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
1
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
2
Migration of M.D., Thailand
Year
Total
% external
Emigrants graduates brain drain
1963
56
233
24.03
1964
81
236
34.32
1965
140
276
51.72
Total
277
745
37.18
Dr.Suwit
3
External Brain Drain (1960-1975)




Mainly to USA (~1,500 M.D.)
Rarely come back
Reduced greatly since1980
Prompted many remedies:
3 years compulsory public works
 Financial incentives
 In-country specialty training
 Increase production - rural
recruitment/placement
 Social advocacy/incentives

Dr.Suwit
4
Compulsory Public Work
• Started with MD graduates since 1972 3 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 1987.
• Rapid expansion of rural hospitals and
better distribution of personnel.
Dr.Suwit
5
Financial incentives
• Started with hardship allowance
for MD in the district hospitals
since 1972 - $US80/month.
• Increased in amount, categories
and professions in respond to
internal brain-drain since 1991.
• No evaluation on their
effectiveness.
Dr.Suwit
6
Monthly Remuneration of MoPH doctors
working in rural hospitals in 2000 ($US)
Salary (new graduates) 200
 Non private practice
250
 On-call services
250-300
 Special procedures 70-130
 Special clinics
100-300
 Hardship allowances
50-500
Total
920-1,680

Dr.Suwit
7
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
8
Proportion of Medical Specialists
and General Practitioners, 1971-1999
120
General practitioners
Specialists (with certicate of specialty training)
80
74.53
70.93 68.82
65.27
61.67
60
40
20
16.08
20.81
25.47
29.07 31.18
34.73
57.77
38.33
53.89
46.11
42.23
1995
1996
1997
1998
1999
1993
1991
1989
1987
1985
1983
1981
1977
1975
1973
2.99 5.96 9.04
1971
0
Dr.Suwit
79.19
1979
Percentage
83.92
49.78 50.22
48.02 51.98
45.96
54.04
45.11
54.89
55.39
44.61
100 97.0194.04
90.96
Year
9
Annual output of medical doctors
Number
1,800
1,600
1,400
1,200
Rapid economic
growth
1,000
800
CPIRD (+300/yr)
Compulsory
public work
600
Increase production
(+340/yr)
400
200
2017
2013
2009
2005
2001
1997
1993
1989
1985
1981
1977
1973
1969
1961
1957
1953
1949
1945
1941
1937
Dr.Suwit
1965
External brain drain
0
Year
10
50
45
Percentage
40
38.91
35
33.55
30
29.77
25
20.77
20
CPIRD
17.55
15
10
5
33.29
30.54
33.29
28.93
26.98
24.54
24.95
24.79
23.37
23.09
24.27
25.09
27.12
46.61
42.71
Proportion of rural medical students
8.89
5.26
11.72
9.52
CPIRD = Collaborative Project to Increase Production of Rural Doctors
Dr.Suwit
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
0
Year
11
Social Incentives
• Rural Doctor Society (RDS) established in
1975 - self-help/advocacy civil society.
• Bi-monthly rural doctor newsletters and
journals published.
• Annual best rural doctor award by the
oldest medical school since 1976.
• Hardship award by the RDS since 1982.
• Career development - doctor in rural
hospital can be promoted to the level of
director of a division or deputy DG.
Dr.Suwit
12
Trade inFinancial services
and internal brain-drain
• 1992 - 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
13
Economic crisis (1997-now)
Bankruptcy of private hospitals-NPL
 Reverse brain drain/H. systems reforms
 New businesses - promotion of mode2

Regular/Package services
 Dental/dentures services
 Health tour/long-stay


More FDI (mode3) on private hospitals
Dr.Suwit
14
Private doctors and beds in Thailand (1970-2000)
Beds
Doctors
45,000
4,500
40,000
4,000
Beds
Doctors
35,000
3,500
BIBF
30,000
3,000
FDI
Econ.
Boom
25,000
20,000
2,500
2,000
15,000
1,500
10,000
1,000
5,000
500
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
Dr.Suwit
0
1970
0
Year
15
Inequitable distribution of doctor (1977-2001)
25
25
Doctors/100 Bed
20
Econ.
crisis
BIBF
20
17.1 17.8
14.0
14.0 13.4
15
13.713.8
12.4
12.2
12.3
11.8
11.110.5
10.810.7
11.5
10.9
9.7
11.4 10.4 10.9
10
10.5 10.2
9.4 9.2
9.3
8.6 8.9
8.5 8.2
7.3 7.2
6.6
5
Doctors/100 Beds
15
10
5
Ratio of doctor density
Econ.
boom
21.3
Ratio of doctor density (BKK:NE)
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
Dr.Suwit
0
1977
0
Year
16
Conclusion
1. 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.
Dr.Suwit
17
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
18
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
Dr.Suwit
19