On behalf of Raks Thai Foundation as a Principal Recipient of the PHAMIT program, I would like to thank the Global Fund to Fight AIDS, Tuberculosis and Malaria, which provided the grant for this migrant program.  In addition, the PHAMIT program has been effectively implemented over five years with the support of all implementing partners: World Vision Foundation of Thailand (WVFT), Foundation for AIDS Rights (FAR), MAP Foundation, Suratthani Catholic Foundation (Stella Maris Center Songkhla), Empower Foundation (Chiang Mai), and Pattanarak Foundation. The Program for Appropriate Technology in Health (PATH) and Department of Health Services Support (DHSS) provide support for migrant health system development and promote migrant-friendly services at government health facilities. The advocacy activities of all partners have encouraged changes in migrant health policy, especially towards migrant health assistants and greater health services for migrants.

With Support of the Institution of Population Research (SIPR), the PHAMIT program has been able to evaluate the effectiveness of the program interventions, and measure behavior changes relevant for HIV prevention.

Finally, I would like to acknowledge Mr. Brahm Press, Migrant Program Specialist of Raks Thai Foundation, for making available documents and reports on five year results of the program.  Also, Mr. Promboon Panitchpakdi, Executive Director of Raks Thai Foundation, for his support on this work.

Introduction

1Overview of Migrants : Thailand has a migrant population of 2.5 million. Most of them entered Thailand illegally through its long, porous land borders with Burma (80%), Cambodia (10%) and Laos PDR (10%). Limited economic opportunities in the source countries and high rates of poverty encourage many young men and women to cross into Thailand to earn money to support their families or to build their futures. Enticements include numerous job opportunities for migrants in Thailand, primarily in sectors such as fishing, construction, factories, domestic work, and agriculture. The majority of the migrants come to Thailand without formal documentation and have illegal status in Thailand. The registration of migrants in 2004 showed that of over 800,000 listed migrants, 55 percent were male and 45 were female.

Table 1. Development Indices for Cambodia, Myanmar and Thailand: 2003

Indicator	Cambodia	Myanmar	Thailand
Population 2003	14,144,000	49,485,000	62,843,000
Annual pop. growth rate	2.4	1.3	0.7
Death rate (per 1000)	10.0	11.2	6.0
Median Age	18	24	31
Total Fertility Rate (per women)	4.7	2.8	1.7
Mortality Rate Under 5 ( per 1000)	106	127	26
Adult literacy rate (%)	68	85	96
GNI (per capita) in USD*	270	220	1,970

Source: ESCAP Population Data Sheet 2003 and *GNI = Gross National Income from UNICEF 2001

2In 2004, an open census allowed 1,284,920 migrants and their dependents to register with a general identification (ID), of which, 849,552 migrants registered with a work permit. As of 2008, the number of migrants with a work permit was less than half a million. Approximately 87,400 migrant workers from Laos and Cambodia are registered under the bilateral memorandum of understanding (MOU) system, of which only 15,000 have entered the country directly under this system. Migrants from Burma still rely on the annual registration because fears of registering with their own government have hampered a similar MOU system. The documented migrants were safe from police arrest, detention and deportation, but were still limited to heath services under the 1,300 baht paid for the health insurance package.  It should be noted that the health insurance package for migrants excludes costly treatment such as antiretroviral treatment (ART) for people living with HIV/AIDS. Undocumented migrants were totally excluded from any of the government services.

3Program Description : The Raks Thai Foundation, with funding support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), started implementing the HIV/AIDS prevention program among the three nationalities of migrant workers in 22 out of 76 provinces of Thailand in 2004.  

4The program was named the Prevention of HIV/AIDS Among Migrant Workers in Thailand, or better knows for its acronym of “PHAMIT,” which means “Friendly Skies” in Thai. It aims to reduce the number of new HIV infections among migrant workers, who can be found especially in the seafood and fishery industries along Thailand’s long coastline, and garment factories and plantations at the border of Burma in Tak, Chiang Mai, and Kanchanaburi, and sex workers located at fishing ports.

5The goals of the PHAMIT program are the following:

• Migrant workers and related populations should use condoms consistently during casual sex and practice reproductive health care.

• Health system should be favorable for migrant workers to receive health prevention and treatment services that are suitable for migrant workers.

• There should be a supportive psychosocial environment for migrant workers and their dependents.

• Political factors should support migrant workers’ health and treatment at the national and inter-country level.

Methods and tools

6Description of the Program Interventions : The PHAMIT program plans to reach its goals through behavioural change communication interventions, increasing access to general health and reproductive health care, increasing information, and developing favourable policies for migrant workers.

7The PHAMIT program also demonstrates the importance of working with other NGO partners: World Vision Foundation of Thailand (WVFT), Center for AIDS Rights (CAR), MAP Foundation, Suratthani Catholic Foundation (Stella Maris Center Songkhla), Empower Foundation (Chiang Mai), and Pattanarak Foundation and Program for Appropriate Technology in Health (PATH  contracted as a technical consultant). A partnership has also been established with the Ministry of Public Health’s Department of Health Services Support (DHSS) to develop “migrant-friendly” health services.  At the same time, at implementation sites, there is involvement of local organizations; civil society (non-governmental organizations, migrant workers’ networks), private agencies (employers of migrant workers, the entertainment industry), and related government agencies (hospitals, health centers/clinics, employment office).

8Over the five year period from October 2003 to September 2008, the PHAMIT activities to reduce migrants’ vulnerability to HIV and improve access to health services are summarized as following:

• Outreach education and behavioral changes communication provided for Burmese and Cambodian migrant workers in 19 coastal provinces and 3 Thai-Burmese border provinces.

• Migrant Health Assistants were able to register/document migrant workers working in programs supporting migrant communities.

• Migrant volunteers were recruited to support delivery of program information, education and communication materials, as well as distributing condoms.

• Condom were distributed through distribution points in migrants’ communities and their workplaces, as well as outreach activities.

• Drop-in center services were promoted as a safe space for migrant workers and their dependents to reach health and HIV prevention activities.  

• Health services were provided on sexually transmitted infection (STI) diagnosis and treatment, as well as voluntary HIV counseling and testing (VCT).

• Legal services on migrant rights and policies were given in collaboration with the Thai Lawyers’ Council and CAR.  Some sites conducted “legal clinics” at migrant communities, and advocated for support of local authorities.

• Community self-help and livelihood security networks were strengthened. These activities also support sustainability of the program.

• A National Conference on migrant workers and access to health in Thailand was organized annually.  It aimed to give updates on the situation of migrants and policy, as well as influencing government policy makers and the public in favor of migrant workers.

• A “Migrant Health Strategy” was drafted with the Department of Health Services Support and submitted to the Thai parliament.  Also developed an HIV master plan for migrant workers based on human rights and international conventions.

• Identified support from relevant stakeholders, employers, media, local authorities and Thai communities.

RESULTS

9Results over 5 years :The Raks Thai Foundation with six NGO participating partners emphasized a comprehensive HIV prevention and health services program through outreach and information, while deepening their commitment to defend migrants’ human rights.  Meanwhile the Department of Health Service Support with PATH focused on developing a migrant health services system.  There were also advocacy activities that led all program partners to become part of a network advocating for the rights of migrant workers, especially health and HIV rights.  The program results over the past five years are shown in Figure 2 as follows:

Behavior Changes Communication – Community Outreach

10Networks of volunteers, supported by Thai and Migrant field workers, reach out to migrants at their workplace, living quarters and entertainment centers. They also help distribute a variety of educational materials and materials related to behavior change produced by PHAMIT partners. The materials are on a range of topics in the languages of the migrants, and include printed materials and audio-discs as well as video-movies and karaoke. Through these networks, the PHAMIT program has reached over 442,000 migrants and more than 20,800 entertainment workers with information about HIV and reproductive health.

11The volunteers also support the operation of the drop-in centers. These drop-ins provide a “safe” place for migrants, especially fishermen, to go to meet other people or spend free time. Informational and recreational materials in the languages of the migrants are also available, and informational activities on HIV and health are organized. At the end of the program’s first phase of development, thirty-eight PHAMIT drop-in centers are operating in twenty provinces.

Condom Distribution

12Condoms have also been distributed through outreach activities and 1,920 distribution points. Over 6,878,500 condoms have been distributed over the course of this phase of the program. The condoms distributed under the program were packaged especially as “PHAMIT” condoms and there were 2 sizes: 49 and 52 mm.

Impact on Behavior

13The Institute of Population and Social Research (IPSR) was employed to conduct the baseline sample survey in 2004 and an end-of-project sample survey in 2008. The baseline survey in 2004 involved 3,374 completed interviews, including 2,590 male and 773 female migrant workers aged 15-49.  The sample represents the total targeted populations in the 24 provinces/sites of the PHAMIT Program.  The population is defined as the registered and estimated migrant workers, as documented in the “Statistical Data of Irregular Migrant Worker Registration under the Resolution of the Cabinet 2001” and the “Estimates of Undocumented Marine Fisheries” by the Raks Thai Foundation. The report focuses on 2,423 migrants from Myanmar (2,026 men and 397 women) who work in the coastal provinces, 466 Cambodian migrants (428 men and 38 women) who work in the coastal provinces, and 485 migrants from Myanmar (258 men and 226 women) who work in the two inland provinces of Chiang Mai and Tak.  

14The impact survey in 2008 was also conducted on purpose using the same sampling procedure and sample size to collect comparable data from 3,387 completed interviews (2,731 male and 656 female). These cases included 2,436 migrants from Myanmar (2,045 men and 391 women) who work in the coastal provinces, 466 Cambodian migrants (428 men and 38 women) who work in the coastal provinces and 485 migrants from Myanmar (258 men and 227 women) who work in the two inland provinces of Chiang Mai and Tak.  

15The comparison of the 2 surveys showed favorable results in terms of behavior changes among the migrant workers under the PHAMIT program. Both surveys asked male migrants questions on condom use during the last time that they had sex, and the question distinguished between regular partners, non-regular partners and sex workers. It is normal in Asia to find a very high level of condom use with sex workers and very low use with the regular partner or spouse. Condom use with regular partners was rare in 2004 (under five percent), but in 2008, the figure had increased significantly, to 24 percent.  However, condom use in this respect still remained at a modest level. On the other hand, it was encouraging to find that, in 2008, condom use with non-regular partners had increased markedly, from 42 to 90 percent for all male migrants.  Similarly, migrants also used condoms more consistently when they had sex with sex workers.  Ninety-one percent of migrants used condoms during their last meeting with sex workers in 2004, as compared to 97 percent in 2008.

16Meanwhile the general awareness of HIV/AIDS was at a very high level in 2004 and increased further in 2008. More comprehensive knowledge on the prevention and transmission of HIV among migrants increased consistently from 2004 to 2008. For example, the percentage of migrants who knew about the use of condom as a means of preventing HIV infection rose from 79 to 89 percent, and from 76 to 95 percent among seafarers and female migrant workers from Myanmar working in the coastal provinces. In 2004, many migrants were not aware of places of HIV testing and they often did not trust in the confidentiality of the results of testing. However in 2008, many more migrants knew places of HIV testing; for example, among migrants in Chiang Mai and Tak, 79 percent knew places of HIV testing in 2008 as compared to only 57 percent in 2004.  Trust in the confidentiality of the results of testing also increased markedly during the same period.  

17Awareness of sexually-transmitted infections (STIs) among migrants was fragmentary in 2004, but by 2008, the situation had clearly improved.  For example, the percentage of migrants from Myanmar who had heard of STIs, apart from HIV/AIDS, had increased from 56 to 85 - 87 percent during the period 2004-2008.  Unfortunately, the proportion of migrants who were infected with STIs but did not receive correct treatment increased slightly.  However, during 2004-2008, many migrants, especially males, had come to understand better the association between STIs and HIV/AIDS (from 77 to 87 percent).  In general, the incidence of ongoing STIs among males also declined during the implementation period from about 2.7 to 1.2 percent, although a marginal increase was observed among women.

18Comparing the Impact Survey in 2008 and its comparison to the Baseline Survey in 2004, the IPSR concluded that the PHAMIT program, with its rigorous and well-coordinated implementation effort, had successfully reached migrant worker population who were most vulnerable.  To a great extent, the program has progressed towards fulfilling its ultimate goal of reducing the incidence of HIV/AIDS among migrant workers and related populations in Thailand and the Sub-region.

19Regarding the national sentinel sero-surveillance among fisheries conducted by the Department of Epidemiology, the Ministry of Public Health reported that the incidence of HIV among migrant workers in fisheries decreased from 5.90 percent in 2000 to 2.50 percent in 2008.  As a proxy indicator in Table 2, the incidence of syphilis cases diagnosed among registered migrant workers going through the health exam for nationwide registration has also decreased from 4.33 per thousand to 1.99 per thousand from 2004 to 2008.

Table 2.Syphilis Cases Diagnosed in Migrant Health Examinations from 2004-2008

Year	Number	Syphilis cases	Per 1,000
2004	884,917	3,828	4.33
2005	610,399	2,057	3.37
2005 round 2	88,622	279	3.15
2006	626,561	2,099	3.35
2007	462,236	1,266	2.74
2008	382,628	760	1.99

Source: Extracted from results of health examination data of migrant worker registration in respective rounds, Ministry of Public Health2008

Increasing Access to Health Services

20Through a partnership with the Department of Health Services Support and PATH, 10 provinces out of a total of 22 provinces were selected as focus areas where the provincial public health office and the government hospitals would initiate “migrants-friendly services” for migrants. A key component of the friendly services model was the Migrant Health Assistant (MHA) who serves as a health communicator and translator, enabling migrants to communicate with the medical personnel more accurately. Many hospitals in the focus areas have set-up hospital signs in the languages of the migrants not only as a guide for directions but as a symbolic gesture of welcome and respect.  

21Furthermore a voluntary counseling and testing (VCT) curriculum was developed for migrants and MHAs were trained in all 10 lead provinces. The training activity was also expanded to other provinces by NGO involvement.  Through its partners, the PHAMIT program provided VCT services to over 2,760 migrants.  

22Meanwhile, over 7,400 migrants and entertainment workers are receiving testing and treatment for STIs through referral services provided by PHAMIT staff, networks of community volunteers, as well as drop-in centers or by visits of mobile clinics to communities.

Migrant Community and Rights

23The PHAMIT program through its partners provided useful skills and basic education, such as Thai and indigenous language instruction, to over 27,460 migrant children; and twenty children’s centers have been established, some of which share space with drop-in centers.

24The migrant rights’ activities focus on increasing the knowledge and awareness about legal issues and policies.  Over 155,080 migrant workers have received information on health and labor rights, including regular updates about migrant registration policy. At the same time, over 13,330 government officials, employers and journalists have attended sensitization workshops on migrants’ rights issues and policies through PHAMIT activities.

Government Policy Advocacy

25The fourth Objective of the program addresses policy: advocating for changes that favor migrants’ health and rights protection. Under this objective, activities are organized to inform government officials, media and the general public about some of the favorable policies.

26PHAMIT partners have been advocating for changes in the political environment to support the following:

• Migrant Health Assistants (MHA) should be approved as a recognized occupation that employers in the health sector can recruit. The Department of Health Services Support promotes use of MHAs by allowing the provincial hospitals to provide stipends at the hospitals.

• Anti-retroviral drugs (ARV) and treatment of Opportunistic Infections (OI) should be provided for migrants as part of the health insurance program for documented migrants, and should also be extended to undocumented migrants. Since 2007, ARV for migrants is provided under the NAPHA Extension Program, implemented by the Department of Disease Control.

• Health financing for migrant health that adequately covers documented and undocumented migrants.

Discussion

27Conclusions : The accomplishments of the PHAMIT program working with migrant workers are a demonstration of the long-term commitment to explore all opportunities to improve access to HIV/AIDS prevention and health services for migrants. Also it demonstrates the alliances that can be built between NGOs and government officials working in the area of HIV prevention services.

Behavior Change Communication

28Behavioral change communication (BCC) materials provided through outreach activities with messages and tools aimed at reducing risky behaviors of HIV/STI infections combined with reproductive health messages are developed in collaboration with all partners. With the participation of migrant workers, the BCC materials developed in the langauges of the migrants were very effective for communication and education.

29Migrant health volunteers assigned to spread the message of HIV prevention to the migrants is an effective and sustainable approach of the program. These volunteers will also continue beyond the project life while they are living in the communities, and assist their friends in accessing services without monthly wages.

30Drop-in Centers are developed as a “safe” place for migrants, especially fishermen, set up near migrant communities and workplaces.  This has helped poor and homeless fishermen to easily obtain information and services. Drop-in centers also provide a base for migrants, volunteers and outreach workers, and serve as a gathering point for clinical services and health education activities.  However sustainability of drop-in centers is difficult to ensure. The program has to leverage funding from local governments or communities to provide continued support.  Some of PHAMIT drop-in centers are now receiving support from local municipalities or fishery associations.

Accessing Health Services

31The Department of Health Service Support (DHSS), Ministry of Public Health, partnered with the Program for Appropriate Technology in Health (PATH) to focus on developing a migrant health services system.  Ten pilot provinces out of the total of 22 provinces implemented the “migrant-friendly services” model by using Migrant Health Assistants (MHAs) as health communicators and translators.  The model succeeded in leveraging funding from local governments to support stipends for these MHAs. Through MHAs, the migrant workers can access health services from the government without barriers in communication.  In early 2008, the MHA was considered as a recognized occupation that academic, foundation and non-government organizations could recruit and register officially.

32PHAMIT also needs to identify provincial partners, e.g. provincial public health offices, provincial and community hospitals, and health centers. The partners may vary from province to province, since apart from the agencies under the Ministry of Public Health, there is no official framework for collaboration on migrant health, although several provinces with large numbers of migrants have set up committees on migration matters that comprise provincial level government agencies and NGOs. Thus collaboration is still taking place on a case-by-case basis. These collaborations have also extended to the government agencies related to migrant employment and security, but there has not yet been a memorandum of understanding (MOU) signed on collaboration for how to handle the issues of migrants.

Cross-border Collaboration

33PHAMIT has collaborated with NGOs and GO at border-crossing points in order to refer migrants to their source communities and to assure continuation of HIV treatment in their home countries. This is handled by different foundations in at least 4 crossing areas:

• Ranong province, Thailand – Kawthong in Tavoy, Myanmar by World Vision Foundation of Thailand

• Kanchanaburi province, Thailand – Mon state, Myanmar by Pattanarak Foundation

• Mae Sot, Tak province, Thailand – Meawadee in Karen state, Myanmar by MAP Foundation and World Vision Foundation of Thailand

• Trad province, Thailand – Koh Kong province, Cambodia by Raks Thai Foundation

34All PHAMIT partners are encouraged to promote cross-border collaborations through bilateral government-to-government channels beginning with agencies in Cambodia, which has already begun to direct migrant workers to anti-retroviral drug therapy at home.

Advocacy and Funding

35It must also be noted that the advocacy networks of relevant organizations for migrants at national and regional levels are an importance channel for encouraging policy changes. With supportive policies, the long-term funding from central government and local authorities can contribute to these programs. Meanwhile Thailand still depends on external funding to support HIV prevention among migrant workers as long as the government policy remains unclear.