1. Global Social Policy
http://gsp.sagepub.com
Addressing the Internal Brain Drain of Medical Doctors in Thailand: The
Story and Lesson Learned
Suwit Wibulpolprasert and Cha-Aim Pachanee
Global Social Policy 2008; 8; 12
DOI: 10.1177/14680181080080010104
The online version of this article can be found at:
http://gsp.sagepub.com
Published by:
http://www.sagepublications.com
Additional services and information for Global Social Policy can be found at:
Email Alerts: http://gsp.sagepub.com/cgi/alerts
Subscriptions: http://gsp.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
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.

2. 12 Global Social Policy 8(1)
Addressing the Internal Brain Drain of Medical
Doctors in Thailand: The Story and Lesson Learned
SUWIT WIBULPOLPRASERT AND CHA-AIM PACHANEE
Ministry of Public Health, Thailand
Thailand is a lower middle-income country in Southeast Asia. Its publicly led
health care system has long been suffering from a problem of inequitable distri-
bution of qualified health professionals. The main cause is the increasing demand
for 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 2m
foreign patients, with annual growth of 10–20%. Increasing demands from these
foreign 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 the
medical 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 to
urban private health facilities, due to this ‘medical tourism’ has aggravated the
long-term problem of inequitable distribution of health professions. However, it
is 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 all
doctors in the country, in 2015.
In Thailand, the public sector, notably the Ministry of Public Health, is the
main 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 while
para-professional health workers serve in poorer rural facilities. In 2005, the
doctor:population ratio in the poorest Northeastern region was 1:7015. This
is a concentration of almost 10 times less compared with 1:7867 in the capital
city, Bangkok. This situation was improved from the 21 times disparity in
early 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 of
incomes between the private and the public health personnel is highest among
doctors, 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 career
development, and limited capacity in foreign language are considered the major
contributing factors that retain qualified health professionals in the country.
In order to overcome the situation of inequitable distribution and ‘internal
brain drain’ of qualified health professionals and to retain them longer in the
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.

3. GSP Forum 13
rural public sector, the government has implemented several supply and
demand side measures.
On the supply side, programmes to increase the number of medical and
other qualified health professional graduates, especially for the rural areas,
have been approved and implemented. For example, a programme to recruit
10,678 new medical students from 2005 to 2014 through the concept of ‘rural
recruitment, 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. This
strategy should be considered as a medium to long-term solution, as it takes
six 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 public
service 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 from
US$12,000 to US$60,000 for the same group of graduates.
Several financial incentives have been employed including hardship
allowance (US$80–800 per month), non-private-practice allowance (US$300
per month), overtime payment (US$400–500 per month), professional hono-
rarium (US$150–300 per month) and non-office hour special intervention
payments (varies). These incentives are additions to the basic salary which is
around US$240 per month. With these financial benefits, a newly graduated
medical doctor working in a remote rural area can earn a monthly income at
the 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 and
informal training, freedom of practice, fairness in management, and social
recognition. 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 to
reach a post at a level equivalent to a Deputy Provincial Governor or Deputy
Director-General of a central department. A system of almost unlimited
opportunity for continuing education for medical doctors and public health
workers 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 as
well as freedom of practice are also promoted and implemented.
These measures, although varied, are only partially adequate in solving the
inequitable distribution of qualified health professionals. They are implemented
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.

4. 14 Global 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 applied
equally to newly, medical graduates allows them to save sufficient amount of
money within one year of public service to pay for the fine of breaching the
required three-year compulsory public work contract. Besides, the new public
sector reform policy, which does not allow employing new graduates as civil ser-
vants but as temporary state employees, has influenced many new graduates to
move from the public sector. Furthermore, the long-term problem of social
inequity and inequity in distribution of wealth in the country also inevitably
reduce the effectiveness of the measures.
In conclusion although ‘medical tourism’ aggravates the internal drain of
health professionals from rural public to the urban private health facilities, the
bigger causes are the increasing demand for health care among the richer
urban Thai population who has higher purchasing power, the social and wealth
inequity, 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 are
major contributing factors to maintain them within the country.
To solve the problems of internal brain drain and inequitable distribution
of health professionals, the government has applied many financial and
non-financial incentives. These measures help alleviate the problem to a
certain extent. However, due to the reactive, piecemeal and non-integrated
nature of the implementation, they are only partially effective. In addition,
there are other external and difficult to control factors including public
sector 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 formulate
more effective integrated measures.
references
Department of Export Promotion (2005) Number of Foreign Patients Entering Thailand
by Country, 2001–2004. Thailand: Ministry of Commerce.
Pachanee, C. and Wibulpolprasert, S. (2006) ‘Incoherent Policies on Universal
Coverage of Health Insurance and Promotion of International Trade in Health
Services in Thailand’, Health Policy and Planning 21(4): 310–18.
Wibulpolprasert, S., Siasiriwattana, S., Ekachampaka, P., Wattanamano, N. and
Taverat, R. (eds) (2007) Thailand Health Profile 2005–2007. Bangkok: Ministry of
Public Health.
SUWIT WIBULPOLPRASERT is Senior Advisor on Disease Control with the Ministry of
Public 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: suwit@health.moph.go.th]
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.

5. GSP Forum 15
CHA-AIM PACHANEE is a Policy and Plan Analyst with the Bureau of International
Health, Ministry of Public Health, Thailand. Please address correspondence to: Ms
Cha-aim Pachanee, Bureau of International Health, Tivanond Road, Nonthaburi 11000,
Thailand. [email: chaaim@health.moph.go.th]
Defending Worker and Community Rights in Addressing the
Global Health Care Workforce Crisis
GENEVIEVE GENCIANOS
Public Services International, France
The World Health Organization (WHO) sounded the alarm bells when it
released its 2006 World Health Report bringing attention to the state of the
world’s health workforce. The report revealed a global shortage of about
4.3m health workers, with the crisis occurring at its most severe levels in the
world’s poorest countries, particularly in sub-Saharan Africa (WHO, 2006).
This global shortage implies that virtually every country in the world is in
need of health workers. Yet it is the poorer countries that end up worse-off
as more and more of their health professionals leave to work in higher-
income countries. Various studies have been presented illustrating the severe
impacts of brain drain on communities, workers, and the overall state of the
health care sector in developing countries. Such impacts seriously undermine
the right of citizens to accessible and quality public health services in devel-
oping countries. Achieving the Millennium Development Goal targets in
health would be impossible when there are no health workers to carry out
primary health care programmes in underserved communities. Moreover,
addressing the global fight to eradicate HIV/AIDS, tuberculosis, malaria and
other global pandemics cannot be done without an available and motivated
health workforce.
In its special chapter on health care worker migration, the Organisation for
Economic Co-operation and Development’s (OECD) International Migration
Outlook 2007 argues that migration is neither the main cause of, nor would its
reduction be the solution to, the global shortage of the health workforce
(OECD, 2007). But it recognizes that migration exacerbates the acuteness of
the problem in certain countries and that migration can be considered more
of 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 G
Migration has both a consequential and direct link to the quality of public
services. On the one hand, a degraded public sector deprives citizens of
essential services and exacerbates poverty, which is a known root cause of
migration. On the other hand, structural adjustments, privatization and the
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.