Four Decades of Integrated Attempts at Retention of Doctors in Rural Areas in Thailand

1. Four Decades of Integrated Attempts at Retention of Doctors in Rural Areas in Thailand Human Resource for Health Results (HR2) Conference Addis Ababa, Etiopia, May 11th 2009

2. Basic Information, 2008 Population: 65.3 millions Life expect. M/F 71.2 /75.0 years IMR: 20 per 1,000 LBs. MMR: 30 per 100,000 LBs. GDP/Capita US$ 3,200, 8,400 (ppp) Dr., nurse, HR/Population 1:2,000, 1:600, 6/1,000 Bed/Population 1:500

3. Rural Urban Community Hosp. (730) (10-120 beds) Health Centres (9,992) ( no medical doctors) Hospitals (<20) Clinics (1,200) Specialized Hosp. (32) General Hosp. (94) (150-1,000 beds) Health Centres (121) (with 2-4 M.D.)28 Public General Hosp. (416) Clinics (13,203) Private - Pluralistic Health Care Systems

4. FivePhases of HRH dynamics • External brain drain (1965-1975) – 25% M.D. • PHC/HFA-more equitable distribution (1976-1987) – rural devel n social campaign • Economic boom with internal brain drain (1988-1997) – mushrooming of private hosp • Economic crisis with reverse brain drain (1998- 2001) – bankruptcy of private hosp • Economic recovery with medical tourism and resumed internal brain drain (2002-2008)

5. External Brain Drain (1960-1975) • Increase demand in develop countries • Mainly to USA (~1,500 M.D. – 25% of all M.D>) • Initiate some remedies • 3 yrs. compulsory public works or US$ 12,000 fines • Increase production – rural recruitment • In-country specialty training • Financial incentives – hardship allowance • Social incentives – rural doctor awards, value

6. PHC/HFA and Rural Development with more equity (1976-1988) • Low and stagnant economic growth - small private for profit hospitals • Strong political commitment for equitable health system - PHC/HFA n shift of budget • Reorientation Of Medical Education (ROME) • Strong social movement - ‘Rural doctor society’ : ‘Dedicated Social Spirit’ • More equitable distribution of MDs

7. Budget (Billion Baht) Year Shift of Budget Allocation from Urban to Rural Health Facilities

9. Economic Boom and Internal brain drain (1990-1997) • Economic boom, 2 digits growth - with mushrooming of urban private hospitals and serious internal brain drain • Severe shortage of doctors in both urban and rural public hospitals – worsening distribution of doctors • Increased financial incentives - hardship, non official hours and non private practice allowance • Increased production or ‘rural doctors’, rural practice as conditions for specialty training

10. Economic crisis with reverse brain drain (1997-2001) • Bankruptcy of private hospitals-NPL • Reverse brain drain – better distribution • New businesses (International Trade) • Package services • Dental/dentures services • Foreign patients, longstays • More FDI on private hospitals

11. Recovery, UC and international trade - New threats since 2002 • Economic recovery - 4.5% in 2007 with increasing demand in private sector • Universal Health Coverage since 2002 increased demand in public sector • Medical travel - 2 mil foreign patients in 2008, increase >10%/yr – US$ 1,200 mil/yr • More female graduates n increase specialty training • Revitalization of private facilities - re-emerging internal brain drain – highly specialized

12. More remedies since 2002 • Capitation budget inclusive of salary • Further increase of production – rural district tract or ODOD • More financial incentives – income higher than the minister, PS, or DGs • More social incentives – >12 yrs rural practice can be promoted to PC 9, the level of a dep governor, DDG. Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

13. Capitation budget inclusive of salary under the UC system • UC policy 2002 - cover all self employed - 75 % of popn • Population based budget allocation based on capitation, inclusive of salary • Rural facilities hire more HRH • Urban facilities refused new staff - more equitable distribution

14. Average Monthly public income of doctors working in different settings with different experiences, 2009 ($US) DG = 2,700 $US/mo, PS = 3,000, minister = 3,200

15. The roles of health professionals • Getting more and more influential • Starting with the Rural Doctor Society – NGOs in the civil servants environment to nursing, dental and pharmacy councils movements • Get involve in formulating the policies and social advocacy – labor market + public conditions – aimed at 60-70% of private incomes • Mainly social movements – never strike • ‘Health team’ movement with some conflicts

16. Three tracts of medical education • National competition – best brains, 1,000/yr, 3 yrs public works or $US 12,000 fines • Provincial competition – CPIRD (Collaborative Project to Increase Production of Rural Doctors) -provincial residence – 1,000/yr, 3 yrs public works or $US 12,000 fines • District competition – ODOD (One District One Doctor) – 500/yr with 12 yrs compulsory public works or $US60,000 fines Dr. Suwit Wibulpolprasert, Ministry of Public Health, Thailand

17. Proportion of Northeast’s to Bangkok’s Population/Doctor Ratios, 1979-2006 Economic recession n PHC/HFA n rural development Econ recovery – UC n influx of foreign patient Double digit econ gwt with private sector Econ crisis Proportion of Northeast’s to Bangkok’s Year Source : Report on Health Resources, Bureau of Health Policy and Plan, MoPH

18. Trend of years staying in a rural districts and projection to 2008 cohort expectation projection

19. Lessons learned from Thailand 1. Many factors involve in the retention of HRH in rural areas, from social equity, to labor market, education systems, motivation and incentives. 2. Continuous and serious implementation of unified, integrated strategies, including integrated rural development, improved rural HS infrastructures, education, social motivation, and financial strategies are needed 3. Watch out for rapid economic growth, demand in rich countries, and international trade 4. Continuous vigilance and participatory national mechanism