1 the motivations, progress, and implications of liberalisation of trade in health services in the...
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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
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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
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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
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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
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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
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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.
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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
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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)
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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
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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
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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
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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