*2.3. Interview and Survey Topics*

The interview and Delphi survey topics were based on the following framework, Figure 2.

We adapted the concept of the social determinants of health [14] to construct the above framework. In the field practice, the interviews started by building rapport with the informants. For the interviews with the non-URAS informants, researchers emphasized the following issues: overarching policy direction of the government towards the care for URAS (such as international relationships and politics, and international laws and regulations ratified by the Thai government); existing legal mechanisms and policy instruments for URAS (such as immigration law, nationality law, and the present health insurance scheme); and the views and attitudes of the informants towards the optimal approach the Thai government could take towards URAS's health. When we interviewed URAS, we focused mostly on their experiences in accessing health care in Thailand and factors that influenced their well-being.

*Int. J. Environ. Res. Public Health* **2021**, *182*, 566 4 of 15

**Figure 1.** Linkage between in-depth interviews and Delphi survey. ure 2.

**Figure 2.** Conceptual framework serving as a basis for the interviews and the Delphi survey.

**Figure 2.** Conceptual framework serving as a basis for the interviews and the Delphi survey. We adapted the concept of the social determinants of health [14] to construct the above framework. In the field practice, the interviews started by building rapport with the informants. For the interviews with the non-URAS informants, researchers empha-The Delphi survey questionnaire consisted of twenty statements in four domains, namely: (i) health financing; (ii) benefit package; (iii) health insurance; (iv) policies to support aspects of well-being (such as education and work rights); and (v) policy direction of the Thai government. A list of all twenty statements is presented in Supplementary File S1. The participants were asked to rate from one (least agree) to five (most agree), noting if and to what extent they agreed with each statement.

#### sized the following issues: overarching policy direction of the government towards the care for URAS (such as international relationships and politics, and international laws and *2.4. Data Analysis*

**Figure 2.** Conceptual framework serving as a basis for the interviews and the Delphi survey. We adapted the concept of the social determinants of health [14] to construct the above framework. In the field practice, the interviews started by building rapport with the informants. For the interviews with the non-URAS informants, researchers emphasized the following issues: overarching policy direction of the government towards the care for URAS (such as international relationships and politics, and international laws and For in-depth interviews, inductive thematic content analysis was exercised. The researchers began by familiarizing themselves with the interview data, reading through the transcriptions and fieldwork memos and listening to the interviewed audios. Keywords and sentences were highlighted and those with similar content were labeled with the same color. Then, several codes with relevant contents were grouped together and merged into theme. We were able to identify six main themes from the interviews. The coding was completed by SJ and RS. If there were any contradictory issues between the two coders, a consultation with a public health expert of the filed would be performed. The manual coding was performed. Microsoft Excel was used to store the quotes. We presented a coding tree in Supplementary File S2. The interview data were triangulated with the field note and policy documents if needed. Before the final report was published, the researchers arranged a stakeholder meeting on 17 August 2020 to ask for feedback or comment on the

findings. For the Delphi survey, descriptive statistics were used. The informants' response was shown in terms of median and percentile.

#### *2.5. Ethical Consideration*

This study obtained ethics approval from the Institute for Human Research Protection, Thailand (IHRP 595/2562). The data collection process of this study strictly followed the Declaration of Helsinki. The informed consent process in this study was firmly approved by IHRP. All informants were given the participant information sheet before the interview and the survey. Written consent was obtained from all Thai informants. For URAS informants, we accepted verbal consent instead of written consent to avoid any sense of coercion. We offered the Thai informants USD 32 each to compensate for their time dedicated to the interview. For URAS, we provided each interviewee a thank you gift of about USD 10 after the interview was completed.

#### **3. Results**

#### *3.1. Themes Identified from the Interviews*

We identified six main themes from the interviews: (i) the Thai Government position on URAS; (ii) opinions on Thailand becoming a party of the 1951 Refugee Convention; (iii) non-government organizations on health promotion for URAS; (iv) options on health insurance management for URAS; (v) working potential of URAS; and (vi) uncertainty of future life plans for URAS.

#### 3.1.1. Thai Government Position on URAS

All stakeholders suggested that the Thai government's position in taking care of URAS was related not only to the healthcare and well-being policies, but also encompassed issues of wider national security and international relations. One of the interviewees pointed out that the Thai government had a clear position to be 'unclear'. If the government's position was too open and supported a human rights concept, there would be concerns that the country could attract more URAS to enter Thailand.

'This is a tricky policy of Thailand . . . . Let it all happen. This is a very interesting point when you talked about international relations. I thought the Thai government might know that the government will be in trouble if they are too stiff. So just ignore it, then there will be an excuse.' (C2)

Some key informants (A1, B2, and C4) identified that the ambiguity of the overarching policy direction towards URAS caused incoherent practices towards the care for URAS among frontline officers, and created a situation where there was no clear agency accountable for the care for URAS.

'In the other sectors, I don't know if they have main officers to take care of urban refugees and asylum seekers. But in the health sector, we don't have any main responsible agencies.' (C4)

Health sector stakeholders (B2, B3, and B5) commented that health services, such as health insurance for URAS, should be free from the limitations caused by national security concerns. However, interviewees who had work experience with the national security sector (C3 and E2) argued that an insurance policy for URAS should be launched but performed covertly.

'This topic is politically sensitive. If the MOPH thinks that health insurance is necessary for them (URAS), we can implement it but this must be done unofficially.' (B3)

#### 3.1.2. Opinions on Becoming a Party of the 1951 Refugee Convention

There were diverse comments about Thailand becoming a party of the 1951 Refugee Convention. Some stakeholders (C3 and E1) commented that the 1951 Refugee Convention

committed Thailand to undertake more works for URAS, yet other agencies that supported URAS, such as UNHCR, were not committed to provide support for Thailand. Moreover, some stakeholders noted that UNHCR was not performing well in taking care of URAS. The UNHCR migrant-screening program was not effective enough to grant refugee status for those really in need.

'In the national security view, becoming a signatory of the Convention (1951 Refugee Convention) is not the best choice.' (E1)

Some interviewees (C1 and F2) commented that Thailand would obtain benefits if the country became a party of the convention. Those gaining substantial benefits from becoming a party were NGOs and academics who could use the convention as a tool to drive the healthcare policy agenda for URAS. For some, the 1951 Refugee Convention did not differ from other conventions that Thailand has signed which also promote human rights.

'In my opinion, the 1951 Refugee Convention is about the protection of refugee rights. This topic appears in international laws. The Thai government has already signed many other conventions that are related to human-rights protection. Therefore, I do not see any difference (if Thailand signs the 1951 Refugee Convention).' (F2)

One of the stakeholders (F3) mentioned that although the Thai government was not part of the 1951 Refugee Convention, the country performed quite well in the care for URAS. The signing of the convention would be an optional benefit, though not necessary.

'I think Thailand has always been a silent country, even though Thailand has not signed the Refugee Convention. But still the fact remains that there have been refugees in Thailand for many years. And I would say we have been handling the refugee situation quite positively.' (F3)

3.1.3. Non-Government Organizations on the Health Promotion for URAS

This theme is linked to the unclear policy direction of the Thai government towards URAS because when officials did not have a clear mandate to deal with URAS, a few NGOs and civic groups stepped in. BRC is amongst a few charitable organizations responsible for the care for URAS. It provided health consultancy services for URAS. Some other functions included home visits, provision of cash-based interventions (approximately USD 96–125 per month) and subsidizing basic medical expenses, especially for children and pregnant women.

'We support vaccination for children under five years and children with health complications and we also cover the medical expense . . . We may ask for support from the hospital if the health condition is severe and creates huge medical expenses.' (A3)

Other NGOs, in addition to the BRC, also intervened. The Buddhist Tzu Chi Foundation organized a clinic for URAS once a month and Asylum Access Thailand (AAT), Center for Asylum Protection (CAP), and Jesuit Refugee Service (JRS) provided legal advice for asylum seekers seeking refugee status. Good Shepherd Bangkok arranged a language school for URAS children, although the school was not authorized by the Ministry of Education. These organizations worked in cooperation with each other, although there was no formal agreement among them.

#### 3.1.4. Options on Health Insurance Management for URAS

The MOPH has implemented a public insurance scheme, namely, the "Health Insurance Card Scheme" (HICS) for Cambodia, Lao PDR, and Myanmar (CLM) migrant workers for more than a decade. The scheme provides comprehensive medical benefits at registered public hospitals. The applicant needs to pay an annual premium, including the health check expense, for about USD 64 [15]. In contrast to the HICS for CLM migrant workers, there has been no public health insurance for URAS so far. In the past there was an attempt to widen the legal interpretation of the HICS to allow URAS to buy the insurance but this failed.

Some interviewees (A2, A3, A4, C3, and E3) mentioned that the Cabinet Resolution on 15 January 2013, by document, did not specify eligible nationalities to the insurance buyer. Therefore, at that time, some hospitals allowed URAS to buy the insurance but then sales were later cancelled due to unclear direction from the Thai government. Some hospitals found that those who bought the insurance were mostly children and elderly people who were prone to sickness.

'We found that most urban refugees were uninsured. Some NGOs said that some URAS were able to purchase the health insurance in the past but this was cancelled because of unclear communication.' (A6)

Some stakeholders (for instance, B1 and G1) mentioned that if URAS were allowed to work, they could have the right to be enrolled in the insurance.

One of the participants (F3) highlighted that health insurance for URAS should not be separated from existing insurance schemes, according to the concept of an 'inclusive policy' and effective pooling of risk.

'First of all, when we talk about health insurance, it will not work when we divide it into different categories, right? The bigger the (beneficiary) pool is, the better the survival of the insurance scheme is, right?' (F3)

However, healthcare providers (D2 and D3) commented that health insurance for URAS should not be part of the UHC policy as it might consume healthcare resources that belonged to Thai citizens. Additionally, if any medical expenses incurred, these should be covered by UNHCR.

'UNHCR is larger than our hospital. Why should the financial support for refugees be our responsibility? UNHCR should support all of them. If your guest overstays in your home and they do not pay electronic bills, food expenses, and medical expenses, how do you think about this? Will you pay for them?' (D3)

#### 3.1.5. Working Potential of URAS

All of the themes above viewed URAS as service users. However, a few interviewees (B1, D4, and E3) suggested that URAS had work potential because some URAS used to work as professionals. Granting URAS the right to work would benefit the country's economy and at the same time decrease public expense.

'If URAS reside in Thailand and do not cause any social problems, we must have information about them, about their residence and we should allow them to work and purchase health insurance.' (E3)

Some URAS interviewees informed us that they could speak many languages and used to work as translators in a range of organizations. Some URAS had tried to find a job online and some had graduated with a degree in their previous country of residence. However, the employment policy for non-Thais does not allow URAS to acquire a work permit.

'(ASK: What's your job now?) I work at home. I find a movie and then translate I the movie. I translate it from English to my own language. I like keeping myself busy because when I'm free, my thoughts get worse. There is lots of negative thinking in my mind. Then I do not feel good.' (G3)
