THAILAND’S RELATIONSHIP WITH THE NEIGHBOURING COUNTRIES IN MITIGATING HIV/AIDS EPIDEMIC WITHIN MIGRANT POPULATION
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CONTENT INTRODUCTION................................................................................................................................... 1 THE COLLABORATION: GMS WORKING GROUP ON HUMAN RESEARCH DEVELOPMENT ... 4 MEMORANDUM OF UNDERSTANDING ON JOINT ACTION TO REDUCE HIV VULNERABILITY ASSOCIATED WITH POPULATION MOVEMENT...................................... 5 MOU’s Collaboration Area 1 ....................................................................................................... 5 MOU’s Collaboration Area 2 ....................................................................................................... 9 MOU’s Collaboration Area 3 ..................................................................................................... 10 MOU’s Monitoring and Evaluation ............................................................................................ 13 EPILOGUE ........................................................................................................................................... 14 Bibliography ......................................................................................................................................... 16
LIST OF TABLES Table 1 GMS HRD Strategies .................................................................................................................. 4 Table 2 MOU's Collaboration Area 1 ....................................................................................................... 6 Table 3 JUNIMA-Collaborated Dialogues for Thailand and the Neighboring Countries ........................... 7 Table 4 MOU'S Collaboration Area 2 ...................................................................................................... 9 Table 5 MOU's Collaboration Area 3 ..................................................................................................... 11 Table 6 MOU's Monitoring and Evaluation ............................................................................................ 13
INTRODUCTION Signed at Nay Pyi Taw on 20 December 2011, the latest Memorandum of Understanding on Joint Action to Reduce HIV Vulnerability Associated with Population Movement between six Greater Mekong Subregion (GMS) countries is the second extension of the MoU that was born in 2001. The first extension was executed in 2004; and the 2010’s 3rd GMS Workshop on HIV Prevention and Infrastructure in Vientiane, with support from Asian Development Bank, marked the commitment of the GMS countries to make the second extension come into force. As the title of the memorandum suggests, this MOU emerges as the attempt of Thailand, China, Cambodia, Laos, Myanmar and Vietnam in mitigating the HIV-related impacts within the migrant population. The six GMS countries continuously perceive the relevance of putting an emphasis towards the migrant population in the region into a specific HIV-management measure since migrant worker is one of the biggest demographic within the most vulnerable populations. The fundamental aim of the MOU is to decrease the HIV Vulnerability and promote access to prevention, treatment, care and support among migrants and other mobile citizens and the affected communities in the Mekong region. In retrospect, this MOU can be seen as an extension of ASEAN’s commitment in reducing the HIV figures in Southeast Asia region – as stated in the association’s Declaration of Commitment: Declaration of Commitment: Getting To Zero New HIV Infections, Zero Discrimination, Zero AIDS-Related Deaths1. Greater Mekong Subregion area is an innate economic zone attached to the 4,350 km-length Mekong River that covers 2.6 million square kilometers and an accumulated populace of, more or less, 326 millions2. The association is coined by Asian Development Bank given the potential economic growth in the area since the diversified economies has been naturally appearing in the Mekong-attached countries in order to benefit each other. The cooperation among the six countries has been indicating a gradual transition from subsistence farming to an open market scheme that gives birth to a rising commercial relations, particularly in cross-border trade and investment. In light of this, the combination of the imbalance economic growth and the inequity of worker supply among the countries have been, inevitably, resulting in labor mobility. In a simple equation, the country that has a higher pace of economic growth but suffers from labor insufficiency demands an influx of labor from the neighboring countries that experience an oversupply. With GDP of US$345.65 billion3, the upper-middle income Thailand is the epitome of the former while low-income Myanmar and Cambodia and lower-middle income Laos are 1
Declaration of Commitment is the alignment of ASEAN with UNAIDS’ 2012-2015 Global Strategy in which ASEAN declares
to reduce the HIV infection through sexual transmission and injecting drug use by 50% each in the region by 2015. 2
Asian Development Bank. (n.d.). Overview of Great Mekong Subregion. Retrieved August 13, 2012, from Asian Development
Bank: http://www.adb.org/countries/gms/overview 3
World Bank. (2011). 2011 World Bank Data by Countries. Washington DC: World Bank.
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the archetype of the latter. In 2010, the immigrants take account of 1.7% of the Thailand’s population4 or 5% of the total workforce5 with the largest registered labor migrant pool came from Myanmar, with an amount of 1,078,767 Burmese workers, followed by Cambodian and Laotian, each represent approximately 100,000 labors6. In regards to this, this paper will limit the scope of the study to lateral relationships between Thailand and the three countries: Cambodia, Laos and Myanmar. In addition, to prevent general misconception, it is important to note that the migrant workers in the context of the paper are the legal low-skilled labor migrants. The notion of refugees, displaced persons and professional migrants is excluded from the course. The term “migrant population” and “migrant workers” are used interchangeably in the report. The undocumented migrants – or those who works illegally in the country – are as well excluded to assure the clarity of the examination presented by the paper. One may wonder why these migrant workers are highly vulnerable to HIV risk such that the MOU came to surface. To examine this, one needs to scrutiny the socioeconomic factors surrounding the labor migrants. Epidemiologists conclude that such a high vulnerability comes from the migrants’ marginal living and working condition that prompt them towards high risk behaviors, such as unprotected sex and drug use7. Migrant workers’ living condition has been notoriously known as depressing due to numerous hardships such as long working hours, unsafe or hazardous working setting, irregular payment of wages and physical and sexual abuse by the employers, local people or fellow migrant workers. With a setting that offers prostitution (with sex workers ranging from local people to illegal or trafficked migrants) and the illegal traffic of opium-based drugs, committing in sex and/or injecting drug use are the migrant’s easy way out to escape their stressful day. With a lack of knowledge and other contributing factors (such as the way of local polices treating the possession of condom as the evidence to detain the sex workers), many male migrant workers who engage in sexual transaction tend to neglect the use of condom, and thus, are vulnerable to HIV infection. The female migrant workers are exposed to HIV risk in a rather different scenario. The hardships of their work even sometimes force the female migrant workers to run away and find themselves open to other forms of exploitation, such as forced sex work. In addition to sexual transaction, the traffic of illegal drugs seduces the migrant workers to indulge in intravenous 4
International Organization for Migration. (n.d.). Thailand Migration. Retrieved August 13, 2012, from International
Organization for Migration: http://www.iom.int/jahia/Jahia/activities/asia-and-oceania/east-and-south-eastasia/thailand/cache/offonce;jsessionid=C6C428B46C80F0D 256367E01E48CFFD5.worker02 5
United Nations Human Rights. (2011). Thailand Joint UPR Submission. Geneva: Office of the High Commissioner for Human
Rights, p. 1. 6
IOM Thailand. (2012). Thailand Migration Report 2011. Bangkok: IOM Thailand, p. 12.
7
Hugo, G. (2008). Migration and Health: Situation Report on International Migration in East and Southeast-Asia. Bangkok:
IOM Thailand, p. 197.
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recreational drugs. Similar to the enigma behind sexual transmission, with lack of knowledge and the possession of needle becoming the evidence for police to arrest the drug user, the migrant workers who inject drug share the unsterile needle, and thus, prone to the infection. In Thailand, the correlation between migration and HIV is problematical seeing the tendency to blame outsiders for the spread of the epidemic8. The overall pattern of HIV/AIDS epidemic in Thailand could be divided into four categories: 1) the old epidemic among migrant workers who already developed signs and symptoms; 2) new infections among some high risk migrants; 3) female migrants who could be infected from their male partners as the infection rate among pregnant migrant women tend to be high; and 4) children of HIV positive migrants9. In conjunction to this, the degree of the HIV infection among foreign migrants in Thailand is unfortunately still unidentified. However, a new study10 in the six provinces most affected by HIV in Thailand has shown that Cambodian migrants bear the highest burden with an HIV prevalence of 2.5%, followed by Burmese and Laotian with 1.16% and 0.51%, respectively, and seafood processing is the most vulnerable type of migrant occupation with an HIV prevalence of 2.34%. Meanwhile the estimated adult prevalence in the country as a whole is 1.3%. In addition, another available data confirms that foreign migrants in Thailand have a higher proportion of HIV cases compared to the general Thai population11. These figures, then, bring out Thailand’s fundamental fear of having the epidemic spreading from the migrants to the Thai general population. In addition to that, each neighboring countries should acknowledge and pay further attention to their border-crossing migrating citizens. Hence, it becomes rational for all the affected countries, particularly Thailand, to cooperate in HIV mitigation measures within the framework of memorandum. Given the explanation above, this paper will shed light on the assessment of Thailand’s mutual relationship with the neighboring countries in the context of memorandum agenda including both bilateral and multilateral cooperation. The research question of the paper is "has the memorandum given a significant HIV mitigation improvement for migrant workers in Thailand?" The paper will begin by entailing the alignment of the memorandum with 4th ASEAN Work Program on HIV and AIDS as well as GMS Health Cooperation. The following section will then signify Thailand’s national AIDS strategy12 8
IOM Thailand, supra note 6, p. 88.
9
Jitthai, N., Yongpanichkul, S., & Baijaisordatl, M. (2010). Migration and HIV/AIDS in Thailand: Triangulation of Biological,
Behavioural and Programmatic Response Data. Bangkok: IOM Thailand, p. 7. 10
Thailand Ministry of Health. (2012). Thailand AIDS Response Progress Report 2012 - Reporting Period: 2010-2011.
Bangkok: Thailand Ministry of Health, p.6.. 11
Ibid.
12
Thailand’s National AIDS Strategy is a government-based HIV/AIDS-mitigation plan that focuses on strategic integration and
response to provincial planning, based on the current government policy direction of provincial cluster strategic management. It also emphasizes the participatory process, having involved the key stakeholders in all stages of the plan's development prior to
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and how the strategy intersects with the memorandum. The Ministry of Health-coordinated national plan on mitigating the epidemic is a crucial point of reference, and thus, the section will assess the cohesiveness between the national AIDS strategies with the memorandum. To implement the MoU, the parties agreed to develop a joint action plant that maximizes opportunities for both bilateral and multilateral cooperation, and therefore, the subsequent chapter will also assess the past and upcoming multilateral and bilateral agenda between Thailand and the three neighboring countries.
THE COLLABORATION: GMS WORKING GROUP ON HUMAN RESEARCH DEVELOPMENT It is important to outline the framework of numerous multilateral association implemented mutually by Thailand and the three neighboring countries to see how the relationships interrelate with each other and to find out what has been covered and what needs to be updated from the concurrence. As it is previously mentioned in the introduction, the memorandum is born from the GMS association, and thus, it is essential to see the underlying principle of the structure of the GMS-based partnership that fundamentally contributes to the shaping of memorandum. In regard to this, it is crucial to look up at the GMS’ sector activity that chiefly intersects with migrant population: GMS working group on human research development (HRD). The main objective of the HRD strategy is to foster sustainable regional human resource development to contribute to increased subregional competitiveness, connectivity and community. The key focuses that are tailored to achieve the objective are summarized in table below: Table 1 GMS HRD Strategies GMS Human Research Development works on cultivating sustainable regional human resource development to increase subregional competitiveness, connectivity and community by focusing on: 1
Promoting regional cooperation in education and skills development
2
Facilitating safe labor migration within the subregion
3
Supporting transmittable disease control
4
Enhancing regional cooperation for social development
5
Strengthening regional institutional links and mechanisms for regional cooperation
From the table above, it is apparent that HIV epidemic prevention and treatment for migrant population is the agenda that GMS needs to sustainably work on. Hence, given that promoting and supporting increased connectivity and regional integration through significant infrastructure investments, Asian Development implementation. In theory, the national strategy is what will fundamentally help Thailand to eradicate the epidemic. In practice, however, the epidemic seems to be the mystery that is impossible to tangle.
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Bank (ADB), the initiator of GMS region creation, must also recognize and understand the social and economic dimensions of mobility, migration, and its increased vulnerability to the spread of HIV/AIDS. Consequently, GMS Human Research Development constitutes sector initiative called HIV Prevention and the Infrastructure Sector in the GMS. This sector initiative is, at the end of the day, is the initiative that triggers Thailand’s cooperation with other GMS countries, particularly the three neighboring countries, in recognizing the needs of migrant populations. The existence of memorandum is unquestionably one particular exhibit of the cooperation. In light of this, the following section will entail further details about the memorandum and the past and upcoming multilateral relationships that are cohesive with the memorandum.
MEMORANDUM OF UNDERSTANDING ON JOINT ACTION TO REDUCE HIV VULNERABILITY ASSOCIATED WITH POPULATION MOVEMENT The memorandum basically aims for two focal objectives: reducing the HIV vulnerability and promoting access to prevention, treatment, care and support among migrants and mobile population and affected communities in countries in the GMS. The areas of collaboration and their key activities were developed by meeting in Migrants' Access to ART on the Migration Continuum in Four GMS Countries in April 2012. The meeting basically assessed the situation of HIV-infected migrants’ access to ART along the migration continuum within the three sending countries and Thailand as the receiving country. The four central government policymakers, local health officials and civil society organizations working with migrants and/or people living with HIV collaborated together to classify main gaps and challenges in the provision of ART to HIV-infected migrants, and came up with a series of recommendations which are then feed into the development of a Joint Plan of Action (JAP) for the memorandum. The series of recommendations eventually make the JAP covers three aspects: (1) promoting enabling environment and mechanism; (2) promoting community-based strategy that reduce HIV vulnerability; and (3) promoting access to HIV and AIDS prevention, treatment, care and support. Thailand with the three neighboring countries, along with Vietnam and southern China, then develop these three areas of collaboration into key activities as summarized in the subsequent subchapters. The subchapters below will provide the strategy and key activities as well as the assessment on each collaboration area.
MOU’s Collaboration Area 1 The first collaboration area focuses on the availability of strategic information and the reformation on laws and policies. The table 2 in the following page provides the strategy and key activities of the first collaboration area.
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Table 2 MOU's Collaboration Area 1 COLLABORATION AREA 1: PROMOTE ENABLING ENVIRONMENT AND MECHANISMS Strategy 1.1 Support enabling policy environment to reduce HIV vulnerability, stigma and discrimination, and promote access to prevention, treatment, care and support by improving systems of governance on development-related mobility 1.2 Strengthen intra- and inter-country multisectoral collaboration, including public-private partnership, on HIV vulnerability related to migrants and mobile population at the local, national and regional levels.
Key Activities Collect evidences to support policy development and share information from research and good practices. Raise awareness and advocate among policymakers for supportive policies. Disseminate and advocate for the implementation of the MOU and joint at various levels and among relevant sectors. Organize regional forums to address issues and share information and experiences on mobility-related HIV issues among relevant stakeholders Support existing or develop new cross-border collaboration, projects and programs Encourage engagement of relevant stakeholders
Enabling environment and mechanisms are definitely the necessary starting points of delivering quality prevention and treatment measures. They work as a substantial ground that clears out potential law-based obstacles that might arise within the HIV-mitigation measures carried out by either governmental or civil society. The collaboration of Thailand and the neighboring countries in this area can be fundamentally seen in international multi-sectoral collaboration that promotes the strategic information and the change in laws and policies, such as National Master Plan for HIV/AIDS Prevention, Care and Support for Migrants and Mobile Population (MMP) and participation in Joint United Nations Initiative on Mobility and HIV/AIDS in South East Asia (JUNIMA)13 that is entitled to the membership of ASEAN. In its main objective, The MMP states that the national authority should revise national laws, decrees and subdecrees as well as national security which obstruct the implementation of HIV prevention, care and support for migrants and mobile populations. On the other hand, JUNIMAS’ key activities are intersecting with the two strategies of this area collaboration. In the context of strategic information, JUNIMA hired an epidemiologist to recommend quantitative and qualitative methodologies for 13
JUNIMA is a bigger-scale multilateral relationship for Thailand and the three neighboring countries given the fact that the pact
covers the member countries of ASEAN (Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand and Viet Nam) and southern provinces of China (Guangxi and Yunnan). As the name implies, JUNIMA brings together governments of ASEAN and Southern China, leading civil society organization networks, and the United Nations family, to promote universal access to HIV prevention, treatment, care and support for mobile and migrant populations in South East Asia and southern China. JUNIMA is strengthening its focal point on the project's three chief work areas - Strategic Information, Policy & Advocacy, and Multi-stakeholder Mechanisms - with the aim of ensuring that effective interventions and successful programmes be further developed.
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conducting bio-behavioural surveillance of migrant workers, based on the factors that put them at increased risk of HIV infection14. The Methodology for Conducting Bio-Behavioural Surveillance on HIV among Migrant Workers in South and South East Asia allows Thailand and the neighboring countries to better capture information on various aspects of migrant behavior and will provide a foundation to guide and assist Thailand and the neighboring countries in conducting evidence informed research in the future15. Though this sounds like great news, it is quite unfortunate that this idea comes to realization eleven years after the memorandum is firstly signed. For a country that hosts a large share of migrant workers, Thailand has been neglecting the HIV prevalence statistics for migrant workers and only incorporates sample reports undergone by civil societies among particular sectors in border towns. This indicates an early sign of the national system’s lack of capacity in mitigating HIV epidemic within the migrant workers. In the context of advocacies and policies, Thailand and the neighboring countries has met several JUNIMA-collaborated dialogues dedicating to migrants’ HIV-vulnerable life. The table below summarizes the aforementioned dialogues16 that can be synthesized as a positive trend on gradual change on policies within Thailand and the neighboring countries. Table 3 JUNIMA-Collaborated Dialogues for Thailand and the Neighboring Countries Convention / Symposium
Objective / Output
Regional Dialogue on Migrants’ Health and Access to HIV Services in the ASEAN Region (November 2011)
To better plan and coordinate with all stakeholders at the country level by not just advocating for migrants’ right to health, but trying to move forward on issues such as: monitoring migrant health, reviewing policylegal frameworks, and looking at health systems.
The 10th International Congress on AIDS in Asia and the Pacific - Symposium on the Financial Crisis, Migration and HIV (August 2009)
To brainstorm on the most effective policies to ensure migrants have adequate access to health care and HIV services throughout the migration cycle.
th
UNAIDS 24 Programme Coordination Board: Special Session: People on the Move (June 2009)
To ensure that National Strategic Plans address the needs of migrants, to ensure that Universal Access targets and indicators are more accurate and appropriate and capture mobile populations.
Given to the assertion above, JUNIMA has conclusively been and will constantly be the regional forum utilized by Thailand and the neighboring countries, in retrospect of ASEAN perspective, to address issues and share information and experiences on mobility-related HIV issues among relevant stakeholders. Judging from the discussion above, the advocacies seem to be delegated in a progressive manner. It is unfortunate that in practice, Thailand’s national AIDS strategy has been moving slowly in improving the 14
JUNIMA. (2012). JUNIMA Progress Report 2009-2012. Bangkok: JUNIMA, p. 1.
15
Ibid.
16
Ibid, p. 2.
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HIV mitigation of the migrant workers. For the whole period of its execution, the basic healthcare financing scheme provided by Thai government to migrant workers, Compulsory Migrant Health Insurance (CMHI), does not cover antiretroviral (ARV)17 medicine nor HIV prevention treatment. CMHI was firstly introduced in 1997, four years before the memorandum was born. The general procedure of the scheme is that migrant workers are covered with health insurance at no less than 500 Baht per person per year. In 2001, the year when memorandum was signed for the very first time, an additional cabinet resolution that required that all registered migrant workers comply with annual health screening at a cost of 300 Baht and annual CMHI membership at a cost of 1,200 Baht was passed. An extra payment of 30 Baht per visit is asked when receiving care from health facilities, in addition. In 2004, the year when the memorandum got its first extension, the price of health insurance cards and health annual screening reasonably increased to 1,300 Baht and 600 Baht respectively. Even though the name of the insurance uses word 'compulsory', The CMHI scheme primarily targets registered migrant workers who will voluntarily apply. Noting on this particular point, the inability of Thai government to make CMHI truly compulsory has been indicating the lack of capacity in providing the general health service to the migrant workers. The CMHI program aims to provide health screening, curative care, health promotion, and disease surveillance and prevention services. However, given the fact that CMHI does not screen for HIV nor provide HIV care, Thailand has been tremendously failing to address the strategies of the first memorandum's collaboration area. The consequence of this is noticeably harmful for the migrant workers. The ARV medicine is, therefore, not provided to the migrant workers in subsidized price and this means that most of the migrant workers will not be able to afford it given the fact that their salary is too low to cover the medical expense. This particular point will be assessed further in the chapter of memorandum’s third collaboration area. In retrospect, the dialogues addressing the needs of migrant in HIV mitigation that have been executed for more than a decade within the framework of memorandum have been lacking of power to actually push the Thailand government to ensure migrants in having adequate access to HIV services throughout the migration cycle. However, bilateral discussion inevitably emerges to initiate a stronger change in advocacies and policies, seeing that one-player local policy reconstruction may not work properly. Myanmar, with the largest number of citizens migrating to Thailand, certainly raises its voice in regard to this. Both ministries of health from Thailand and Myanmar conduct an annual meeting that always include the topic of health of Burmese migrant workers. Thailand and Myanmar are planning to streamline the migrant worker hiring process with Thai authorities. In light of this, the hiring system might be changed into government-to17
ARV means antiretroviral medicine, the drugs that are supposedly taken by HIV-infected people to keep their viral load low
and give them a longer time before acquiring AIDS.
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government contracts in the long run18. Government-to-government contract is believed to be a better mechanism in ensuring the welfare of the migrant workers since it will eradicate the third party (such as an agent that connects the migrant workers with employers) that has been notoriously known for its hidden tax – a commission that an agent acquires by absorbing a large share of migrant worker’s original salary amount. The nonexistence of leeching agents will at least give the workers a higher purchasing power for ARV medicines if the medicines are still not available in subsidized price.
MOU’s Collaboration Area 2 The second collaboration area focuses on implementing a community-based development measures. The strategy and key activities of the second collaboration area is summarized in Table 4 below. Table 4 MOU'S Collaboration Area 2 COLLABORATION AREA 2: PROMOTE COMMUNITY-BASED STRATEGIES THAT REDUCE HIV VULNERABILITY Strategy
2.1 Promote community-based development approaches using people-centered methodologies by empowering communities affected by development-related mobility to prevent HIV infection.
Key Activities Involve communities and key affected population and migrant workers in the planning, implementation and monitoring of interventions. Develop activities for affected communities to understand, anticipate and adjust to development factors that contribute to HIV vulnerability resulting from mobility. Strengthen collaboration amongst agencies, including the private sector, involved in and related to development planning and projects / programmes.
Prominent accomplishment of the community-based HIV strategy for mobile population has been carried out in Thailand by Prevention of HIV and AIDS among Migrant Workers in Thailand (PHAMIT) Project19. With the emphasis on community outreach using trained peer educators and developing and strengthening comprehensive referral networks, the first phase (2003-2009) reached over 480,000 migrants with HIV prevention agenda in twenty-two provinces in Thailand. With profound involvement of local communities as well as migrant workers, PHAMIT improved migrants’ awareness and knowledge about HIV, increased the usage of condom and endorsed the uptake of proper reproductive and sexual health services as well as voluntary confidential counseling and testing. The execution of 18
PHAMIT Project. (2012, August 7). Migrant News: Burmese Gov't to Offer Migrants Change to Return Home. Retrieved
August 16, 2012, from PHAMIT Project: http://www.phamit.org/news-detail.php?id=108 19
PHAMIT Project is born from The Comprehensive HIV Prevention among Most-At-Risk Population in Promoting Integrated
Outreach and Networking (CHAMPION) Project , which is a Round 8 grant under The Global Fund to Fight AIDS, Tuberculosis and Malaria given to Thailand.
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agenda might involve the use of the native languages of the migrant workers and this tremendously assures the effectiveness of the program. In ten provinces, health service that was migrant friendly was utilized by Migrant Health Assistants at public hospitals. Today, PHAMIT strategies cover 34 provinces with the biggest low-skilled migrant population and the projects are implemented by different partners assigning to different provinces. The two prominent partners are civil societies Raks Thai Foundation and World Vision Foundation of Thailand covering 14 and 9 provinces, respectively. The majority of the fund is given by international civil societies such as Global Fund to Fight AIDS, Tuberculosis and Malaria (GFFATM)20. In regards to this, PHAMIT Project can be seen as a strong collaboration amongst agencies involved in and development planning and this surely embodies the key activity of the second collaboration area. However, there were reports indicating that the local government regime still tightly controls the measures of raising awareness about the epidemic21. The civil societies have been complaining of the limits on the number of people who can attend the HIV prevention workshops and prohibitions on their activities in many parts of the country, particularly in sensitive ethnic minority areas. This clearly contradicts the collaboration area’s strategy. Such contradiction urges for a reconstruction within the local policies; which refers to the first collaboration area. If the Thailand government keeps failing to redress the issue, the international civil societies may withdraw the support and leave the migrant workers in cold.
MOU’s Collaboration Area 3 The last collaboration area puts emphasis on promoting the access to HIV and AIDS prevention, treatment, care and support towards the HIV-vulnerable migrant worker population. The strategy and key activities of the second collaboration area is summarized in Table 5 below.
20
The Global Fund is a collaboration of public and private sectors in a form of international financing institution committed to
attaining and distributing additional resources to prevent and treat HIV and AIDS, Tuberculosis and malaria worldwide. The Global Fund’s structure is based on the concepts of country ownership and performance-based funding; meaning that people in countries implement their own actions based on their priorities and the Global Fund provides the fund in exchange to achievement of the verifiable results. 21
IRIN PlusNews. Thailland: Migrant workers unprotected and uninformed. November 12, 2007. http://www.plusnews.org/
Report/75261/THAILAND-Migrant-workers-unprotected-and-uninformed (accessed September 14, 2012).
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Table 5 MOU's Collaboration Area 3 COLLABORATION AREA 3: PROMOTE ACCESS TO HIV AND AIDS PREVENTION, TREATMENT, CARE AND SUPPORT Strategy
Key Activities
3.1 Promote leadership and political commitment at the community, national and regional levels to improve access to prevention, treatment, care and support.
Conduct dialogues between sending and receiving countries on access to prevention, treatment, care and support services for migrants and mobile population.
3.2 Support strategies that ensure access to comprehensive HIV and AIDS prevention, treatment, care and support for migrant and mobile populations.
Develop a joint mechanism for provision of quality care, including ART and referral system for migrants and mobile population.
In the context of care provision for migrants living with HIV, Thailand’s National AIDS Strategy has not given any significant change regardless the strategies provided in the third collaboration area. Within the current and previous national strategy frameworks, provincial healthcare providers are forced to make complicated ethical and moral choices22. Authoritatively, registered and non-registered Burmese, Cambodian and Laotian labor migrants are unable to get access to ARV treatment since it is not covered in,CMHI, the basic migrant worker health insurance. In practice, however, health personnel provide them these drugs through special programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFFATM). However, GFFATM is not expansive and only cover approximately 2,300 migrant workers in certain areas23. HIV-infected pregnant migrants, fortunately, are able to receive AZT24 to prevent the virus transmission to the child under the National Health Care scheme, but only if they are legally documented. If unregistered, it is up to health personnel to decide whether they get treated. In the cities of Kanchanaburi and Trad, for instance, they were being treated, but in the city of Tak only the women who remained in contact with doctors, generally those who return for antenatal care, were receiving AZT25. In other words, the previous national strategy, which was aligned with the national health policy, does not acknowledge a mandatory HIV healthcare delivery towards the migrant workers. With the upcoming national AIDS strategy for 2012-2016, however, the government of Thailand is expected to take 22
IOM Thailand, supra note 6, p. 88.
23
UNAIDS. Feature Story of 2012. May 2, 2012. http://www.unaids.org/en/resources/presscentre/featurestories/2012/
may/20120502seamigrants/ (accessed July 13, 2012). 24
AZT, abbreviation for azidothymidine, is a type of ARV drugs that significantly reduce the replication of virus and works
progressively to prevent the virus transmission from mother to baby. 25
IOM Thailand, supra note 6, p. 88.
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pioneering move to ensure that migrants have a better access to the treatment26. The new national strategy is proposing the idea of HIV treatment and care being assured for any HIV-infected individuals living in Thailand, regardless of their nationality as long as he or she legally enters and stays in the country. Professor Dr. Supang Chantavanich, the director of Asian Research Center for Migration, confirms this advance step by noting that the ARV treatment will later be available to the infected migrant workers under a subsidized price27. Given the fact that the outline of National AIDS Strategy 2012-2016 has not been published officially yet, if the provision of subsidized-priced ARV medicines for migrant workers is really executed, this might be the biggest achievement the memorandum has resulted yet. The accommodation of subsidized-priced ARV definitely correlates strongly with the strategies of the third collaboration area. Another memorandum’s accomplishment for the year of 2012 is a bilateral cooperation between Thailand and Cambodia. Historically, the bilateral collaboration on HIV treatment for migrant workers has been conducted since 2002 when Thailand's government-led pharmaceutical manufacturer called Government Pharmaceutical Organization (GPO)28 began to export the ARV drugs they produced to Cambodia. Cambodia, given to their low-income economy capability, could not locally produce the generics ARV drugs, and thus, depended on the import of GPO-produced ARV at differential (affordable) price. During this process, importation authorization is considered on a case-by-case basis. However, it is believed that Cambodia Pharmaceutical Entreprise (CPE) will produce the drugs for the domestic Cambodian market 29, and thus, the bilateral trade will come to a lesser degree. In the context of mobile population, another bilateral cooperation between the two countries has recently emerged. Cambodian migrants who return to their home country to obtain a three month supply of ARVs 30. This envisions how these migrants are privileged with a time span in which they should not worry about their medication supply while trying to adjust back in their country (e.g., finding a new job and/or accessing the new healthcare provider). Given the fact that Cambodian migrant workers has the highest HIV prevalence amongst the low-skilled migrant worker population, it is understandable that Cambodia is the first neighboring countries with whom Thailand undergo such cooperation. In regards to this point, the remaining big question is whether and 26
Supra note 23.
27
Chantavanich, Professor Dr. Supang, interview by Safir Soeparna. The Future of Migrant Worker (September 27, 2012).
28
GPO is a national enterprise under the Ministry of Public Health signed by Her Royal Highness Princess Srinagarindra, the
Princess Mother, in 1966. GPO has been merely contributing itself to the Thai society in providing better standing of living for all Thais and people of neighboring countries through a production and supply of quality medicines at affordable prices, 29
TREAT Asia. (2004). TREAT Asia Special Report: Expanded Availability of HIV/AIDS Drugs in Asia Creates Urgent Need for
Trained Doctors. Bangkok: AMFAR, p. 11. 30
UNAIDS, supra note 10.
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when such cooperation gets duplicated to Myanmar and Laos. With the prospect of the subsidized-priced ARV medicine becoming available to migrant workers this coming year, the expansion of ARV-supply joint mechanism to Myanmar and Laos should not be a difficult priority.
MOU’s Monitoring and Evaluation The three aforesaid collaboration areas are inadequate without a proper channel of surveillance. Monitoring and evaluation should act as a binding retaliation that reminds Thailand, Myanmar, Cambodia and Laos of the betterment for HIV-mitigation measures dedicated to migrant workers. Table 6 MOU's Monitoring and Evaluation MONITORING AND EVALUATION Strategy Use the annual meetings of the focal points for monitoring the progress of the implementation of the MOU Action Plan
Establish an M&E framework to review progress in the implementation of the MOU
Establish reporting mechanism to the signatories of the MOU
Key Activities Review progress and identify follow up actions in annual meetings of focal points, held either independently or in conjunction with the annual meetings of ATFOA, JUNIMA, ADB, and others. Develop M&E tools in line with the activities of the Joint Action Plan Conduct Joint Review of progress in implementing the MOU Report to the biennial ASEAN Health Ministers Meeting plus China, or alternative meeting as required
The Table 6 above signifies the major role of institutions that share a same value, vision and mission in reducing the HIV prevalence within the migrant workers. Throughout the paper, there are numerous governmental party and international and local civil societies that have been put under the spotlight. These institutions will ensure the continuity of memorandum by enacting regular benchmarking and assessment. The Meeting of GMS Working Group on Human Research Development – the main umbrella of memorandum – is annually held and the meeting includes the improvement on migrant workers’ welfare under its Labor and Migration subsector framework. The next meeting – the 11th Meeting – will be held in Myanmar under a tentative schedule. This annual panel is accompanied by a more specific workshop co-organized with JUNIMA and titled GMS Workshop on HIV Prevention and Infrastructure, in which the dialogue on migrant workers has always been a key section. The system of scorecard, in which a country is scored and diagnosed based on the provision of healthcare for migrant workers in the ASEAN region, has been proposed and developed by JUNIMA since 2010. The scorecard system is
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believed to ensure a gradual improvement in dispersing ART to the infected-migrant workers. The implementation of it may come into force this year or next year.
EPILOGUE Although migration has transformed into a fraction of the economic functioning of Thailand (the receiving country) and Cambodia, Laos and Myanmar (the sending countries) migrants are often perceived as invisible individuals when it comes to human rights protection. The table 7 in the following page indicates a glimpse of the epidemic’s severity within the mobile population in Thailand. Table 7 Severity of HIV Epidemic within Migrant Workers in 200931 Total Three Nationalities Total
1,314,382
Cambodia Total 124,761
M
32
Laos 33
F
78,945
45,816
Myanmar
Total
M
F
Total
M
F
110,854
52,980
57,674
1,078,767
591,370
487,397
Agriculture
221,703
HIV Prevalence within agricultural workers: 0.7%
Seafood Process
136,973
HIV Prevalence within seafood-processing workers: 2.34%
56,578
HIV Prevalence within deep-see fishing workers: 1.96%
Fishing
HIV Prevalence per Nationalities
2.15%
0.51%
1.16%
Migrant workers are prone to be exploited and marginalized throughout the migration process. Numerous researches show that migrant populations are vulnerable to discrimination, exploitation and harassment at home and abroad, by employer, broker, fellow migrant and/or the locals. Their basic rights oftentimes are violated in the context of both working condition and incentive. Migrants find it difficult to access legal or social protection and generally lack access to HIV services and information while inaccurate knowledge and sub-culture values affect the behavior of migrant workers that make them prone to HIV, sexual transmitted disease and unplanned pregnancy. Lacking of HIV knowledge and treatment is what sparks an unwanted scenario in which the epidemic within migrant workers may fuel up the outbreak towards the general Thai population. Without significant measures, this epidemic will end up 31
The table is compiled from combination of two separate data sets. The source of number of migrant workers is from Office of
Foreign Workers Administration, Department of Employment, Ministry of Labour, Statistics on Foreigners Obtaining Work Permits during 2009, presented in Thailand IOM Report 2011. Meanwhile, the source of HIV prevalence is attained from 2010 IBBS studies in six provinces, presented in UNGASS Thailand Report 2012. Agriculture sector represents the sector with the most migrant workers while seafood process and fishing sector signify the third and fifth biggest migrant population, respectively. 32
M sign in the table indicates male worker.
33
F sign in the table indicates female worker.
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transforming economic function shaped by migration into an economic setback in which the productivity is hampered and further expense will be burdened to the four countries. To mitigate the epidemic within the mobile population, Memorandum of Understanding on Joint Action to Reduce HIV Vulnerability Associated with Population Movement emerged under the framework of GMS. With its three collaboration areas, GMS memorandum exerts a role as initiator and insurer: initiator in a sense that the memorandum triggers a new measure, such as Thailand being possibly more flexible in dispersing ARV medicines to all migrant workers by providing them in subsidized price and cooperating with Cambodia in supplying the home-returning migrant with 3-months supply of ART; and insurer in a sense that the memorandum extends its reliance on the strategic provision by other institutions such as JUNIMA, which then, signifies the expansion of relationships of Thailand in the Southeast Asia region. However, given the fact that memorandum has actually existed for almost eleven years, the improvement is taking such a slow pace. The lack in data showcasing HIV prevalence in migrant workers, the difficulties local authority has created to hamper the continuity of community-based HIV mitigation conducted by civil societies, and the exclusion of ART medicine in Compulsory Migrant Health Insurance (CMHI) signifies how memorandum does not give tremendous accomplishment regardless numerous dialogues and meetings that have been executed by the countries in partnership with civil societies. Until the execution of the new National AIDS Strategy for 2012-2016, Thailand’s national policies are still ineffective in ensuring adequate access to health care and HIV service throughout the migration cycle. In other words, only few has been accomplished and there are still gaps in ensuring comprehensive HIV services for migrants in Thailand and the memorandum becomes the parameter in filling up the gap. Thailand and the three sending countries should strongly acknowledge that the obstacles of cross border navigate different regulations and social adjustment.
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Bibliography Asian Development Bank. Overview of Great Mekong Subregion. http://www.adb.org/countries/gms/overview (accessed August 13, 2012). Chantavanich, Professor Dr. Supang, interview by Safir Soeparna. The Future of Migrant Worker (September 27, 2012). Hugo, G. Migration and Health: Situation Report on International Migration in East and Southeast-Asia. Bangkok: IOM Thailand, 2008. International Organization for Migration. Thailand Migration. http://www.iom.int/jahia/Jahia/activities/asia-and-oceania/east-and-south-eastasia/thailand/cache/offonce;jsessionid=C6C428B46C80F0D256367E01E48CFFD5.worker02 (accessed August 13, 2012). IOM Thailand. Financing Healthcare for Migrants: A Case Study from Thailand. Bangkok: International Organization for Migration, 2009. IOM Thailand. Thailand Migration Report 2011. Bangkok: IOM Thailand, 2012. IRIN PlusNews. Thailland: Migrant workers unprotected and uninformed. November 12, 2007. http://www.plusnews.org/Report/75261/THAILAND-Migrant-workers-unprotected-and-uninformed (accessed September 14, 2012). Jitthai, N., S. Yongpanichkul, and M. Baijaisordatl. Migration and HIV/AIDS in Thailand: Triangulation of Biological, Behavioural and Programmatic Response Data. Bangkok: IOM Thailand, 2010. JUNIMA. JUNIMA Progress Report 2009-2012. Bangkok: JUNIMA, 2012. Mekong Migration Network. Overview of Mekong Migration: Statistics. March 9, 2010. http://www.mekongmigration.org/?page_id=26 (accessed August 13, 2012). PHAMIT Project. Migrant News: Burmese Gov't to Offer Migrants Change to Return Home. August 7, 2012. http://www.phamit.org/news-detail.php?id=108 (accessed August 16, 2012). Thailand Ministry of Health. Thailand AIDS Response Progress Report 2012 - Reporting Period: 20102011. Bangkok: Thailand Ministry of Health, 2012. TREAT Asia. TREAT Asia Special Report: Expanded Availability of HIV/AIDS Drugs in Asia Creates Urgent Need for Trained Doctors. Bangkok: AMFAR, 2004. UNAIDS. Feature Story of 2012. May 2, 2012. http://www.unaids.org/en/resources/presscentre/featurestories/2012/may/20120502seamigrants/ (accessed July 13, 2012). United Nations Human Rights. Thailand Joint UPR Submission. Geneva: Office of the High Commissioner for Human Rights, 2011. World Bank. 2011 World Bank Data by Countries. Washington DC: World Bank, 2011. 16
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