Inaccessible Healthcare
Affordable healthcare should be a human right, but in Singapore, it has been made inaccessible to migrant workers. In 2007, all government subsidies for migrant workers were removed and replaced with medical insurance schemes for companies to purchase¹. In 2017, the MOM was asked to raise the compulsory minimum medical insurance coverage of $15,000 for domestic workers. Then Minister for Manpower Sam Tan responded by saying the ministry was looking into the issue, working with stakeholders and would announce the findings "at the right time"².
5 years on, this minimum coverage value still has not been significantly raised³, subsidies remain unavailable, and workers continue to have their access to healthcare denied and policed by their employers; in many cases resulting in untreated illnesses and/or death.
Photo by Reuters, Migrant workers resting at a swab isolation facility during the COVID-19 pandemic.The visualisation below illustrates the typical journey of a migrant worker with a severe stomach ache. What could and should be a simple journey to a polyclinic, a subsidised referral to a specialist at a hospital, and a gastritis diagnosis is instead an arduous process—potentially broken by at least 7 systemic barriers. Healthcare is made inaccessible to workers on multiple fronts: financially, physically, informationally (because healthcare providers update employers instead of workers), in terms of language (and sometimes medical racism), and bureaucratically. Healthcare journeys often don’t even begin because workers are afraid of being sent home when employers find out they are ill and require rest or medical care. When they do begin, they end just as quickly because workers are unable to afford treatment.
The following screenshots show a WhatsApp conversation between a migrant worker, S, and his employer. S asked to see the doctor in July 2021 and despite acknowledging that it might be kidney stones (which it was), his boss did not give him permission to go, instead recommending ‘Chinese medicine’. When employers purchase their own medication for workers, they are able to control costs and save money while performing minimal care. Ultimately, however, they are endangering worker’s lives because medication should be professionally prescribed.
When S’s employer says “[w]e have a lot of workers, they looking at each other first”, he is insinuating that if they allow one worker to see the doctor, others will demand the same. Unsurprisingly, S’s problem persisted and 4 months later in November 2021, he asked to see the doctor again. This time his employer appeared to give permission but eventually did not pay for his consultation or treatment. S made it past the first 2 barriers in the illustrated patient journey after 4 months but his treatment journey would have ended at the third barrier had he not received financial assistance from Migrant Mutual Aid. As of July 2022, he still has not received compensation from his company for his medical expenses.
Listen to Sharif speak about what he believes are the state and employer’s responsibilities when it comes to a worker’s health
Chelladurai Lenin was a 42-year-old Indian worker who fell at a construction site and suffered injuries to his head. According to his employer who left him on a pavement along Upper Changi Road, he did not want to be sent to the hospital because he was hired illegally and was afraid of being deported. Lenin eventually died on the pavement from a fractured skull and bleeding in the head.
Myo Min Aung was a 28-year-old Burmese worker who fell from a height while painting a link bridge at Vivocity. Similarly with Lenin, he was hired illegally. After the fall, his employers put him in the back seat of a car and changed Myo’s work attire for civilian clothes. They drove around for 30 minutes before dumping him at Upper Circular Road, after which they called an ambulance shortly before Myo was pronounced dead. The coroner later found that Myo could have survived his injuries had care not been delayed.
Mohd Kamaluddin was a 28-year-old Bangadeshi worker who died of heart and lung failure after suffering from chickenpox for 6 days. It was reported that Kamaluddin’s employer had abandoned him and 178 other workers at their worksite, and calls to the employer about ill workers were ignored. Workers also claimed that they were not given proper meals. Kamaluddin’s employer was quoted saying, “I have 700 to 800 workers in the dormitory. It is not unusual if someone dies a natural death.”
It is important to pause and note that these are just some reported cases. There is a whole demographic of workers who die due to inaccess to a holistic system that can care for them from beginning to end. We spoke to the Migrant Mutual Aid team who were in touch with a Bangladeshi worker, ‘M’, who suffered and eventually died from cancer of the bladder. He had undergone some scans after experiencing painful urination but the outcome of these scans detailing his Stage 4 diagnosis were withheld from ‘M’ by his employer. As a result he was also prevented from seeking follow-up treatment. By the time ‘M’ changed employment, re-visited the doctor, and learnt about his diagnosis, the cancer had metastasized. He passed away on 3rd July 2022.
Would these workers be alive today if they had received the appropriate medical care at the appropriate time? Why were there no crisis responses in times of crisis? Just as working in construction or households is not itself the reason for death, these medical conditions are not purely a result of work—they result from choices by people in government, companies, and society.
To die from chickenpox in a country that boasts a first class medical system begs the question: did these workers have their healthcare rights protected and was treatment made accessible to them?
Inaccessible Healthcare Leads to Death
Considering an average Singaporean’s monthly salary is $4,680⁴ and a migrant workers’ estimated monthly salary is between $432-$600/month⁵, MMWs and FDWs have approximately 10% of the spending power of a Singaporean but are charged 500% more for relatively basic treatment procedures.
Consider, for example, an instance where a worker requires hospitalisation and treatment for ‘Abdominal Pain or Inflammation of Lymph Nodes’. Compared to a Singaporean patient who pays $2,668, a migrant worker is charged $13,340. Even in an instance where their company or employer exercises their insurance, this amount constitutes 86% of the insurance limit, meaning they cannot afford to fall ill for the rest of the year. In other instances, such as ‘Bronchitis & Asthma’, the total cost incurred is twice what insurance can cover, and so employers are unlikely to permit treatment and hospitalisation.
In 2018, the MOM claimed that “the current compulsory minimum coverage of $15,000 was sufficient to meet 97%, or the vast majority, of all inpatient and day surgery bills for FDWs in the last three years”⁶. Looking at our graph, this might seem true at face value, but it also does not account for the fact that many of these conditions are—on their own or in succession—very close to the $15,000 limit. More importantly, note that the claim “97%, or the vast majority” is only based on samples of the pool of workers whose medical care happens to fall under insurance coverage limits—it does not include workers who are sent home and do not get to exercise their insurance at all. The relevant data that is important is the number of workers who are sent home because the cost of treatment is,or is deemed to be, too high. However, this data is unavailable as the MOM does not conduct or administer exit surveys to workers.
Considering employers are the insurance policyholders, how does this coverage limit shape the way they permit insurance to be exercised and when workers can access treatment? More importantly, why is a population so integral to the functioning of our society and economy priced out of healthcare?
In instances when workers are permitted to see the doctor or visit the hospital, many companies make illegal salary deductions to avoid covering healthcare costs. Below is an audio recording from a worker, J, who had been experiencing pain in his anal region and went to the doctor for exploratory tests. He stopped going when his employer began asking about salary deductions even though the pain had not subsided. He was eventually repatriated.
Transcription: “That day you go to the hospital one ah this one the receipt coming already. Now the boss ask ah…ask you this one payment how to pay? You want every month cut money or one time?”
Workers should be able to access and use their insurance through insurance cards, for example. As expounded on in the timeline above, costly procedures can only be advanced with a monetary deposit of Letter of Guarantee, which places the entire trajectory of a worker’s health in the hands of their employers—many of whom are more interested in productivity and keeping costs and overheads low.
Listen to Bhing & Maw Lwin explain what happens during the compulsory 6-monthly checkup and how reproductive healthcare is not insurance-claimable.
(In)access to Reproductive Healthcare
As mentioned by an employment agent in the Chapter 4 video (see Agents of Exploitation), health screenings for FDWs are primarily to ensure that they are fit to work. Many FDWs fit Singapore cancer screening guidelines—it is advised that women receive a mammogram every year from ages 40-50, and pap smear every 5 years after age 25—but are not given access to this during their compulsory checkups. These procedures are also not subsidised or insurance-claimable. This is especially dangerous when we think about how workers who do have cancer but do not have access to these early detection procedures end up getting diagnosed very late, lessening their chances of survival.
Similarly, the termination of pregnancies is not subsidised or covered by insurance, despite being the only option should an FDW wish to continue work in Singapore. Again, this is dangerous for FDWs who do get pregnant and experience complications. According to both the Employment of Foreign Manpower Act (EFMA) and MOM’s Work Permit Conditions, pregnancy is not illegal or grounds for repatriation; what is forbidden is carrying the pregnancy to term and delivering the baby in Singapore⁷. The state’s decision to then leave these procedures unsubsidised yet require that clinics/employers notify the MOM if their domestic worker gets pregnant is a confusing and contradictory position to take. Are they truly invested in an FDWs right to a voluntary abortion or is the lack of privacy and dignity in access to healthcare simply to “discourage a large pool of unskilled or lower skilled migrant workforce from sinking roots in Singapore”⁸?
Are we ready to look at labour as people first, rather than economic digits? Are we concerned about how diseases, illnesses, and changes to a person’s body impact them and their life chances, instead of how useful or productive they can be to the economy? In many cases, it is cheaper to repatriate a sick worker and rehire a healthy one than to treat them; but to truly embody the Ministry of Health’s (MOH) “[belief] in ensuring quality and affordable basic medical services for all”, migrant workers must be seen and treated beyond their ability to work. Migrant workers, like all people, deserve uncomplicated access to healthcare.
Looking Beyond “Fit for Work”
¹TODAY, 7 December 2006, "Maids need better healthcare protection" + TODAY, 18 December 2006, "Ban cleaning of windows, urges MP"
²TODAY, 8 May 2017, "Foreign domestic workers to be better insured against accidents from Oct"
⁴https://tablebuilder.singstat.gov.sg/table/TS/M182981
⁵Figure is based on 6 days a week at $18-$25/day as per findings from on the ground organisers
⁷Human Rights Watch interview with Ng Cher Pong, Kenneth Yap, and Wing Git Chan, Foreign Manpower Management Division, Ministry of Manpower, Singapore, November 2, 2005.
⁸E-mail correspondence from the Foreign Manpower Management Division, Ministry of Manpower, Singapore to Human Rights Watch, November 11, 2005.
Next Section: