BANGKOK, Feb 9 (Thomson Reuters Foundation) - Zaw, an illegal Burmese migrant dying of AIDS-related illnesses, spent a weekend hunched over in waiting rooms at three Thai hospitals near Bangkok - each denying him care as he gasped for breath, his lungs full of fluid.
At a fourth hospital that admitted him, a doctor drove a large-gauge needle between his ribs, draining litres of fluid, but by then the 34-year-old was gravely ill.
Zaw died 40 days later - a death the Bangkok-based HIV Foundation that was helping him says could have been prevented with timely care.
Hospitals across the country are denying insurance and care to migrant labourers like Zaw despite an insurance scheme launched over a year ago, officials and rights advocates say.
"That's the story we have once every six to eight weeks: people in this situation, and we can't get them the care they need in time," Scott Berry, an Australian adviser for the HIV Foundation, told the Thomson Reuters Foundation.
"If we have a Thai, who has an identification card, we can pay for them to get them into a hospital, but if they're from another country, then we find that really difficult to do."
Thailand hosts an estimated 3 million migrant labourers, mostly from neighbouring Myanmar, Cambodia and Laos, and 1.6 million of them are legally registered with the government.
The country has had a health package for migrants for more than 10 years, officials say, but an August 2013 policy expanded the migrant health insurance benefits - at a cost of 2,100 baht ($64) per person - to include HIV prevention, care and antiretroviral (ARV) drugs.
"If you are non-Thai... documented or undocumented, you are eligible for that health insurance," said Sumet Ongwandee, director of the health ministry's bureau of AIDS and sexually transmitted diseases.
However, he and his colleagues acknowledge that many hospitals still turn away migrants because they do not understand how the insurance scheme works and worry they will have to cover the costly HIV care out of their own budgets.
For each migrant who buys health insurance, 600 baht ($18) is put into a fund for treatment of people with HIV/AIDS, and 50 baht ($1.50) into a fund for "high cost" care, including AIDS-related opportunistic infections such as tuberculosis, pneumonia and encephalitis.
Hospitals caring for HIV/AIDS patients need only to file claims and will be fully reimbursed, said Buncha Kakhong, head of the health insurance group in the permanent secretary's office at the health ministry.
The ministry called in staff from the 800 hospitals around the country twice in the second half of last year to tell them how HIV/AIDS claims are made and how the central HIV/AIDS fund works, but some still may not understand, he said.
Hospitals are obliged to let patients buy an insurance card, Buncha told the Thomson Reuters Foundation. The ministry is trying hard to improve awareness, but there are no punishments for those who fail to provide service, he said.
Thailand has made huge strides in fighting HIV, slashing the estimated number of people infected to 8,100 in 2013, from 143,000 in 1991, and last year extending free ARV drugs to all Thais with HIV.
HIV prevalence is about 1 percent among Thais aged 15 to 49, and about 1 to 2 percent among migrants.
Migrants, who do low-paying, backbreaking jobs across the country, face widespread exploitation and discrimination.
In the past, when migrants with AIDS sought care at hospitals, the staff would hand them over to NGOs, who would help transport them to the border, where they would die, too poor or ill to cross the border to return home, said Promboon Panitchpakdi, head of the Raks Thai Foundation.
Access to care for migrants with HIV has improved dramatically over the past decade, said Promboon, whose organisation has long worked on HIV prevention and care for migrants.
It is not clear yet if the migrant health insurance is sustainable and if its funds will cover the costs of care, he said. He urged Thailand to allocate part of its tax earnings to the health and welfare of migrants, and draft a law to back up the migrant insurance scheme.
"You can't have a large health insurance without a law that enforces (it)... Who knows, the next government may say, 'Oh, let's not do ARVs any more,'" he said.
Meanwhile, many hospitals remain reluctant to sell insurance to ill people, leaving those who are HIV-positive fighting for their lives.
"Although the policy was clear, localities were confused on issues of reimbursement and who was responsible for these migrants," said Brahm Press, head of the MAP Foundation, an NGO in the northern city of Chiang Mai that works with Burmese migrants.
"We then started hearing about discrimination where hospitals were rejecting migrants they knew were HIV-positive."
The denial of care has also endangered the lives of babies born to migrant women with HIV.
Thailand prides itself on testing nearly all pregnant Thai women for HIV and providing ARVs to prevent mother-to-child transmission. The rate of HIV transmission from Thai mothers to their babies was 2.3 percent in 2013.
For non-Thais, however, only 71.5 percent of the HIV-positive women who seek antenatal care get ARVs. The rate of HIV transmission from these mothers to their babies is 4.8 percent.
The HIV Foundation, which has helped about 1,600 people since it began its work three years ago, has assisted six pregnant Burmese women with HIV, five of whom did not start ARVs until a month or so before their due dates.
"That's very late," said Piyathida Smutraprapoot, who is in charge of HIV/AIDS prevention, care and treatment for the Bangkok metropolitan area. "We want pregnant women to get tested early, and ... start treatment immediately."
Early ARV treatment will reduce the risk of the child contracting HIV from her.
One Burmese woman found out she was HIV-positive at her first antenatal visit, when she was six months pregnant.
She told the Thomson Reuters Foundation that she pleaded in vain with staff at a public hospital in Bangkok to sell her health insurance - even padding the 2,100-baht ($64) fee with a 3,900-baht ($120) bribe.
In her eighth month of pregnancy, with help from the HIV Foundation, she received ARV drugs to protect her unborn child from contracting the virus.
The baby's first HIV test in October, at one month old, came back negative. The result of his second test in January is pending. He has a last test when he is nine months old.
Only then can doctors declare him HIV-free.
Reporting by Alisa Tang, Editing by Tim Pearce