1. 1 The motivations, progress, and implications of Liberalisation of Trade in Health Services in the ASEAN context Cha-aim Pachanee Suwit Wibulpolprasert Ministry of Public Health, Thailand

2. 2 Interest of ASEAN countries on regional trade in health services ModeExportImport 1 cross border supply 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. 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. 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. 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. 6 Incoherent policies on universal coverage of health insurance and promotion of international trade in health services in Thailand Cha-aim Pachanee, Suwit Wibulpolprasert Health Policy and Planning. 2006; 21: 310-318.

7. 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. Year Visits / capita / yearPop. (million) Total visits (OP equiv.) that require MD (million) No. of additional MD Required OPIP Total In private sector 20012.84 (1) 0.076 (1) 62.0198.65 - 208.07 -- 20033.62 (1) 0.086 (1) 63.3247.50 -258.392,443 -2,795 1,002 - 1,146 20074.29 (2) 0.099 (2) 65.7302.10 - 315.151,596 -1,838 654 - 753 20115.16 (2) 0.113 (2) 68.2371.17 -386.661,639 - 1,889 672 - 775 20156.03 (2) 0.127 (2) 70.7445.59 -463.701,891 - 2,175 775 - 892

8. 8 Number of foreign patients entering Thailand by country, 2001-2003 Country / Region200120022003% of change 2001/2002 % of change 2002/2003 Japan118,170131,684162,90911.8828.81 USA49,25358,40285,29220.6143.88 UK36,77841,59974,85613.1179.95 Taiwan ROC26,89827,43846,6242.0369.92 Germany19,05718,92337,055-0.7095.62 IndochinaNA 36,708NA India20,31023,75235,52816.9549.56 Middle EastNA20,00434,704NA73.49 Bangladesh14,54723,80334,05163.6843.08 France15,10217,67925,5829.7944.70 Austria14,26516,47924,22815.5247.02 ScandinaviaNA 19,851NA South Korea14,41914,87719,5883.1731.67 CanadaNA 12,909NA Eastern EuropeNA 8,664NA Others32,036723,4460315,0186.4034.86 Total550,161630,000973,53214.5154.52

9. 9 (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 OPIP Total% of MD required in private sector % of MD required by the whole system 2003 1.26 (1) 0.0632.53109 - 131114 2007 2.45 - 2.62 (2) 0.122 - 0.1314.90 - 5.25115 - 16018 - 217 - 8 2011 4.14 - 4.75 (3) 0.207 - 0.2378.89 - 9.50159 - 24424 - 319 - 11 2015 6.06 - 7.48 (4) 0.303 -0.37312.13 - 14.95176 - 30323 - 349 - 12 Total visits (OPD equiv.) require MD (million)

10. 10 Projected Demand for MD by Foreign Patients in 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%433-69056-7719-24 14-16%234-38630-4311-15 10-12%115-20015-226-8

11. 11 Internal Brain Drain of Medical Doctors

12. 12 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. 13 Further Research Questions Growth of foreign patients Trend of health care seeking behaviours among Thai patients Workload of health personnel Consequences and effectiveness of incentive schemes provided to health personnel

14. 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