Health Services and FTA Suwit Wibulpolprasert Ministry of

Health Services and FTA Suwit Wibulpolprasert, Ministry of Public Health, Thailand, 2 September 2005

4 main categories of trade in services Border CB Services Suppliers )S( Consumers )C( CA CP Natural person Services S NP

Services Sector Related to Health Business Finance - Health professions - Health Insurance - Investment Loans Education - Training of HR Distribution - Drug retailing H & Social - Hospital/ambulance cares Travel - Epidemics Environment - Environmental Health

Barrier to trade in health services Entry VISA Work Permit License - practice/premise Investments permit Finance - Insurance/Self Socio-Cultural* Effectiveness/satisfaction *

Mode 1: Cross border trade on Health: INDIA

REVENUE from e-Health- INDIA Revenue of the BPO Industry Estimates by ESC , 1999 ESC - Electronics & Computer Software Exports Promotions Council

Mode 2: Number of foreign patients in Thailand, by country of origin, 2001 -2003 Source: Export Promotion Department (2004) 2001 2002 2003 % change 2001/2002 % change 2002/2003 Japan 118, 170 131, 684 162, 909 11. 9 28. 8 US 49, 253 58, 402 85, 292 20. 6 43. 9 UK 36, 778 41, 599 74, 856 13. 1 79. 9 Germany 19, 057 18, 923 37, 055 -0. 7 95. 6 NA 20, 004 34, 704 NA 73. 5 Other 326, 903 359, 388 578, 716 10. 1 61. 3 Total 550, 161 630, 000 973, 532 14. 5 54. 5 Middle East Note: The number of foreign patients has been counted in term of revisit since 2003

%increase of foreign patients 2000 -2001 38% 2001 -2002 14. 5% 2002 -2003 54. 5%

Percentage of foreign patients by region, 2001 Source: Service Trade Division , Department of Export promotion, Ministry of Commerce, 2002

Mode 3: Commercial presence of Thai health providers abroad – Hospital management service • In 2003, Bumrungrad Hospital signed two 5 yr contracts with hospitals in Burma and Bangladesh. • In the last 10 yrs, Bangkok hospital has established 12 branches in Southeast Asia and South Asia – targetting tourist towns.

Mode 3: Commercial presence of foreign health service providers in Thailand – Possibility of majority foreign share holders since 1999 – FDI in private hospitals in Thailand is very small, contributing <5% of total investment: Strong private sector and too good public services. Singapore is moving in. – AFAS requires 49: 51 in 2006 and 70: 30 in 2012

Mode 4: Medical doctors and nurses working abroad – Massive outflow of medical doctors even without liberalisation agreement – between 1965 -75 lost 1, 500 doctors to the US, one fourth of all doctors – Much less outflow now due to high demand in the private sector and language limitation – Crisis in Africa, paradise for India and PL

Mode 4: Foreign health personnel working in Thailand. – Very rare. – Need a license examination in Thai. – Temporary license for public or NGO services can be obtained through Mo. PH’s recommendation, e. g, working in remote areas. – AFAS: Mutual recognition – learn from EC

Foreign practitioners received licenses in Thailand (1946 -2003) Number Exam in Thai Year Source: Thai Medical Council

Thailand’s Dual Tracks Policy • Universal Coverage of Health Insurance in 2001 and universal access to ARVs in 2003: Rapid increase in local demand • Medical Hub Policy since 2002: Rapid Influx of Foreign Patients • Competing for limited health resources particularly Human Resources

Vision for 2008 Thailand Center of Excellent Health Care of Asia Output . 1 Medical Services . 2 Health Promotion . 3 Herbal Products

Estimated Accumulated Income = 4, 051 m. EU. in 2008 Current estimated income = 502 m. EU.

Strategies to promote mode 2: Foreign Patients to Thailand – Establishing excellence in specialist areas – Overcome language barriers – Service apartments for relatives of patients; – Health tourism package – Encourage referrals – Establish offices abroad. – Invest in modern medical equipments.

Implications on Health Systems • Tiered Health Services • Brain drained: Virtual and Real - Virtual in Mode 1 -3 - Real in Mode 4: Africa crisis • Cadre mix: Doctors to Nurses in Phillipines • Doctors-patients relationship

Percent of Net Loss of Doctors (Resign-Reapply) as Compare to New Graduates, Mo. PH Percentage Foreign patents UC Economic crisis Year

Responses a. Increase production of doctors 10, 000 in next 15 years a. Increase incentives a. Import of foreign doctors: Mode 4?

Political Engagement • Constructive engagement with negotiators • Inform the implication on essential government policy, e. g. the universal coverage scheme, the universal access to ARVs • Negotiate for more health budget

Networking among different sectors MOC Dept. of Trade Negotiation MOF Dept. Export Promotion Fiscal Policy Research Institute Permanent Secretary Office Hlth. Service Support Dept. Div. Medical Registration Bureau of Policy & Strategy Bureau of Trade in Services Health Services Div. Ministry of Public Health Service Business Div. Universiti es Researcher s IHPP HSRI WRO National Health Assembly Representative s Civil society RO Policy Unit Health Policy Unit Informal Network Researcher s WHO/HQ Private Sector

Percentage Peace, Economic growth and Health Budget Year Source: Bureau of Budget

Health/National Budget 986. 6 mil฿. 5, 571. 8 mil฿. 16, 225. 1 mil฿. 140, 000 mil. ฿ 335, 000 mil. ฿ (4. 0%) (4. 8%) (3. 4%) 29, 000 mil. ฿ 1972 1981 59, 227. 3 mil฿. (7. 2%) 1990 77, 720. 7 mil฿. (8. 1%) National budget Health budget 825, 000 mil. ฿ 1999 1, 028, 000 mil. ฿ 2004