field of malaria control. We were confronted with a worrying situation linked to the financing of care for migrants. SMRU offered free care, thanks to funding from various donors including the European Union. However, over time, and since Thailand is a middle-income country, external donors gradually reduced their funding.

Hence, I was interested in the concept of community-based insurance and I thought about the possibility of submitting this concept to donors. The SMRU projects were cost-effective, so we needed to assess their feasibility and acceptability to migrants. We conducted a preliminary research phase: a survey among migrants that revealed a strong interest in this micro-insurance concept. On this basis, a feasibility study, financed in part by the French L’Initiative and carried out with the participation of a microfinance specialist and an expert in computer systems, helped us to develop the framework for his insurance. We wrote the operational specifications (in particular the first M-Fund Plan and the member management software) and policy specifications (with the help of the United Nations Children’s Fund (UNICEF)and the Thai Government). Finally, we consulted with insurance companies to check whether the concept was viable. In total, the preparatory phase lasted almost three years.

3. Following this preliminary phase, when did the M-Fund start ?

At the beginning of 2017, we obtained confirmation of the Thai Ministry of Health (MOH) interest in initiating this project. Since public hospitals that receive unregistered migrants and treat them have to cover the costs of doing so, their budgets are impacted by this and thus buy-in from the MOH was important..

UNICEF, who had already funded a survey on the basket of services to be covered during the feasibility study, secured the funds to conduct the pilot phase, and we also invested our own funds. We started the M-Fund in the Maesot district of Tak province to study its feasibility and acceptability to the migrant population. The migrants quickly began to enroll and we gradually expanded operations to Tak’s Mae Ramat and Phop Prah districts. Because of the mobility of migrants, who cross the border and live on both sides, we felt it was necessary to offer them the same system as in Burma, especially in the poor districts of Myawaddy on the other side of the border. In 2019, we replicated the project in Sakaeo province on the Cambodian border and, in 2020 in Kanchanaburi province, south of Tak.

Figure 1. Geographical coverage and M-Fund partner structures

In the long run, our ambition is to extend the M-Fund to other areas of the country, since it is estimated that more than one million people are without health coverage, of which only 35,000 are currently members of the M-Fund.

4. How does the M-Fund work?

The deployment of the M-Fund coverage plan went through four phases, during which we systematically asked ourselves questions about its financial viability and the level of medical coverage. We relied on detailed analysis of our data and economic modeling by microinsurance experts to tell us where the financial break-even point would be.

In each case, we defined the basket of care according to the most important needs, both for outpatient consultations and hospitalizations. On both sides of the border, we sought to collaborate with partner non-government organization (NGO) structures (SMRU and Mae Tao Clinic), but also with the Thai hospitals that migrants wished to access, despite certain language barriers that may exist. Some private clinics also participate in the project. Thanks to these partnerships, the migrants have access to a high quality range of health care services.

The condition for accessing the M-Fund is simple: one must register and pay a monthly fee of THB100, i.e., about €2.6 per month. This level of monthly payment was also based on strong demands from the migrants during the feasibility study, which revealed that one of the major difficulties of the Government’s migrant health insurance for regular migrants is the mandatory prepayment of two years of health coverage. Migrants are often paid daily and paying such an amount is insurmountable for most, especially if they have to insure other family members. The M-Fund was designed on the basis of user demand, and today more than 80% of members pay monthly, and a minority pay quarterly. This system makes our task more complex because it requires us to contact members each month to renew their subscriptions, but it is important to the success of the project.

The operation is based on two crucial pillars:

• Community-health workers (CHWs): They are employed by Dreamlopments, and disseminate information about the insurance coverage. The CHWs include new M-Fund members and ensure monthly and quarterly renewal. They are often migrants themselves, speak our members’ language, know where to find the migrants, often know them personally, and travel to their workplaces and homes.
• The M-Fund digital application: Each CHW has access to the secure M-Fund application from their phone or tablet, and it is also used in partner health facilities. It keeps track of all member profiles and medical events covered, and enables the quick reviews of coverage details from a member’s electronic membership card linked to an anonymous QR code .

5. What care is covered by this insurance?

As I mentioned, we went through four plans, each with choices regarding enrollment principles and covered care.

At the beginning (Plan 1.0), the scheme covered all medical services, both consultations and hospitalizations, including chronic diseases and pregnancy care. There was no compulsory tenure, no waiting period between enrollment and commencement of benefits, and no requirement to enroll the insured migrant’s family members. Since the M-Fund is a voluntary insurance program, this model quickly proved unsustainable because we had too many members with high needs, and we made the first changes after an eight-month pilot phase.

In Plan 2.0, we introduced a mandatory component to the voluntary scheme to dilute the risk.  For enrolled members with chronic conditions or pregnancy, it became mandatory to enroll other family or community members.

In Plan3.0, we introduced a differentiation between outpatient and inpatient care. We also harmonized the coverage limit for all M-Fund members (with or without chronic diseases) and limited it to THB5,000 THB (€132) per person per year for consultations, and THB45,000 (about €1,200) per person per year for hospitalization. Most of our members do not exceed these limits.

In Plan 4.0 which we have been using since March 2021, we have reluctantly decided not to accept new subscriptions from already pregnant women but women who have already subscribed to the M-FUND, and have become pregnant, are covered. People with chronic diseases (e.g., diabetes, hypertension, HIV, tuberculosis, others) can still join M-FUND under the “Chronic Diseases” option in which they are required to contribute an additional TH 200 per month, and to bring on board with them two additional members without any pre-existing disease. Women enrolled in M-FUND who become pregnant must also take the “pregnancy” option, pay an additional TH 200 per month, and bring two additional members. People aged 50 and over must take the “Senior” option and pay an additional monthly THB100 and enroll two more members.

Figure 1: Insurance Plan Summary

The “basic” fee, however, has never changed since the beginning of the project: THB100 per person per month, which is the amount suggested by the participants during the feasibility study. We regret the choices that led to the exclusion of certain services or certain categories (women who have already started a pregnancy) because we want to offer the widest possible coverage to as many people as possible. However, we must temper this with the imperative of achieving a financial balance in the long run.

6. How can you ensure this microfinance mechanism’s sustainability?

In total, since the beginning of the project, THB65.8 million (€1.7 million) of health services have been covered by M-FUND and paid to partner hospitals, mainly public hospitals in Thailand. In comparison, a total of THB42.1 million (€1.1 million) has been collected in member contributions, representing a ratio of health care costs to member contributions of 1:56 since the beginning of the project.

However, this ratio has steadily declined since the beginning of the project under the various M-FUND Plans. It was 4:0 under Plan 1.0, and since the implementation of Plan 3.0 in October 2019, an average ratio of only 1:3 has been achieved. Currently, with Plan 4.0, it is anticipated that all costs of care and a portion of operational costs will be covered through member contributions. Between June and August 2021, an increase in care costs occurred due to the COVID-19 crisis. In cases where members use services beyond their M-FUND coverage limit, the costs of care are generally covered by the Government partner hospitals.

It is estimated that there are more than 1 million unregistered migrants in Thailand in need of health coverage, and about 1 million registered migrants who do not have or are outside the Government insurance scheme. The M-FUND today covers only 35,000 migrants when it could benefit many more. This would dilute the risk and make the system more sustainable. Today, 67% of our policyholders are women, as it is common for their husbands (registered with a work permit) to sign up for Government health insurance; however, wives and other dependents are not covered and use the M-FUND. Allowing these migrants to enroll in the M-FUND would increase the member pool, especially of healthy members, with less frequent and lower health care use.

Thailand is developing a health insurance reform for migrants and we are working with the MOH and other partners to ensure that the lessons generated by the M-FUND are taken into account in order to achieve the effective coverage of all migrants, as well as have the M-FUND formally integrated as one of the protection schemes for migrants throughout Thailand.

Today, in addition to subscriptions, we are grateful of the support of the Global Fund and L’Initiative. We also receive a small amount of private donations from regular supporters. We are once again pursuing the goal of achieving financial sustainability while providing our members with the broadest possible coverage. Our long-term goal is to replicate the M-FUND in other contexts, to bring together migrants and refugees with similar needs in a mutual aid and health protection scheme.