Elsevier

The Lancet

Volume 377, Issue 9767, 26 February–4 March 2011, Pages 769-781
The Lancet

Series
Human resources for health in southeast Asia: shortages, distributional challenges, and international trade in health services

https://doi.org/10.1016/S0140-6736(10)62035-1Get rights and content

Summary

In this paper, we address the issues of shortage and maldistribution of health personnel in southeast Asia in the context of the international trade in health 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 import health 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 health services with domestic health needs and equity issues.

Introduction

The quality, composition, and distribution of the health workforce is widely recognised as a crucial determinant of health system performance1 and of maternal and child health outcomes.2 The ten countries in the Association of Southeast Asian Nations (ASEAN) region (Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam) exhibit a wide diversity in socioeconomic status, political systems, health systems, and health situation.3, 4 As elsewhere in the world, most countries in the region face problems of health workforce shortages and maldistribution that hamper progress towards the health Millennium Development Goals and contribute to inequalities in health outcomes.5 The region is perhaps unique, however, with respect to the rapid growth of trade in health services, including migration of health personnel and medical tourism. Indeed, medical tourism has emerged as a key economic strategy for several countries, notably Singapore, Malaysia, and Thailand.

We aimed to consider the shortage and maldistribution of health personnel in countries in southeast Asia in the context of the engagement of these countries in the international trade in health services. We analyse the situation and identify factors contributing to shortages and maldistribution that are experienced in many countries in the region. Trade in health services is a recent venture for some countries in southeast Asia, and the effect of these international movements on the health workforce is discussed. Webappendix p 3 shows a conceptual framework of the issues and analysis discussed in this paper.

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.

Although all groups of health personnel—doctors, nurses, public health specialists, health administrators, and laboratory technicians—are essential in management and provision of effective health services, we concentrate on doctors, nurses, and midwives because comparable data are most readily available for these groups.

Section snippets

Data and methods

We sought to compile comparable data for stock, distribution, and production of health workers in southeast Asia and for health-worker migration and medical tourism (see panel for search strategy). For Cambodia, Indonesia, Laos, Thailand, and Vietnam, data for the number of doctors, nurses, and midwives were compiled from official statistics to obtain more complete information. These data included both the public and private sectors, apart from Cambodia and Vietnam. For the other five

The stock of human resources for health

The availability of a qualified health workforce is a crucial determinant of a health system's capacity to deliver services to the population. Webappendix p 4 shows the relation between health workforce densities (measured by the number of doctors, nurses, and midwives per 1000 population) and gross national income per head in the ten countries in the ASEAN region. The aggregate level of human resources in southeast Asia suggests no critical shortage, with a regional average of 2·7 doctors,

An overview of trade in health services in southeast Asia

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

Discussion

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.

Search strategy and selection criteria

The paper is based on data and information obtained from various published and unpublished sources. We sought to compile comparable data for stock, distribution, and production of health workers in southeast Asia and for health-worker migration and medical tourism. We also reviewed published and unpublished articles and documents about these issues. We reviewed English literature through Pubmed, Google Scholar, Google search, and institutional websites such as WHO, the Organisation for Economic

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