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 .