Global Social Policy http://gsp.sagepub.comAddressing the Internal Brain Drain of Medical Doctors in Thailand: TheStory and Lesson Learned Suwit Wibulpolprasert and Cha-Aim Pachanee 2008; 8; 12 Global Social PolicyDOI: 10.1177/14680181080080010104 The online version of this article can be found at:http://gsp.sagepub.com Published by:http://www.sagepublications.com can be found at:Global Social Policy Additional services and information for http://gsp.sagepub.com/cgi/alerts Email Alerts: http://gsp.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: Downloaded from http://gsp.sagepub.com at Australian National University on March 17, 2008 © 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. 12Global Social Policy 8(1)Addressing the Internal Brain Drain of MedicalDoctors in Thailand: The Story and Lesson LearnedSUWIT WIBULPOLPRASERT AND CHA-AIM PACHANEEMinistry of Public Health, ThailandThailand is a lower middle-income country in Southeast Asia. Its publicly ledhealth care system has long been suffering from a problem of inequitable distri-bution of qualified health professionals. The main cause is the increasing demandfor health care services in urban private hospitals aggravated, in the past decade,by the aggressive export of health services. In 2006, there was an estimated 2mforeign patients, with annual growth of 10–20%. Increasing demands from theseforeign patients result in increasing demands for health professionals in the pri-vate sector, especially highly qualified medical doctors and nurses. In 2004–5,more than 350 highly qualified doctors left the public sector, mainly from themedical school hospitals, to join private hospitals. In addition, most public med-ical doctors also practise in the private hospitals during non-official hours. The‘internal brain drain’ of health professionals, from rural public health facilities tourban private health facilities, due to this ‘medical tourism’ has aggravated thelong-term problem of inequitable distribution of health professions. However, itis not the main cause of inequity as it is estimated that additional demand for med-ical doctors in the private sector, due to an increase in number of foreign patients,will account for 23–34% of total private medical doctors or a mere 9–12% of alldoctors in the country, in 2015.In Thailand, the public sector, notably the Ministry of Public Health, is themain provider of health services and owns the majority of health resources,including health professionals. However, well-trained professionals, espe-cially doctors, concentrate their services more in the richer urban areas whilepara-professional health workers serve in poorer rural facilities. In 2005, thedoctor:population ratio in the poorest Northeastern region was 1:7015. Thisis a concentration of almost 10 times less compared with 1:7867 in the capitalcity, Bangkok. This situation was improved from the 21 times disparity inearly 1970s, but was worse than the 8 times disparity of the mid-1980s.Income gap among private and public health professionals is one of the fac-tors contributing to the inequitable distribution. A study found that the gap ofincomes between the private and the public health personnel is highest amongdoctors, up to 6–11 times in 1997, and the situation remains unchanged.Particularly, those that serve foreign patients tend to have higher income.Compared with other developing countries, especially those in Africa,Thailand does not have the problem of ‘external brain drain’ of health profes-sionals. Favourable income, good working environment, opportunity for careerdevelopment, and limited capacity in foreign language are considered the majorcontributing factors that retain qualified health professionals in the country.In order to overcome the situation of inequitable distribution and ‘internalbrain drain’ of qualified health professionals and to retain them longer in theDownloaded from http://gsp.sagepub.com at Australian National University on March 17, 2008 © 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. GSP Forum13rural public sector, the government has implemented several supply anddemand side measures.On the supply side, programmes to increase the number of medical andother qualified health professional graduates, especially for the rural areas,have been approved and implemented. For example, a programme to recruit10,678 new medical students from 2005 to 2014 through the concept of ‘ruralrecruitment, local training and hometown placement’ is being implemented.Experiences in the past confirm that this strategy for training health profes-sionals encourages longer working duration in the public rural areas. Thisstrategy should be considered as a medium to long-term solution, as it takessix years to train a new medical doctor.In order to retain qualified health professionals in the rural public facilities,both financial and non-financial incentives have been implemented in addi-tion to the compulsory public services. The three year compulsory publicservice for all medical graduates, which has been enforced since 1967, was fur-ther lengthened to 12 years in 2005 for the special recruits from the rural dis-tricts. The penalty fine for breaching the contract was also increased fromUS$12,000 to US$60,000 for the same group of graduates.Several financial incentives have been employed including hardshipallowance (US$80–800 per month), non-private-practice allowance (US$300per month), overtime payment (US$400–500 per month), professional hono-rarium (US$150–300 per month) and non-office hour special interventionpayments (varies). These incentives are additions to the basic salary which isaround US$240 per month. With these financial benefits, a newly graduatedmedical doctor working in a remote rural area can earn a monthly income atthe amount equivalent to the salary of a Director-General of a central depart-ment of the Ministry. These incentives are also applied to other health pro-fessionals but to a lesser degree.Moreover, several non-financial measures are also being implemented, includ-ing improving working conditions, career development, continuous formal andinformal training, freedom of practice, fairness in management, and socialrecognition. Housing, transport and subsidized meals, as well as well-equipped and well-staffed facilities are the norm. Physicians, while still work-ing in rural district hospitals, have opportunities for career development toreach a post at a level equivalent to a Deputy Provincial Governor or DeputyDirector-General of a central department. A system of almost unlimitedopportunity for continuing education for medical doctors and public healthworkers is also available, through formal and informal training programmes.Besides this, there is social recognition, such as an annual award for out-standing health personnel, another measure implemented. In addition, fair-ness in promotion to higher career and transparency and accountability aswell as freedom of practice are also promoted and implemented.These measures, although varied, are only partially adequate in solving theinequitable distribution of qualified health professionals. They are implementedDownloaded from http://gsp.sagepub.com at Australian National University on March 17, 2008 © 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. 14Global Social Policy 8(1)in a reactive, piecemeal and fragmented manner, and some measures even counteract others. For example, the increased financial incentives that are appliedequally to newly, medical graduates allows them to save sufficient amount ofmoney within one year of public service to pay for the fine of breaching therequired three-year compulsory public work contract. Besides, the new publicsector reform policy, which does not allow employing new graduates as civil ser-vants but as temporary state employees, has influenced many new graduates tomove from the public sector. Furthermore, the long-term problem of socialinequity and inequity in distribution of wealth in the country also inevitablyreduce the effectiveness of the measures.In conclusion although ‘medical tourism’ aggravates the internal drain ofhealth professionals from rural public to the urban private health facilities, thebigger causes are the increasing demand for health care among the richerurban Thai population who has higher purchasing power, the social and wealthinequity, and the education systems of the qualified health professionals.Thailand has not had the problem of ‘external brain drain’ of health profes-sionals in the past three decades. Favourable income, good working condi-tions, career development, and limitation of foreign language capacity aremajor contributing factors to maintain them within the country.To solve the problems of internal brain drain and inequitable distributionof health professionals, the government has applied many financial andnon-financial incentives. These measures help alleviate the problem to acertain extent. However, due to the reactive, piecemeal and non-integratednature of the implementation, they are only partially effective. In addition,there are other external and difficult to control factors including publicsector reform and social and economic inequity which hinder their effec-tiveness.There is an urgent need for a comprehensive assessment of all the incen-tives and the measures used to solve internal brain drain and to formulatemore effective integrated measures.r e f e r e n c e sDepartment of Export Promotion (2005) Number of Foreign Patients Entering Thailandby Country, 2001–2004. Thailand: Ministry of Commerce.Pachanee, C. and Wibulpolprasert, S. (2006) ‘Incoherent Policies on UniversalCoverage of Health Insurance and Promotion of International Trade in HealthServices in Thailand’, Health Policy and Planning 21(4): 310–18.Wibulpolprasert, S.,Siasiriwattana, S., Ekachampaka, P., Wattanamano, N. andTaverat, R. (eds) (2007) Thailand Health Profile 2005–2007. Bangkok: Ministry ofPublic Health.SUWIT WIBULPOLPRASERT is Senior Advisor on Disease Control with the Ministry ofPublic Health, Thailand. Please address correspondence to: Dr Suwit Wibulpolprasert,5th Floor, Building 1, Office of the Permanent Secretary, Ministry of Public Health,Tiwanond Road, Nonthaburi 11000, Thailand. [email: firstname.lastname@example.org]Downloaded from http://gsp.sagepub.com at Australian National University on March 17, 2008 © 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. GSP Forum15CHA-AIM PACHANEE is a Policy and Plan Analyst with the Bureau of InternationalHealth, Ministry of Public Health, Thailand. Please address correspondence to: MsCha-aim Pachanee, Bureau of International Health, Tivanond Road, Nonthaburi 11000,Thailand. [email: email@example.com]Defending Worker and Community Rights in Addressing theGlobal Health Care Workforce CrisisG E N E V I E V E G E N C I A N O SPublic Services International, FranceThe World Health Organization (WHO) sounded the alarm bells when itreleased its 2006 World Health Report bringing attention to the state of theworld’s health workforce. The report revealed a global shortage of about4.3m health workers, with the crisis occurring at its most severe levels in theworld’s poorest countries, particularly in sub-Saharan Africa (WHO, 2006).This global shortage implies that virtually every country in the world is inneed of health workers. Yet it is the poorer countries that end up worse-offas more and more of their health professionals leave to work in higher-income countries. Various studies have been presented illustrating the severeimpacts of brain drain on communities, workers, and the overall state of thehealth care sector in developing countries. Such impacts seriously underminethe right of citizens to accessible and quality public health services in devel-oping countries. Achieving the Millennium Development Goal targets inhealth would be impossible when there are no health workers to carry outprimary health care programmes in underserved communities. Moreover,addressing the global fight to eradicate HIV/AIDS, tuberculosis, malaria andother global pandemics cannot be done without an available and motivatedhealth workforce.In its special chapter on health care worker migration, the Organisation forEconomic Co-operation and Development’s (OECD) International MigrationOutlook 2007 argues that migration is neither the main cause of, nor would itsreduction be the solution to, the global shortage of the health workforce(OECD, 2007). But it recognizes that migration exacerbates the acuteness ofthe problem in certain countries and that migration can be considered moreof a symptom than a determinant of the shortage.H E A LT H S E C T O R R E S T R U C T U R I N GMigration has both a consequential and direct link to the quality of publicservices. On the one hand, a degraded public sector deprives citizens ofessential services and exacerbates poverty, which is a known root cause ofmigration. On the other hand, structural adjustments, privatization and theDownloaded from http://gsp.sagepub.com at Australian National University on March 17, 2008 © 2008 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.