Human resources for health in southeast Asia: shortages, distributional challenges, and international trade in health services
Churnrurtai Kanchanachitra, Magnus Lindelow, Timothy Johnston, Piya Hanvoravongchai, Fely Marilyn Lorenzo, Nguyen Lan Huong, Siswanto Agus Wilopo, Jennifer Frances dela Rosa
Key messages
•Like other regions, many countries in southeast Asia suffer from problems in the health workforce related to shortages, skill mix imbalances, and maldistribution of skilled staff.
•Low-income countries face common problems of health-worker density and distribution due to low production capacity, restricted capacity for employment of graduates, and low pay in the public sector. But use of health services is also low, as a result of poor-quality services, financial barriers, and cultural factors. Because of the low quality of services and training, migration of health workers is not yet a major issue, but wealthy and middle-income patients often seek care elsewhere in the region.
•Health-worker density and production varies substantially among middle-income countries, but all face difficulties in attracting health workers to remote areas, because of fiscal constraints and inadequate financial and non-financial incentives for health workers.
•A distinctive feature of southeast Asia is its high level of engagement in international trade in health services, including migration of health workers and provision of services to international patients.
•Although international trade in health services is not the main cause of health-worker shortages or maldistribution in southeast Asia, it clearly affects health-worker production and employment patterns, particularly in middle-income and high-income countries.
•The rapid growth of export-oriented private training in the Philippines and Indonesia has mitigated the effect of migration on the total stock of health workers, but poor regulation of private training has compromised quality and contributed to overproduction of health workers with scarce employment prospects.
•Medical tourism has grown rapidly in Singapore, Thailand, and Malaysia, and has emerged as an important source of revenue. The effects of medical tourism on domestic health systems have been small so far, but are contributing to a brain drain of highly skilled specialists to private hospitals serving foreign patients.
•National policy coherence is needed to balance benefits gained from trade in health services, while maintaining the health of the population. This balance will require a combination of policies, including careful human-resource planning and strengthened oversight of private training institutions, improved quality and accreditation systems, public-partnership arrangements, and measures to improve retention and recruitment of staff in rural areas.
Trade in health services
An overview of trade in health services in southeast Asia
- 의료서비스의 Trade는 여러 동남아 국가에서 심각하며, 환자와 의료인력의 이동 둘 다를 포함하는 것임.
- 싱가폴, 말레이시아, 태국은 외국에서 환자를 끌어모으는 중요한 허브이며, 인도네시아와 필리핀은 의사와 간호사를 수출하는 허브이다.
- 캄보디아나 라오스와 같은 저소득 국가에서 의료인력의 이동은 언어 장벽이나 의사의 수준(qualification)을 밖에서 인정해주지 않는 문제 때문에 제한적이다. 그러나 이 지역의 다른 중소득 국가와 마찬가지로 환자가 외국으로 나가는 경우는 많다.
- 이렇게 해외로 의료서비스를 받기 위해 나가는 인구들은 대부분이 잘 사는 사람들로서, 그 지역에서 받기 힘든 의료서비스나 더 양질의 의료서비스를 받기 위해서 외국으로 가는 것이지만, 해외로 나가는 환자들 중 저소득층 인구도 많이 있다.
Trade in health services is substantial in many southeast Asian countries, and includes international movement of both patients and health workers.31 Singapore, Malaysia, and Thailand are important medical hubs, attracting patients from within and outside the region, whereas Indonesia and the Philippines export many doctors and nurses. In low-income countries such as Cambodia and Laos, movement of health workers is limited by language barriers and qualifications that are not recognised outside the respective countries; however, similarly to many of the middle-income countries in the region, there is a substantial flow of patients to facilities abroad. Although this flow consists mainly of better-off individuals who travel abroad for services that are either unavailable locally or are perceived to be of better quality, many patients from low-income segments of the population cross the borders from Laos, Cambodia, and Myanmar to access services in Thailand and Vietnam, or to use services as registered or unregistered migrants.
아래의 표는 다양한 형태의 의료서비스교환(trade in health service)를 보여주고 있다.
Table 3 shows countries' engagement in different modes of trade in health services.25 and 32 These modes are:
(1) cross-border trade (telemedicine and medical transcription);
(2) consumption abroad (movement of foreign patients);
(3) commercial presence (foreign direct investment); and
(4) temporary movement of natural persons (migration of human resources for health).
이 보고서에서는 환자의 이동, 그리고 의료인력의 이동에 초점을 맞춰서 보고자 한다.
In this report we focus on the two modes of trade in health services in which countries in the region are actively engaged—movement of patients (mode 2) and movement of health workers (mode 4). Engagement of the southeast Asian region in mode 1 (cross-border supply) and mode 3 (foreign direct investment) remains limited. One example of mode 1 trade is the export of medical transcription services from the Philippines to the USA. In terms of foreign direct investment in the region, only 1% of total hospital beds in Indonesia are foreign owned, and 3% of total investment in private hospitals in Thailand is by foreign agencies.32
의사 인력과 간호사 인력의 유출
Export of doctors and nurses
필리핀과 인도네시아의 많은 의료인력이 동남아 다른 국가 또는 세계 여러 국가로 이동해간다. 말레이시아 역시 싱가폴, 중동, OECD국가로의 의료인력의 유출을 겪고 있으나, 말레이시아와 싱가폴은 동남아시아의 주요 유입국이기도 하다.
Many health workers from the Philippines and Indonesia migrate to countries within southeast Asia and to the rest of the world. Malaysia also experiences outmigration of health workers to Singapore, the Middle East, and OECD countries. However, Malaysia and Singapore are also popular destinations for health workers in southeast Asia.
2000년 기준으로 110,774명의 필리핀 간호사가 OECD국가에서 근무하고 있는 것으로 확인되며, 전체적으로는 163,756명의 필리핀 간호사가 해외에서 근무하고 있다. 매년 나가는 필리핀 간호사는 2000년대에 약 7600명이었으나 2009년에는 13000명으로 증가하였다. 사우디, 미국, 영국, 아랍에미레이트 등이 주요 이민 국가이다. 이러한 이주의 원인에는 임금 격차가 주로 작동한다.
About 110 774 Filipino nurses were estimated to work in OECD countries in 2000 (table 4).43 and 44 In total, an estimated 163 756 Filipino nurses were working abroad in 2000.45 The number of Filipino nurses who migrate annually (to all destinations) increased from 7683 in 2000, to 13 014 in 2009,46 with Saudi Arabia, the USA, the UK, and the United Arab Emirates being the top destinations (figure 4). Migration is in large part driven by the substantial wage premium associated with overseas employment—a nurse in Manila earns US$58–115 per month, compared with $5000 a month in the UK or USA.47
두 가지 종류의 의료인력 이주가 있는데, 임시이주는 시간이 제한된 work visa를 통해 나가는 것으로 주로 중동이나 ASEAN국가에서 관찰된다. 반대로 영구이주는 이런 work contract를 따르지 않는 것으로 1990년대 초반에 필리핀 간호사의 영구이주가 비자조건이 완화되면서 심해졌다. 이러한 두 가지 이주 형태가 갖는 함의는 서로 다른데, 임시이주는 결국 본국으로 돌아올 것이고 본국으로 돈을 송금하는 경우도 더 많다.
There are two types of health-worker migration. Temporary migration refers to health workers who have time-restricted or contract work visas as are often seen in Middle Eastern and ASEAN countries. Conversely, permanent migration refers to those whose stay in destination countries does not depend on work contracts. In the early 1990s, permanent migration of Filipino nurses was driven by relaxation of resident visa requirements, particularly in the USA and the UK. Temporary and permanent migration have differing implications for the health system, since temporary migrants are more likely to return to work in their home country and to send remittances to family than are permanent migrants.
해외로 이민을 가는 것의 한 가지 장점은 본국으로 송금하는 것인데, 이러한 송금을 통해서 본국에 있는 가족의 경재 상태를 향상시킬 수 있고, 지역 경제에도 긍정적 효과가 있다. 그러나 이주가 갖는 부정적 측면을 보면, 예를 들면 필리핀에서 미국으로 나가는 간호사의 수요가 늘어나면서 필리핀 의사가 간호사가 되기 위해서 다시 수련을 받는 경우가 생기고 있다. 2001년과 2003년에 각각 2000명, 3000명의 의사가 nurse medic으로서 재수련을 받았다.
One of the potential benefits of migration of health workers are the remittances sent home by migrants to their families. Such income can improve the economic status of migrant families while also having a positive effect on the local economy.48 But migration also has potential downsides. For instance, the recent upsurge in the demand for nurses abroad and opportunities for permanent emigration to the USA resulted in Filipino doctors retraining as nurses in order to seek overseas employment as nurses.48 Roughly 2000 and 3000 doctors in 2001 and 2003 were retrained as so-called nurse medics.48 These nurse medics sought to take advantage of opportunities open to nurse migrants.
필리핀의 이러한 경험은 국제적 수요와 국내 수요-공급의 복잡한 관계를 보여준다. 2009년의 세계 경제 위기로 인해서 해외로 이주하는 간호사의 수요가 줄었다. 간호사들은 해외로 지원하기 전에 주로 병원에서 2~3년간 근무를 해야 하기 때문에 이 시기가 병목구간으로 작용했다.
The experience in the Philippines illustrates the complex interactions between global demand and domestic supply and demand. By 2009, the global recession had led to a drop in international demand for migration of nursing staff (including sharp reductions in work visas for entry into the USA), even as nursing schools continued to produce new graduates. Nurses are typically required to have a licence as well as 2–3 years' experience in a referral hospital before they can apply for overseas employment visas, and this requirement has emerged as a major bottleneck.
필리핀 간호사 수출
In 2008, the Philippines Overseas Employment Administration reportedly had 20 000 unfilled job orders for nurses to the Middle East, Singapore, and Europe.49 Thus, whereas some hospitals in the Philippines have reportedly had to close wards because of loss of experienced staff and sometimes entire teams, other hospitals have a backlog of junior nurses seeking internships. A survey of 200 public and private hospitals found that administrators had little difficulty recruiting nurses with less than a year's experience, but had more difficulty recruiting experienced nurses, particularly in private hospitals, which offered lower wages on average than did public hospitals.50 The Philippines is thus hampered by its low capability to employ the new nurses it has produced, and is now in surplus.
인도네시아 역시 많은 간호사를 수출하고 있다. 경험 많은 간호사와 조산사의 유출 문제가 심각하다.
Indonesia also exports many nurses. Muslim countries such as Saudi Arabia, the United Arab Emirates, Malaysia, and Singapore are the main destinations. Few data are available, however, either for migration or employment in the domestic private sector. With lower health-worker production capacity per population than that of the Philippines, outmigration of experienced and highly skilled nursing and midwife staff creates great challenges for the system, and exacerbates the problems of shortage and quality of care in the Indonesian health system.32
싱가폴은 동남아시아의 주요 의사 수입국이다. 2009년에는 1000명의 외국 의사를 모집하는 것을 목표로 삼았고, 보건부에서는 싱가폴로 이민왔을 때의 혜택을 광고하고 있다. 최근의 통계를 보면 2/3의 싱가폴 의사, 그리고 공공부문의 1/3정도 의사가 외국에서 교육받은 의사이다. 싱가폴은 또한 간호사도 외국에서 수입하고 있다.
Singapore is the major importer of doctors in southeast Asia. In 2009, a recruiting target was set of up to 1000 foreign trained doctors. The Ministry of Health has a webpage to advertise the benefits of migration to Singapore. Recent statistics show that two-thirds of doctors in the country and a third of doctors in the public sector are foreign-educated (including those Singaporean doctors who trained abroad).14 Singapore also imports nurses from other countries—an estimated 30% of all nurses working in the country are foreigners.
최근 여러 국가들이 bilateral 혹은 multilateral agreement를 맺는 경우가 많아서, 영국과 필리핀이 2002년부터 2006년까지 225명의 간호사에 대한 계약을 맺었고, 일본과 캐나다도 필리핀과 인도네시아와 계약을 맺었다.
Recent years have seen a tendency for recruitment patterns to shift from individual applications or institution recruitment to bilateral and multilateral formal agreements between origin and destination governments. For instance, the Philippines and Indonesia have entered into bilateral agreements with several countries. The UK–Philippines agreement, signed in 2002, resulted in the recruitment of 225 experienced Filipino nurses from 2002 to 2006. The agreement came to a close in 2006, when the UK declared that nurse shortage was no longer a concern.51 Japan and Canada also entered into agreements with the Philippines and Indonesia to provide skilled nurses.
the ASEAN Framework Agreement on Services
At the regional level, the ASEAN Framework Agreement on Services, signed in 1995, progressively liberalises trade in services, with health being one of the 11 priority sectors. In 2001, members began negotiating mutual recognition arrangements to facilitate flow of professionals, as agreed by the Framework Agreement, with the expectation of achieving free flow of health workers by 2010. The agreements call for mutual recognition of qualifications and professional licences across ASEAN countries. A mutual recognition arrangement on nursing services was signed in 2006, followed by an agreement for medical practitioners in 2008. The diversity of the ASEAN region, including differences in the quality of education and training, licensing requirements, language, and cultural dimensions of daily medical practices between countries, makes implementation of these agreements challenging.15 These barriers, as well as additional requirements of 3 years of work experience for nurses and 5 years for doctors, have posed difficulties for the free flow of health professionals in southeast Asia.
Discussion
다섯 개 ASEAN국가는 WHO의 기준에 미달하고 있다. 태국과 말레이시아는 경제수준에 비추어 의료인력 밀도가 낮으며, 필리핀과 싱가폴, 브루나이는 밀도가 높다.
Southeast Asian countries face diverse health workforce challenges. Although there is not an aggregate shortage of health workers at the regional level, five countries in the ASEAN region (Indonesia, Vietnam, Laos, Cambodia, and Myanmar) fall below the WHO threshold of 2·28 doctors, nurses, and midwives per 1000 population. Thailand and Malaysia have low densities of health workers in view of their level of economic development, whereas the Philippines, Singapore, and Brunei have high densities.
국제 기준에 비교를 하지 않더라도, 이 지역의 국가들은 qualified and motivated 의료인력을 더 양성해야 할 압박을 받고 있다. 그러나 많은 동남아 국가에서 경제적 능력이 공공부분 인력고용 확장의 한계로 작용하고 있고, 졸업한 의사와 간호사가 일자리를 찾지 못하고 있다. 따라서 의료인력의 양성과 배치의 연계를 효과적, 계획적으로 하는 것이 중요하다.
Irrespective of how health-worker density relates to international norms, most countries in the region face pressures to increase the availability of qualified and motivated health workers in order to meet the needs of the population. Increased production of health workers clearly has an important part to play in addressing this challenge. However, in many southeast Asian countries, fiscal capacity restricts the scope for expansion of public-sector employment, and many graduating doctors and nurses are not able to find jobs in the health sector. This problem points to the need to strengthen the link between production and use or deployment of trained workers through health workforce planning and effective engagement (and regulation) of medical education providers.
이러한 인력부족에 대응하는 한 가지 방법은 일부 임상기능을 더 낮은 레벨의 인력에게 맡기는 것이다. 이는 taskshifting이라 불리는 것으로, 비용-효과적인 방법이며 이를 통해서 지역사회 수준 의료인력에 대한 의존을 높일 수 있기도 하다.
One approach to improving the availability of staff with limited resources is to shift some clinical functions and other responsibilities to lower level staff. This process—often referred to as taskshifting or substitution—has been found to be a cost-effective solution to increase access to services in various settings, although the evidence from middle-income countries is scarce.52, 53 and 54 Taskshifting can also entail increased reliance on community-level workers, such as the community midwives that are widely deployed in Myanmar, which might be particularly helpful in contexts with underuse of facility-based services.
그러나 의료인력의 밀도가 높아졌다고 해서, 의료서비스 공급가능성으로 이어지는 것은 아니며, 이는 특히 빈곤층이나 농촌 지역 인구에서 심하다. 많은 국가들이 배치와 유지의 문제를 안고 있으며, 공공부문에서 그러한 문제가 더 심하다. 몇몇 국가에서는 이러한 문제를 일부 해결하는데 성공한 바 있으나, 여전히 이러한 문제는 심각하다. 또한 이러한 경우에 한 가지 접근법만을 사용하는 것 보다 여러 접근법을 동시에 활용하는 것이 좋은 것으로 알려져 있다.
However, a high health workforce density does not necessarily translate into improved availability of services, in particular for poor and rural populations. As elsewhere in the world, many countries in southeast Asia face persistent challenges in deployment (and retention) of doctors, nurses, and midwives to rural and remote areas, resulting in a high degree of inequality in the distribution of the health workforce (particularly doctors) across provinces and regions. Many countries are also having difficulty retaining staff in the public sector, with potentially adverse implications for the availability of services for the poor and near-poor populations, who tend to be less likely to use private formal providers. Some countries in the region have had success in addressing these challenges (panel 2), but imbalances remain substantial. Although there are significant gaps in the evidence base with respect to how best to address these imbalances, there is growing consensus on the mix of approaches that countries should consider to improve deployment and retention.59 and 60 Experiences in specific countries show that comprehensive strategies are more effective than a single approach (panel 2). However, countries need to be able to respond to changing situations to ensure sustainable outcomes.
Panel 2.
Experiences of coping with shortage, maldistribution, and retention of health workers in southeast Asia
In reponse to a shortage of midwives in Cambodia, the government established in 2003 a 1-year primary midwife programme, recruiting local students with grade 7 education. The programme was scaled up nationwide in 2005, including recruitment of grade 10 students to improve quality. The government's goal of one primary midwife in each health centre was achieved in 2009. In Laos, a low-grade auxiliary nurse training programme was implemented between 1960 and 2002, after which a 3-year nursing and midwifery programme was adopted to ensure standards. These programmes have increased access to midwives in rural areas, but recent midwifery assessments concluded that most of these midwives lacked basic lifesaving skills.20 Both Cambodia and Laos have introduced Health Equity Funds to increase access for poor patients and to generate additional revenue for health workers. Cambodia also piloted performance-based contracting through non-governmental organisations, which improved availability of health workers and reduced absenteeism.
Myanmar linked licensing of medical doctors with rural area practice. Nurses are obliged to work for the public sector for 3 years, otherwise their licences to practise will be withdrawn.55 Compulsory rural practice has a short-term effect, however, so other measures were introduced in parallel, including financial and non-financial incentives such as social recognition and career advancement.56
Vietnam requires 4 additional years of training for existing assistant doctors in health centres at commune level to qualify as a medical doctor. Additionally, Vietnam increased student recruitment from local areas and for ethnic minorities in disadvantaged isolated communities (without entrance examination requirements), improved collaboration between local hospitals and medical schools to accelerate in-service training, expanded the 4-year community doctor training programme for grassroots-level staff, and rotated high-level staff to work in low-level facilities.
Thailand responded with integrated approaches for rural retention, including recruitment of local students, local training, and home-town placement of nurses and doctors. Mandatory government bonding was initiated in the 1970s, and both financial and non-financial incentives or motivation were subsequently provided for doctors in rural practice.57 This measure reduced the gap in density of doctors between the poorest northeast region and Bangkok from 21 times in 1979 to 9·4 times in 2000. Despite these efforts, retention of doctors in rural areas beyond the bonding period is difficult—impeding factors include preferences among physicians for urban practice and specialisation training.58
의료인력의 밀도가 낮다는 것이 인구보건요구를 달성하는데 유일한 제한사항은 아니다. 이런 동남아 국가에서 의료서비스의 이용 자체가 낮은데, 의료인력이 부족한 것이 한 가지 이유일 수는 있지만, 서비스의 질이 낮은 것, 경제적 장벽, 그 외 다른 요인들도 중요하다.
Of course, low health workforce density is by no means the only constraint to meeting population health needs. In many of the low-income countries in southeast Asia with low health-worker density (critical shortage), use of health services is often also low. Scarcity of human resources is one factor in this situation, but poor-quality services, financial barriers, and other factors might be more important. Hence, efforts to expand the health workforce in these contexts need to go hand-in-hand with complementary measures to reduce financial and other barriers to service use.
We have also drawn attention to the growing trade in health services, and the significance that this trade has for health systems and policies for human resources for health in the ASEAN region. High-income and middle-income countries are participating more actively in this trade than are those with low incomes, with flows of both patients and health workers. Indonesia and the Philippines both export many doctors and nurses, although from very different starting points in terms of the organisation of medical education and training. Thailand and Malaysia are actively involved in provision of health services to foreign patients, but have little involvement in the export of health personnel. Singapore and Brunei are the main importers of foreign health workers, and Singapore is also engaged in medical tourism. Conversely, low-income countries in the region (Cambodia, Laos, Myanmar, and Vietnam) are not engaged extensively in the trade in health services, except with respect to wealthier patients seeking care in middle-income and high-income countries.
- Trade는 점차 늘어날 것으로 예상됨.
Trade in health services is likely to continue to grow. Many countries are actively promoting medical tourism. For instance, the Thai Government is promoting Thailand as a major medical hub in Asia as part of an effort to expand and diversify exports. Moreover, the ongoing process of regional (ASEAN) integration, which has already led to mutual recognition arrangements for three groups of health professionals (doctors, nurses, and dental practitioners) and other measures to facilitate the movement of labour, is likely to result in increased movements of human resources for health within the region. However, in practice, language skills and technical competence will remain key criteria for potential employers, so the freedom to move will not necessarily translate into employment opportunities for health workers, in particular those from low-income countries.
- Medical Tourism이 장점도 있을 수 있으나
Medical tourism and remittances from overseas workers can generate substantial economic benefits,
and potentially generate broader benefits for patients and health workers through investments in facilities and health-worker training, increased competition, and strengthened accreditation and quality standards.
- 그러나 단점도 많음. : 의료인력 양성과 고용 패턴에 영향을 주며, 불평등을 심화시키고, 두뇌유츨이 생기고, 첨단 기술이 도입되는 것은 지속가능하지 않음
But these benefits are by no means automatic, and trade in health services also has many potential downsides.
Although the evidence suggests that trade in health services is not the main driving force behind health-worker shortages or maldistribution in the ASEAN region, this trade clearly affects health-worker production and employment patterns, particularly in middle-income and high-income countries. Migration can deplete the domestic stock of health workers, particularly specialist doctors and experienced nurses, with effects on the quality and availability of services. Similarly, medical tourism can exacerbate inequalities in access to health care because of a brain drain of highly skilled health professionals from public to private hospitals and from rural to urban areas.37 Medical tourism can also lead to a rapid expansion of high-end, technology-intensive health care, which might not be sustainable over time and can distort practices and priorities in the broader health system.
- Trade에 대해 가능한 대책들 : Codes of practice(본질적으로 자발적임), Bilateral agreement
Although the growing trade in health services is clearly an important policy challenge for countries in the region, how countries should respond to this challenge is less clear. What can countries do to maximise benefits from the trade in health services? Can the risks be mitigated or managed? How should benefits, risks, and the interests of sending and receiving countries be balanced? So far, the evidence base to answer these questions is weak, in part because the way in which trade in health services affects health systems is highly context-specific. With respect to movement of health workers, banning of migration is widely recognised as neither possible nor ethical.61 One route to addressing this challenge has therefore been to establish codes of practice for the international recruitment of health personnel.
One such code of practice was adopted by the 2010 World Health Assembly, which aims to lay down principles for ethical recruitment of health personnel to maximise benefits and mitigate negative effects on countries while maintaining the rights of migrant health personnel.62
However, the code is voluntary in nature, and in view of the complexity of migration as an international occurrence, its implementation will inevitably be challenging.
Another route to address the challenge of migration is through bilateral agreements covering agreed numbers of migrants, but potentially also allowing for technical assistance and capacity building—measures that should allow the return of migrants to their home countries to train and to teach, provide compensation where necessary, and forge partnerships between hospitals from sending and receiving countries.63 Experiences from other regions suggest positive results.
For example, the UK and South Africa signed a memorandum of understanding in 2003 that established time-limited placements between countries and a framework for ethical recruitment of health personnel. This memorandum has resulted in a decrease in the number of South African nurses and midwives working in the UK, and the twinning policy has improved quality of health personnel in South Africa.63
- Medical Tourism에 대해 가능한 대책들 - Trade보다는 경험이 적음
So far, there has been less experience with similar measures implemented to balance the benefits and risks associated with medical tourism—for example, through local agreements, agreements between the public sector and providers or associations engaged in the provision of services for international patients, or codes of good practice. Such measures could have potential, in particular if accompanied by strengthening of quality and accreditation throughout the health system, to stimulate transfer of capacity and good practice from private providers through partnerships with medical education institutions, and to reallocate benefits from trade in health services to public sectors, especially to rural areas that might have been affected by internal brain drain.
More generally, the effects of trade in health services on health systems hinge on how the supply of health workers responds to a growth in migration and medical tourism. The supply of health workers, in turn, depends on how the health education system is organised and regulated. Countries in southeast Asia offer very different models in this respect. The rapid growth of export-oriented private training in the Philippines and Indonesia has mitigated the effect of migration on the total stock of health workers, but poor regulation of private training has compromised quality and contributed to overproduction of health workers with scarce employment prospects. Thailand on the other hand has no policy of training for the purposes of working abroad, and the private sector plays a very small part. Strong oversight is needed to ensure quality and to regulate output in the Philippines and Indonesia, whereas training policies especially for highly specialised staff in Thailand might need to take into consideration the projected growth of medical tourism.
Human resources for health in southeast Asia: shortages, distributional challenges, and international trade inhealth services.
Abstract
In this paper, we address the issues of shortage and maldistribution of health personnel in southeast Asia in the context of the international trade inhealth services. Although there is no shortage of health workers in the region overall, when analysed separately, five low-income countries have some deficit. All countries in southeast Asia face problems of maldistribution of health workers, and rural areas are often understaffed. Despite a high capacity for medical and nursing training in both public and private facilities, there is weak coordination between production of health workers and capacity for employment. Regional experiences and policy responses to address these challenges can be used to inform future policy in the region and elsewhere. A distinctive feature of southeast Asia is its engagement in international trade in health services. Singapore and Malaysia importhealth workers to meet domestic demand and to provide services to international patients. Thailand attracts many foreign patients for health services. This situation has resulted in the so-called brain drain of highly specialised staff from public medical schools to the private hospitals. The Philippines and Indonesia are the main exporters of doctors and nurses in the region. Agreements about mutual recognition of professional qualifications for three groups of health workers under the Association of Southeast Asian Nations Framework Agreement on Services could result in increased movement within the region in the future. To ensure that vital human resources for health are available to meet the needs of the populations that they serve, migration management and retention strategies need to be integrated into ongoing efforts to strengthen health systems in southeast Asia. There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in healthservices with domestic health needs and equity issues.
Copyright © 2011 Elsevier Ltd. All rights reserved.
Comment in
- Mental health in southeast Asia. [Lancet. 2011]
Comment on
- Southeast Asia: an emerging focus for global health. [Lancet. 2011]
- Challenges in infection in ASEAN. [Lancet. 2011]
- Health in southeast Asia. [Lancet. 2011]
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