1

The motivations, progress, and implications of Liberalisation of

Trade in Health Services in the A SEAN context

Cha-aim PachaneeSuwit Wibulpolprasert

Ministry of Public Health, Thailand

2

Interest of ASEAN countries on regional trade in health

services

Mode Export Import

1 cross border supply

No real interest No real interest

2 consumption abroad

Singapore, Malaysia,Thailand

Indonesia, Cambodia, Laos, Brunei, Myanmar, Brunei

3 commercial presence

Singapore, Malaysia, Thailand

Thailand, Indonesia, Philippines, Vietnam, Laos, Cambodia, Myanmar

4 movement of natural person

Philippines, Indonesia

Singapore, Brunei, Thailand

3

Countries that export health professionals

The Philippines, Indonesia: countries can absorb only 30 percent of health graduate professions

Nurses from these countries are found working in the UK, US, Middle East

9,000 of Philippino doctors attend nursing school, 3000 have been exported, 3000 in the process, 3000 in training.

Indonesia produces 40,000 nurses per year and can absorb only 5,000. The MoH established the Centre for Empowering of Profession and HRH for Foreign Countries to facilitate nursing export

Want to liberalise Mode 4 to facilitate movement of health personnel

4

MRAs in health services within ASEAN

MRAs focus on nursing and medical professionals Final draft of MRAs on nursing has been agreed among

negotiators Not real MRA, more hurdles e.g. require 3 years of practices

(currently not required) and have to conform with local regulations

Several barrier limiting MRA:• Different education standards and programmes• Different in the scope of nursing practice• Level of entry into nursing programme• Level of standardized nursing definitions• Continuing competence • Regulatory system and licensing of practice• Language barriers• Cultural sensitivities

Negotiators are from professional council and very conservative

5

Mode 2 - revenue from foreign patients / a dual market structure / severe maldistribution of health resources / create internal brain drain & widened gap of salary.

Mode 3 - a tiered healthcare system and increasing inequality of services between urban and rural hospitals

Mode 4 - brain drain can constraint the development of the national healthcare system.

change the provider-patient relationship from patron-client to contractual relationship.

foreign professionals can create oversupply and competition with local professionals.

The possible impacts of liberalization of health related services under AFAS

6

Incoherent policies on universal coverage of health insurance and promotion of international trade in health

services in Thailand

Cha-aim Pachanee, Suwit WibulpolprasertHealth Policy and Planning. 2006; 21: 310-318.

7

Projected Demand for Medical Doctors by Thai

patients

(1) Data from Health and Welfare Survey by National Statistical Office (2) Projecting rate of future increase in Outpatient (OP) and In-patient (IP) visits by using average rate in the previous three biennial periods giving equal weight to each period.

YearVisits / capita /

year Pop. (million)

Total visits (OP equiv.)

that require MD (million)

No. of additional MD Required

OP IP Total In private sector

2001 2.84(1) 0.076(1) 62.0 198.65 - 208.07 - -

2003 3.62(1) 0.086(1) 63.3 247.50 -258.39 2,443 -

2,795

1,002 -

1,146

2007 4.29(2) 0.099(2) 65.7 302.10 - 315.15 1,596 -

1,838 654 - 753

2011 5.16(2) 0.113(2) 68.2 371.17 -386.66 1,639 -

1,889 672 - 775

2015 6.03(2) 0.127(2) 70.7 445.59 -463.70 1,891 -

2,175 775 - 892

8

Number of foreign patients entering Thailand by country, 2001-2003

Country / Region 2001 2002 2003 % of change 2001/2002

% of change 2002/2003

Japan 118,170 131,684 162,909 11.88 28.81

USA 49,253 58,402 85,292 20.61 43.88

UK 36,778 41,599 74,856 13.11 79.95

Taiwan ROC 26,898 27,438 46,624 2.03 69.92

Germany 19,057 18,923 37,055 -0.70 95.62

Indochina NA NA 36,708 NA NA

India 20,310 23,752 35,528 16.95 49.56

Middle East NA 20,004 34,704 NA 73.49

Bangladesh 14,547 23,803 34,051 63.68 43.08

France 15,102 17,679 25,582 9.79 44.70

Austria 14,265 16,479 24,228 15.52 47.02

Scandinavia NA NA 19,851 NA NA

South Korea 14,419 14,877 19,588 3.17 31.67

Canada NA NA 12,909 NA NA

Eastern Europe NA NA 8,664 NA NA

Others 32,0367 23,4460 315,018 6.40 34.86

Total 550,161 630,000 973,532 14.51 54.52

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(1) Figure from the survey by Ministry of Commerce plus 30 percent of the under-surveyed. (2) Estimation with the assumption of increase at the rate of 18-20 percent per year (3) Estimation with the assumption of increase at the rate of 14-16 percent per year (4) Estimation with the assumption of increase at the rate of 10-12 percent per year

Conditions for projection:1. IP visit is equal to 5 percent of OP visits and 20 times of OP workload

2. Every patient requires medical doctor 3. One medical doctor provides services to 10,000 – 12,000 OPD visits / year

Projected Demand for Medical Doctors by foreign

patients

Year

Foreign patient visits (million)

Additional MD required by foreign patients

OP IPTotal % of MD req

uired in private sect

or

% of MD requ ired by the w hole system

2003

1.26(1) 0.063 2.53

109 -

131 11 4

2007 2.45 -

2.62(2)

0.122 -

0.131 4.90 - 5.25

115 -

160 18 - 21 7 - 8

2011 4.14 -

4.75(3)

0.207 -

0.237 8.89 - 9.50

159 -

244 24 - 31 9 - 11

2015 6.06 -

7.48(4)

0.303 -

0.373

12.13 -

14.95

176 -

303 23 - 34 9 - 12

Total visits (OPD

equiv.) require MD

(million)

10

Projected Demand for MD by Foreign Patientsin 2015

based on success of the International Trade Policy

% of Increase of Foreign Patients

Additional MD required (2015)

% of the private sector

% of the whole system

18-20% 433-690 56-77 19-24

14-16% 234-386 30-43 11-15

10-12% 115-200 15-22 6-8

11

Internal Brain

Drain

of Medical Doctors

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1. Supply Side Interventions Increase production of medical graduates Import of foreign medical doctors Hiring of retired medical doctors Compulsory public services Provision of financial & non-financial

incentives

Responses from Thai Government

2. Demand Side Interventions Health promotion campaigns

Promotion of primary care

13

Further Research Questions

• Growth of foreign patients

• Trend of health care seekingbehaviours among Thai patients

• Workload of health personnel

• Consequences and effectiveness of incentive s chemes provided to health

personnel

14

Recommendations

Strengthened national health care systems, including primary care system, coverage of health insurance particularly for the poor and underprivileged

Strengthen regulations of private health services and educational facilities eg. premise control, professional practice, quality assurance

Building research capacity to monitor consequences of trade liberalisation

Learning from the experiences of other regional trade agreements, e.g. the EU, the Caribbean