A New Compact for Migrant Health: Insurance for Migrant Workers from South and Southeast Asia

Each year around 169 million people cross borders in search of better economic opportunities, with the largest number migrating to Arab states and the largest share from Southeast Asia and South Asia. These migrants play a crucial role in the economic fabric of both their host and their home countries, performing essential jobs and sending back billions in remittances annually.

But what happens when migrant workers fall ill abroad? They may have little access to healthcare or lack the means to pay for that care. We propose a new compact for migrant health between the highest sending and receiving country blocs—an initiative that could be a win-win for both sending and receiving countries. Specifically, the initiative would establish a robust safety net that ensures the provision of high-quality healthcare services to migrant workers. This approach not only enhances the health outcomes of migrants but also boosts the productivity of workers, thereby fostering economic stability and growth by protecting a crucial segment of the workforce.

The economic power of migrants

According to the International Labour Organization, Arab states host the highest proportion of migrant workers to all workers (40.8 percent). Most of these migrant workers come from Southeast and South Asia. The country with the highest remittances as a share of GDP in South Asia is Nepal at 23.1 percent, while in Southeast Asia, it is the Philippines, at 9.4 percent, corresponding to US$ 9 billion and US$ 38 billion in 2022, respectively.

Top destinations for Nepali workers are primarily Qatar (31.8 percent), the United Arab Emirates (UAE) (26.5 percent), and Saudi Arabia (19.5 percent). Top destinations for Filipino workers are Saudi Arabia (22 percent) and the UAE (13.7 percent). Table 1 shows details on the top sending and receiving countries.

Table 1. Top sending countries in Southeast and South Asia with top receiving countries in Arab states

The problem: Health care access for migrant workers

Migrant workers may experience many health challenges, including weather-related illness, mental health challenges, and back pain—not surprising given the physically demanding labor that many migrant workers do, such as construction. When migrant workers fall ill, they not only face barriers to healthcare access due to cost and lack of insurance, but they also often face communication, linguistic, and cultural barriers, and potentially even stigma. Foregoing care and avoiding financial burden may be their default response.

While estimates of demand among migrant workers for access to healthcare are hard to come by, some reports indicate significant numbers of deaths, an indication of a larger number of illnesses and hazards underlying those fatalities. As many as 10,000 migrant workers from South and Southeast Asia die every year in the Gulf states due to “natural causes” or “cardiac arrest.” In the preparations for the 2022 FIFA World Cup in Qatar alone, at least 6,750 South Asian migrants died, most of whom were from India and Nepal.

Designing health insurance pool options

To address healthcare access challenges, we propose that countries consider a pooled health insurance system that spans the five top home countries (Philippines Vietnam, Indonesia, Nepal, India) and the five top host countries (Saudi Arabia, UAE, Qatar, Oman, Bahrain).

Why health insurance? By pooling risks of multiple migrants, an insurance scheme can spread the financial risks and burden of healthcare costs across a larger group of people, enabling greater access and affordability to health care. By being able to afford health care services, migrant workers can reduce the risk of financial catastrophe from seeking care and avoid foregone care, thereby increasing their productivity and well-being. Many countries are seeking to improve the financial risk protection that their citizens face by pursuing programs for universal health coverage, for which health insurance is one key option.

There are at least three ways to design an insurance pool, with each additional country member adding more resources to the pool but also adding complexity in terms of reimbursement and claiming systems. All options depend on who might be a first adopter to pilot this approach and would depend on a coalition of the willing.

In exploring how to make this concept a reality, it will be necessary to compare coverage, benefits, and payments of both receiving and sending countries. What healthcare costs do countries currently cover for their citizens and how is healthcare currently provided for migrants? Receiving countries could align and establish minimum standards for coverage for citizens and then expand these standards to migrants. Alternatively, establishing standards for inclusion of migrants could be the basis of pursuing minimum standards for citizens.

1x1 approach: One sending country to one receiving country

The simplest approach would be a proof-of-concept approach in which one sending country and one receiving country make a bilateral agreement to create a mutual health insurance pool, stipulating terms and conditions that apply to their specific needs. But the restriction of this approach is the limitation in the budget and risk pooling, particularly given different occupational profiles of each country’s migrant worker populations–e.g. construction workers versus domestic workers.

5x1 or 1x5 approach: Five sending countries to one receiving country / one sending country to five receiving countries

Another approach is a one-to-multiple or multiple-to-one arrangement between sending and receiving countries. Whether organizing multiple sending countries to a single receiving country is simpler or harder than the opposite is unclear. But the pooling would happen in either case at the single country. That is, the pool of a single receiving country for multiple countries could be managed by the single receiving country as a starting base.

5x5 approach: Five sending countries to five receiving countries

The most complex of the pooling arrangements would be the 5x5 approach. While complex, it has the advantage of the largest pool and diversified risks. It might also give migrants more power to bargain between the countries they are considering migrating to.

Finding the coalition of the willing

The challenge of migrant worker healthcare is ripe for international cooperation and partnership. In any partnership, it’s best to seek willing and enthusiastic partners rather than engage those who are only half-hearted in their initial interest.

Political prioritization and leadership are essential. The national governments of the sending and receiving countries, particularly the ministries or departments of finance, health, and labor and employment, are key.

Sending countries (and even receiving countries) should also consider establishing data and communication systems to track international labor flows, including where their migrant workers go, what types of jobs they get there, and how much they send home in remittances. Data systems could track migrant workers’ health, safety, and security. In an era of mobile phones, communication with migrant workers should be integrated from the start of any such data system and could also be the basis of their health insurance plans.

International financial institutions could help to bring seed capital to pilot an idea. The World Bank, Asian Development Bank, and Islamic Development Bank can bring necessary financial resources and expertise for designing and evaluating this new compact, but it would require going beyond typical country-by-country models of funding allocations.

UN organizations can provide technical assistance, guidelines, and evidence about what works. For example, the World Health Organization regional offices in Southeast Asia, Western Pacific, and the Middle East and North Africa could offer support on digital health systems that could be integrated with customs and border control or the design of benefit packages for an insurance pool. International Labour Organization and International Organization for Migration could bring their perspectives on the laws, the rights and well-being of migrant workers and international labor relations.

This new compact for migrant health—which could become a 5x5 Program—is more than just an insurance card or program. It represents a commitment to the health and dignity of migrant workers and to ensuring the continued sustainability of this source of economic growth. By pooling resources and sharing risks, these countries can create a safety net that provides quality healthcare to those who need it most, regardless of their location. The time is ripe for a new compact for migrant health, one that builds a system that respects and protects the millions of migrants who are a backbone of this global economy.

With thanks to Mead Over, Anita Kappeli, and Ole Norheim and the participants of the Annual International Symposium (https://www.uib.no/en/bceps/169781/bceps-international-symposium-2024) of the Bergen Center for Ethics and Priority Setting held over June 11 to 14, 2024  for helpful comments.