Covid 19: Healthcare access consideration for non-citizen vulnerable groups

By: Evelyn S. Devadason

The Covid-19 pandemic has glaringly exposed the problem of healthcare neglect for the marginalised foreign segments of the community, namely refugees and asylum seekers, undocumented (unregistered) migrants and stateless persons. Worth noting here is that foreigners only make up a small proportion of the statelessness segment as this group includes broader categories of citizens before Independence, indigenous people (nomadic tribes), individuals that have lost their documentation such as birth certificates or marriage licenses, street (or abandoned) children and adopted children that were born in Malaysia and children with mixed marriages or born before the marriage was registered.

The three non-citizen groups mentioned above are vulnerable to contracting the disease as they live in remote areas and crowded conditions with inadequate sanitation, they lack access to healthcare and health insurance and plausibly have underlying and untreated medical conditions. The lack of basic needs, that goes beyond food provision, further puts pressure on these groups to take health risks to make ends meet.  Specifically, the lack of finance and the high cost of healthcare following from the differential pricing for foreigners in public hospitals stops them from seeking medical treatment even when they have symptoms of Covid-19. The problem of healthcare avoidance is even more acute among the undocumented migrants due to fears of retaliation, detention and deportation.

Another compelling reason to focus on the three non-citizen groups is that they are not made up of small numbers. The reported statistics for Malaysia indicate 178,140 refugees and asylum seekers [registered with United Nations High Commissioner for Refugees (UNHCR) as at August 2020], between two to four million of undocumented migrants and an estimated 12,000 stateless persons in Peninsular Malaysia as of 2019. The number of foreign stateless persons (which includes children of refugees and migrants) is not determined for Sabah, though they are dominant in this State. The total number of non-legal-non-citizens in the country therefore remains unknown.

The limited or rather unaffordable access to healthcare for the three non-citizen communities reflects the historical and ongoing segregation, and intersectional nature of the treatment towards the ‘foreign counterparts’ of the society. The lack of an inclusive approach on healthcare access mirrors cracks in the health system, which in turn, facilitates the transmission of communicable diseases like Covid-19 within those communities and thereby posing risks to the wider population. While there is no data on the number of Covid-19 cases among the non-legal foreigners, the reported cases of 2,683 positive Covid-19 cases among registered migrant workers as of 6 August 2020 suggest a looming problem if the former were also to be accounted for.

Covid-19 affects everyone and carries an important public health lesson at a time where the disease continues spreading with no end in sight. Therefore, cultivated ignorance or deliberate neglect for the so-called “undeserving illegals” in terms of access to healthcare and health rights are conditioned states that should no longer persist. Revisiting common sense on the importance of ‘healthcare for all’ through actionable policy targets is needed now more than ever.

For addressing the gaps in healthcare accessibility, a proper surveillance system is necessary for the vulnerable non-legal-non-citizen groups. For this, robust data should be compiled for the three groups. The existing data on these communities are largely survey-based and therefore remain limited and fragmented. The data gathering of non-legal-non-citizens in the country is recognisably not an easy task and it would require more investments by the government and close collaboration between the government, non-governmental organisations (NGOs) and relevant community-based networks to reach out to the relevant groups.

A comprehensive and reliable database on the health status and health needs of these non-legal foreign communities is not just for the immediate purpose of contact tracing, but for identifying sustainable solutions through targeted policy responses for the three heterogeneous groups. New policies for increasing healthcare access need to be supported with revisions or refinements to existing regulations on healthcare, such as the higher fee structure for foreigners at public healthcare facilities and the mandatory reporting requirements of undocumented migrants seeking treatment at public hospitals.

Hopefully, the pandemic generates adequate discussions on healthcare disparities, particularly healthcare rights for the ‘non-legal foreign’ marginalised groups. While the focus on the marginalised and needy citizens are clearly warranted during this pandemic, it is also time to bridge the healthcare access divide to accommodate the non-citizens. In that context, the proposed Non-Citizens Health Act prescribing basic healthcare rights for all non-citizens should be given due consideration and subject to debate from a public health perspective.

Evelyn S. Devadason is Professor at the Faculty of Economics & Administration, University of Malaya, and Vice-President of the Malaysian Economic Association