Investigation into health disparities among stateless children in Tak Province, Thailand

Abstract

Statelessness is the worst possible form of violation of fundamental human rights which can lead to serious adverse health outcomes in children. Thailand is one of many countries where stateless people are concentrated. In Thailand, stateless people are defined as nationals without birth registration documents stating their Thai citizenship, even though they have been residing in the country for generations especially along the Thai-Myanmar border area including Tak Province. Previous research suggests that health service utilization is much lower in stateless people compared with their Thai counterparts due to the lack of formal access (accessibility) to government health facilities. Additionally, financial barriers (affordability) led to catastrophic health spending amongst the stateless. To address this issue, the Thai Cabinet introduced “Health Insurance for People with Citizenship Problem (HIPCP)” scheme in 2010 to increase health service utilization among the stateless population leading to improving health outcomes. However, despite the HIPCP policy in place since 2010, little is known about the policy on the magnitude of use of medical services amongst stateless children that may lead to better health outcomes.

The primary aim of this thesis is to investigate whether access to care improves the health outcomes of stateless children through adequate utilization of health services. Tak Province has been selected as the study site since it has the largest proportion of stateless people compared to other provinces. The objectives of the study are threefold: (1) To summarize the policies for the provision of healthcare services for stateless populations in ASEAN countries; (2) To compare healthcare utilization of children by insurance status: UCS, HIPCP, and uninsured; (3) To compare the presence of cases with diseases, and death in children by insurance status: UCS, HIPCP, and uninsured.

Regarding methods of corresponding objectives, a scoping review was conducted for objective-1, while multivariate analysis was applied, using longitudinal health facilities-based data, for objective-2 and objective-3. Data were used from four selected border districts of Tak Province: Mae Ramat, Tha Song Yang, Phop Phra, and Umphang. The electronic medical records of children aged between 0-15 years were retrieved for those who visited health facilities between January 1, 2013 and December 31, 2017. Univariate and multivariate analysis were performed based on the types of outcome data.

The findings suggest that none of the ASEAN countries have explicit healthcare policies for stateless people except Thailand. The ratification of international human rights treaties relating to the right to health of people does not necessarily translate into the provision of healthcare policies for the stateless population.

Regarding service utilization, outpatient (OP) and inpatient (IP) use rates of the HIPCP were 25% lower (incidence rate ratio [IRR] = 0.75, 95% confidence interval [CI] = [0.68, 0.82], p<0.001) and 29% higher ( IRR = 1.29, 95% CI = [1.23, 1.35], p<0.001), respectively as compared to the UCS. In addition, the HIPCP patients had 34% longer hospital lengths of stay (LOS) (IRR = 1.34, 95% CI = [1.27, 1.41], p<0.001) relative to the UCS patients. Regarding health outcomes, a multivariate analysis revealed that the HIPCP had 2.6 times greater odds of malaria (adjusted odds ratio [AOR] = 2.55, 95% CI = [1.60, 3.94], p<0.001), and 2.1 times greater odds of conjunctivitis (AOR = 2.11, 95% CI = [1.18, 4.18], p = 0.016) than the UCS. The study also suggested that the uninsured had 2.6 times greater odds of death (AOR = 2.60, 95% CI = [2.05, 3.25], p<0.001) than the UCS. On the other hand, the HIPCP was not associated with death (AOR = 0.63, 95% CI = [0.37, 1.00], p = 0.070) when compared with the UCS.

In conclusion, the study demonstrates that the OP service utilization rate of stateless children insured with the HIPCP is significantly lower than their Thai counterparts with the UCS. Additionally, stateless children may be more likely to experience infectious diseases than Thai children. Besides, stateless children are more likely to use IP care and to stay longer at the hospital than their Thai counterparts. This worse off health of stateless children may draw immediate policy attention to overcome the inherent weakness of the HIPCP policy to be implemented. Additional research is needed to examine the causes and outcomes of these differences to shrink disparities in health outcomes.

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