*3.2. Delphi Analysis Results*

The Delphi survey among 13 experts found that the issues that the participants agreed upon most were that URAS should have the right to work, the right to buy MOPH health insurance or insurance provided by the private sector, the right to access basic education, the right to live outside the detention centers, and the right to receive medical benefits that cover treatment for public health threats and conditions (e.g., tuberculosis and influenza). All of these issues received the median score of five. Issues that most experts rated the least (median = two) were; 'Overall, the Thai government presents appropriate policy direction towards URAS', 'The medical benefit for URAS should focus on emergency illnesses and accidents only', and 'The medical charge of URAS should be mainly shouldered by NGOs', Figures 3–7. *Int. J. Environ. Res. Public Health* **2021**, *182*, 566 9 of 15 *Int. J. Environ. Res. Public Health* **2021**, *182*, 566 9 of 15

**Figure 3.** Delphi survey asking about the main responsible authority that should cover medical charges of URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. MOPH = 3, NHSO = 3, URAS = 3, UNHCR = 4, NGO = 2. **Figure 3.** Delphi survey asking about the main responsible authority that should cover medical charges of URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. MOPH = 3, NHSO = 3, URAS = 3, UNHCR = 4, NGO = 2. **Figure 3.** Delphi survey asking about the main responsible authority that should cover medical charges of URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. MOPH = 3, NHSO = 3, URAS = 3, UNHCR = 4, NGO = 2.

**Figure 4.** Delphi survey asking about the benefit package that should cover for URAS. Note: The Scheme 25. th and 75th percentile, respectively. Basic disease = 4, emergency and accident = 2, communicable disease = 5, similar to Thai citizens = 4, similar to migrant workers = 4, mental disease = 4. **Figure 4.** Delphi survey asking about the benefit package that should cover for URAS. Note: The Scheme 25. th and 75th percentile, respectively. Basic disease = 4, emergency and accident = 2, communicable disease = 5, similar to Thai citizens = 4, similar to migrant workers = 4, mental disease = 4. **Figure 4.** Delphi survey asking about the benefit package that should cover for URAS. Note: The Scheme 25th and 75th percentile, respectively. Basic disease = 4, emergency and accident = 2, communicable disease = 5, similar to Thai citizens = 4, similar to migrant workers = 4, mental disease = 4.

center = 5.

*Int. J. Environ. Res. Public Health* **2021**, *182*, 566 10 of 15

**Figure 5.** Delphi survey asking about the main health insurance provider that should cover for URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. HICS = 5, SSS = 4, NHSO = 4, Private **Figure 5.** Delphi survey asking about the main health insurance provider that should cover for URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. HICS = 5, SSS = 4, NHSO = 4, Private organization = 5. URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. HICS = 5, SSS = 4, NHSO = 4, Private organization = 5.

**Figure 6.** Delphi survey asking about the other aspects of well-being that should urban refugees should have rights. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th **Figure 6.** Delphi survey asking about the other aspects of well-being that should urban refugees should have rights. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. Enjoy basic education = 5, get work permit = 5, register to civil profile = 4, live outside detention center = 5. **Figure 6.** Delphi survey asking about the other aspects of well-being that should urban refugees should have rights. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. Enjoy basic education = 5, get work permit = 5, register to civil profile = 4, live outside detention center = 5. *Int. J. Environ. Res. Public Health* **2021**, *182*, 566 11 of 15

percentile, respectively. Enjoy basic education = 5, get work permit = 5, register to civil profile = 4, live outside detention

**Figure 7.** Delphi survey asking about position of Thai government towards URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. Ratify to the 1951 Refugee Convention = 3, appropriate position of Thai government = 2. **4. Discussion Figure 7.** Delphi survey asking about position of Thai government towards URAS. Note: The square on the line denotes the median score. The left and right ends of the line denote the score at 25th and 75th percentile, respectively. Ratify to the 1951 Refugee Convention = 3, appropriate position of Thai government = 2.

#### **4. Discussion**

organization = 5.

policy and the attitudes of all relevant stakeholders towards the well-being of URAS. The interviews and Delphi-survey suggested that the ideology of national security and international relations influenced the concept of human rights for URAS. The concept The study is among the very first studies in Thailand, which focus on the country policy and the attitudes of all relevant stakeholders towards the well-being of URAS.

The study is among the very first studies in Thailand, which focus on the country

of URAS health has been tightly woven with foreign policy issues over many years. Health

in many other parts of the world. For example, according to a study by Klaus, the campaign for the restriction of rights for immigrants and refugees in Poland was used by the populist political parties to win the election in 2015 [18]. By late 2015, the Polish government launched the Antiterrorist Act stipulating that every foreign citizen would be put under surveillance without any court control with an ultimate aim to stop a refugee influx

With regard to URAS problem solving mechanism, the UN agencies usually puts emphasis on the "relief" of URAS' suffering rather than addressing the structural problems that compromise the well-being of migrants. The same situation often occurs with NGOs or charitable organizations that most of the time serve as humanitarian support for URAS. This problem reflects the limitation of UN agencies that do not have solid legal mechanisms to force or even encourage any particular nation to re-orientate its health system by making it more "inclusive" for all people on its soil. Therefore, a more practical approach for UN agencies and NGOs is to comply with the local government. However, this approach has a setback as most of the NGOs' (or even UNHCR's) activities usually end up with a humanitarian relief for URAS (or any activities that make URAS more "resilient" with the status quo health system) as it is less disputable compared with shaking the structural problems or recognizing URAS as part of the society on equitable grounds

Although Thailand is not a signatory to the 1951 Refugee Convention, the country has long been a key member of ASEAN [20], which has its own agreement among member states to guarantee human rights, including the right to health for everybody in the region. Therefore, Thailand cannot deny its responsibility to protect the health of URAS. However, it appears that current Thai laws are not developed to protect URAS from the outset. The majority of byelaws for non-Thais mostly concern migrant workers, but not URAS.

into the Polish territory.

with the nationals [19].

The interviews and Delphi-survey suggested that the ideology of national security and international relations influenced the concept of human rights for URAS. The concept of URAS health has been tightly woven with foreign policy issues over many years. Health issues are still considered "low politics", while foreign policy is deemed to be "high politics" in decision making [16,17]. This situation has occurred not only in Thailand, but also in many other parts of the world. For example, according to a study by Klaus, the campaign for the restriction of rights for immigrants and refugees in Poland was used by the populist political parties to win the election in 2015 [18]. By late 2015, the Polish government launched the Antiterrorist Act stipulating that every foreign citizen would be put under surveillance without any court control with an ultimate aim to stop a refugee influx into the Polish territory.

With regard to URAS problem solving mechanism, the UN agencies usually puts emphasis on the "relief" of URAS' suffering rather than addressing the structural problems that compromise the well-being of migrants. The same situation often occurs with NGOs or charitable organizations that most of the time serve as humanitarian support for URAS. This problem reflects the limitation of UN agencies that do not have solid legal mechanisms to force or even encourage any particular nation to re-orientate its health system by making it more "inclusive" for all people on its soil. Therefore, a more practical approach for UN agencies and NGOs is to comply with the local government. However, this approach has a setback as most of the NGOs' (or even UNHCR's) activities usually end up with a humanitarian relief for URAS (or any activities that make URAS more "resilient" with the status quo health system) as it is less disputable compared with shaking the structural problems or recognizing URAS as part of the society on equitable grounds with the nationals [19].

Although Thailand is not a signatory to the 1951 Refugee Convention, the country has long been a key member of ASEAN [20], which has its own agreement among member states to guarantee human rights, including the right to health for everybody in the region. Therefore, Thailand cannot deny its responsibility to protect the health of URAS. However, it appears that current Thai laws are not developed to protect URAS from the outset. The majority of byelaws for non-Thais mostly concern migrant workers, but not URAS. The most relevant law relating to URAS is the 'Regulation of the Office of the Prime Minister: Screening process for aliens entering the Kingdom of Thailand and incapable of returning to their home country' B.E. 2562 (2019). It establishes a screening mechanism for groups of aliens in line with the nature of Thai society and international situations in order to reach sustainable solutions for Thailand's alien management problem [21].Yet, the regulation still lacks operational details. Whether Thailand will become a party of the 1951 Refugee Convention or not may not be so important, what may be more important is to have a clear stance on the Thai government's responsibility to take care of URAS.

As long as there is no clear direction from central authorities, there will always be variation in day-to-day operations of the treatment of URAS among street-level bureaucrats [22]. A clear example can be noticed in the recent COVID-19 pandemic in Thailand. Though the Thai government publicly announced to the wider public that all COVID-19 patients (regardless of the nationalities) are able to access free treatment of COVID-19. The hospitals are able to reimburse the healthcare cost from the MOPH and the National Health Security Office (NHSO). However, in practice, there are also administrative problems in reimbursing the healthcare cost for undocumented migrants, not to mention URAS [23,24].

If the Thai government steadfastly rejects the accession of the 1951 Refugee Convention, the domestic mechanisms to take care of URAS health should be strengthened. Moreover, the Thai government should learn from international experience, especially from countries that accepted a refugee influx while refraining from the 1951 Refugee Convention. Janmyr raised the case of Lebanon as an example of a country that is not a party of the 1951 Refugee Convention, but is hailed by the international community for its generosity towards refugees as probably hosting the highest number of refugees in the world in proportion to its population size [25]. Lebanon already has human rights obligations towards refugees on its territory by virtue of membership of the United Nations and its ratification

of a number of core human rights instruments [25]. Another interesting issue is the URAS right to work and eligibility to be enrolled in public health insurance in Thailand. For the right to work, Brown et al. suggested that the lack of legal instruments to allow URAS to work legitimately has caused URAS to face a greater risk of being arrested or detained [26].

Additionally, the provision of the right to work is likely to lead to better quality of life for URAS because they will be able to access the labor market and gain sustainable livelihood opportunities. The right to work will also allow URAS to gain increased selfreliance and dignity and improve mental health [27,28]. Fleay and Hartley cited a case study in Australia, suggesting that without the right to work, asylum seekers in Australian communities faced exacerbated feelings of anxiety, sadness, and fear [29]. Most of this study's interviewees, including those who participating in the Delphi survey, indicated that the right to work should be implemented as soon as possible with no critical disagreement from the wider public. The law to promulgate this policy—Royal Ordinance Concerning the Management of Employment of Foreign Workers, B.E.2560 (2017)—is in place [30] and only a Cabinet Resolution is required to implement the policy concretely.

Giving URAS the right to work also means that Thailand will benefit from an increased labor force (and some URAS are quite well educated). The opening of employment opportunities helps improve the registration data of URAS and positively affects the Thai economy. Additionally, to deal with the refugee crises, it has been recommended that, while poorer countries accede to host refugees, richer countries should help provide financial support to those host countries in order to protect refugees' health and well-being [31]. Since Thailand host numbers of refugees from various nations, this may benefit Thailand as well.

High healthcare costs and financial difficulties are also a key barrier faced by refugees and asylum-seekers [32]. According to Elsouhang et al. possessing health insurance was significantly associated with increased utilization of medical services among Iraqi refugees in the United States of America [33]. In the Thai context, the financial difficulties that URAS face are not just a matter concerning the work performance of an individual, but these also intertwine with the legal design of a system that does not allow URAS to work legitimately. Moreover, the inclusion of URAS in public health insurance schemes may benefit not only URAS, but the health system as a whole. A substantial volume of literature shows that the exclusion of non-national populations (such as migrants, refugees, and asylum seekers) from official primary health care might save costs early on, but this effect might be lost as costs are shifted to healthcare providers in secondary care or community settings [34]. Again, the promotion of the right to public health insurance for URAS is interlinked with the affordability of insurance, which is also linked to the right to work. It is also linked to the regulation of the state which needs to be clearly specified in laws or official state regulations in order to avoid haphazard interpretation by local healthcare providers [35].

Concerning methodological approaches, some limitations remain in this study. Firstly, this study did not encompass all types of refugees and asylum seekers. Those who were detained in detention centers and those living in the temporary shelter areas along the country border were excluded. A discussion on policies to take care of the health of these populations necessitates a more extensive review on the relevant laws and perhaps requires a wider range of interviewees (including police and state prosecutors). Secondly, the issue of healthcare for URAS is relatively sensitive. According to research ethics, in the fieldwork, the researchers needed to disclose their own work status as persons working with the MOPH, which may have created an unfavorable feeling among the URAS interviewees. For example, some URAS might feel uncomfortable disclosing their life stories or unpleasant experiences with state officials to the researchers. In contrast, state official interviewees may have tended to answer the interview questions in a way that tried to meet the researchers' expectation (social desirability bias). However, the researchers addressed these issues by using methodological triangulations (such as contrasting the interview findings with the review on policy documents). Lastly, suggestions from the interviews or Delphi survey (for instance, the provision of rights to employment and public health insurance enrollment)

does not mean final consensus from policy experts and of course does not mean that these suggestions can be implemented without societal disagreement. In reality, to implement such policies, there needs a much wider consultative process from all angles of the political sphere. Further studies that explore policy feasibility for URAS are of great value.
