Dr.Suwit Wibulpolprasert 1 International Trade and Movement of Health Professions: Experiences from the Health Sector in Thailand Suwit Wibulpolprasert Deputy Permanent Secretary Ministry of Public Health, Thailand 11 April 2002

Dr.Suwit Wibulpolprasert 2 External Brain-Drain From developing countries in respond to demand for continuing education, financial incentives, and demand in developed countries. Mainly medical doctors and nurses - high demand, good quality graduates, good command of English, biggest gap of income.

Dr.Suwit Wibulpolprasert 3 Year Emigrants Total graduates % external brain drain Total Migration of M.D., Thailand

Dr.Suwit Wibulpolprasert 4 External Brain Drain ( ) l Mainly to USA (~1,500 M.D.) l Rarely come back l Reduced greatly since1980 l Prompted many remedies: u 3 years compulsory public works u Financial incentives u In-country specialty training u Increase production - rural recruitment/placement u Social advocacy/incentives

Dr.Suwit Wibulpolprasert 5 Started with MD graduates since years with the public sector, 2/3 to the rural district hospitals. USD 12,000 fine, if breach contract. Began with Pharmacists and Dentists in Rapid expansion of rural hospitals and better distribution of personnel. Compulsory Public Work

Dr.Suwit Wibulpolprasert 6 Started with hardship allowance for MD in the district hospitals since $US80/month. Increased in amount, categories and professions in respond to internal brain-drain since No evaluation on their effectiveness. Financial incentives

Dr.Suwit Wibulpolprasert 7 Monthly Remuneration of MoPH doctors working in rural hospitals in 2000 ($US) Salary (new graduates)200 Non private practice250 On-call services Special procedures Special clinics Hardship allowances Total920-1,680

Dr.Suwit Wibulpolprasert 8 In-country specialty training Started by the Medical council since 1971, 3-5 years of training. Thai board of medical specialties are granted - now 45 specialties. Mainly start after 3 years of public work, except in rare specialties. More than 2/3 of Thai M.D. are specialists.

Dr.Suwit Wibulpolprasert 9 Proportion of Medical Specialists and General Practitioners, Year Percentage

Dr.Suwit Wibulpolprasert 10 Annual output of medical doctors Year Number Rapid economic growth CPIRD (+300/yr) Increase production (+340/yr) External brain drain Compulsory public work

Dr.Suwit Wibulpolprasert 11 Proportion of rural medical students Year Percentage CPIRD = Collaborative Project to Increase Production of Rural Doctors CPIRD

Dr.Suwit Wibulpolprasert 12 Social Incentives Rural Doctor Society (RDS) established in self-help/advocacy civil society. Bi-monthly rural doctor newsletters and journals published. Annual best rural doctor award by the oldest medical school since Hardship award by the RDS since Career development - doctor in rural hospital can be promoted to the level of director of a division or deputy DG.

Dr.Suwit Wibulpolprasert 13 Trade inFinancial services and internal brain-drain Established BIBF (Bangkok International Banking Facilities) with rapid influx of low interest tax free loans. Mushrooming of private hospitals in big cities with massive migration of doctors from rural public hospitals. April 1997, 21 district hospitals went on without a single full time doctor.

Dr.Suwit Wibulpolprasert 14 Economic crisis (1997-now) Bankruptcy of private hospitals-NPL Reverse brain drain/H. systems reforms New businesses - promotion of mode2 l Regular/Package services l Dental/dentures services l Health tour/long-stay More FDI (mode3) on private hospitals

Dr.Suwit Wibulpolprasert 15 Private doctors and beds in Thailand ( ) Y ear Beds Doctors Econ. Boom BIBF FDI

Dr.Suwit Wibulpolprasert 16 Inequitable distribution of doctor ( ) Year Doctors/100 Bed Ratio of doctor density Econ. boom BIBF Econ. crisis

Dr.Suwit Wibulpolprasert External brain-drain may occurred unrelated to GATS commitment. However, GATS mode4 may sustain and facilitate it. 2. Mode2/3 and trade in other services may resulted in internal and external brain-drain. 3. Multiple integrated strategies, implemented seriously are needed to mitigate the problems. Conclusion

Dr.Suwit Wibulpolprasert 18 The way forwards We shall need a radically new manner of thinking if mankind is to survive Albert Einstein We need Conscious revolution towards civilized globalization and international trade

Dr.Suwit Wibulpolprasert 19 Barrier to Mode 4 for health professionals Entry VISA Work Permit License - practice/premise Investments permit Finance - Insurance/Self Socio-Cultural * Effectiveness * * GATS can not reduce these barriers