Our earlier article “I don’t understand, I don’t know press one or two” gives the half-funny, half-sad story of Rana Mohammad Masud trying to contact National University Hospital (NUH) to make an appointment. It ended with TWC2 deciding that left on his own, there was no way he could get to a doctor; we’d have to intervene.
It was not a life-or-death problem, but that we had to move mountains to get him a smallish medical procedure is a cautionary tale that speaks of how hard it can be for migrant workers to access medical care.
When he finally saw a doctor on 24 August 2020, the doctor was mystified.
“Why hadn’t the metal wires in Masud’s left thumb been removed long ago?” he asked Debbie Fordyce, the TWC2 volunteer (and current President) who accompanied Masud to the hospital.
The doctor explained that, normally, removal could be done about six weeks after insertion. The wires having been inserted in August 2019, they should have been taken out in October 2019.
Indeed, Masud had a scheduled date in October 2019 for their removal, Debbie explained, but all sorts of bureaucratic hurdles then got in the way resulting in a delay of ten more months.
X-rays of Rana Mohammad Masud’s left hand
Fortunately, in Masud’s case, it was still possible to do so now. But some other surgical implants might not be so tolerant of delays in removal. Other workers with those implants, facing similar bureaucratic delays, might thus have their medical care compromised as a result.
The doctor told Masud he would do it immediately. He found a time slot in the afternoon to perform the removal. It didn’t even need an operating theatre; it could be done in the clinic itself, such a simple procedure it was.
Whose responsibility to ensure medical care?
So, what happened with the previous (October 2019) date for removal of the wire implants? Very simply the employer refused to provide a letter of guarantee to the hospital to pay for the removal. The employer insisted that Masud’s injury was not work-related and it wasn’t the employer’s responsibility to pay.
The employer was ignoring the law. The Employment of Foreign Manpower (Work Passes) Regulations 2012 > Fourth Schedule > Part III > Section 1 says:
1. Except as the Controller specifies otherwise in writing, the employer is responsible for and must bear the costs of the foreign employee’s upkeep (excluding the provision of food) and maintenance in Singapore. This includes the provision of medical treatment ….
The sentence continues a bit more to allow for co-payment by the employee if such a provision is in the employment contract (which in Masud’s case, we didn’t think any such provision for co-payment existed). There is nothing there that narrows the employer’s responsibility to work-related conditions only.
A page on the Ministry of Manpower website further explains to employers that
As an employer, you must buy and maintain medical insurance coverage of at least $15,000 per year for each Work Permit holder. The insurance should cover inpatient care and day surgery, including hospital bills for conditions that may not be work related.
The law itself can hardly be clearer. However, benevolent laws are only good if they are enforced, and in TWC2’s experience, MOM’s enforcement mechanism cannot be relied on — for reasons we don’t fully understand.
Going around in circles
After Masud told us that he couldn’t even reach a human being by calling the hospital’s phone number, Debbie stepped in. She too had difficulty reaching a human being or getting a straight answer (after several attempts), and finally made a personal visit to NUH “because phone calls kept me going round in circles.”
There she was unambiguously told that the hospital would not schedule an appointment unless somebody paid outstanding amounts that had remained in arrears since the year before. The implication was that if TWC2 wanted an appointment for Masud, then TWC2 would have to pay the employer’s prior bills.
The amounts were:
- $112.65 on 29 July 2019;
- $75.75 on 7 August 2019; and
- $114.65 on 25 September 2019.
In other words, our medical institution was saying money first, patient care later. For $303.05 worth of arrears.
We explained that while TWC2 would be willing to pay for removal of the implants, it was not correct for us to be expected to pay previous charges incurred by Masud’s employer. It would set a terrible precedent and create moral hazard. We would pay for the specific help we wanted to provide for a worker but neither the patient nor TWC2 should be held liable for the irresponsibility of third parties.
Since the matter had to be taken up to a more senior level than the business office we were dealing with, we wrote an email to NUH’s higher-ups.
Transient Workers Count Too (TWC2), is willing to pay for the consultation and the [removal of wires in his left thumb]. This procedure was earlier scheduled for Oct 2019, but did not take place for lack of [letter of guarantee] from the employer.
I was informed that because three previous invoices totalling $303.05 remain unpaid, he is not able to schedule an appointment. While TWC2 is prepared to pay for the procedure, we do not feel we should be liable for previous invoices that should be the responsibility presumably of the employer.
In case the hospital expected the patient himself to pay, we added,
As the patient has been unable to work since the injury due to the cancellation of his work permit, and has been without any means of support for over a year, it is not possible for the patient to resolve the debt to the hospital.
Three days later, we were notified of an appointment date, at which the metal wires were removed. We were glad to see that the senior levels of NUH were understanding. In the end, we were billed for only the consultation, X-ray and procedure — $398.55 inclusive of Goods and Services Tax.
Bad employer or bad system?
Singaporeans, brought up to be wary of criticising the government, might be quick to put the blame on the employer for creating a situation in which a worker was nearly prevented from getting medical follow-up, even when doctors in their professional opinion felt that the wires had to be removed and within six weeks. Possibly we might blame the hospital administration too for being intransigent.
Both criticisms would be valid, though not sufficient.
However, if we really want to understand the root of the problem, we need to look at how our migrant worker system has been designed. By the government.
Nice laws are written but enforcement is left to chance. Officialdom is not taken to task for not doing their job.
At a deeper level is an ideological problem — that the social safety net for migrant workers is not the responsibility of the State but the responsibility of employers. Immediately, this creates two major weaknesses:
- Employers can be ephemeral — companies can be closed, they can go bankrupt, bosses of small companies can emigrate, disappear or be convicted for an unrelated crime and sent to jail, leaving no one to run the affairs of the company or discharge its responsibilities.
- Employers have far fewer resources than the State — and the provision of a social safety net, by definition, requires very elastic resources because of huge unknowns.
The point is taken that the above issues have been anticipated; that is why the law requires insurance to be bought. Yet, this only goes halfway to resolving the problem.
Firstly, what if the employer fails to pay the premium or renew the insurance policy after the first year?
Secondly, the worker cannot access the insurance protection directly; he must go through the employer who has the discretion whether or not to activate the policy’s provisions.
In Masud’s case, the system expected the employer to pay first and (up to him) claim from his insurer. So long as the employer refused to pay, the whole issue got stuck.
It would be better if the insurer provided every worker with a card which the worker can present to any approved medical clinic or hospital if he needs treatment. The clinic or hospital can then bill the insurer directly. Insurers, being much bigger companies than two-bit employers, are much more likely to honour the claims. That way, we don’t saddle our clinics and hospitals with unpaid bills too.
This simple fix will go a long way.
Better yet, we should re-examine whether it is wise to continue the policy of placing the burden of the social safety net on employers. This isn’t an either/or question. There can be a variety of hybrid solutions.
The bottom line is this: it’s not only a problem of recalcitrant employers and lethargic enforcement. At a governance level, we have designed a system that may not be fit for purpose.