Suwit Wibulpolprasert

Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience

Inequitable distribution of doctors with high concentration in urban cities negatively affects the public health objective of Health for All. Thus it is one of the main concerns for most health policy makers, particularly in developing countries. This paper aims to summarize strategies to solve inequitable distribution of human resources for health (HRH) between urban and rural areas, by using four decades of experience in Thailand as a case study for analysis.

Monitoring global health: time for new solutions

Improved global health monitoring requires new technologies and methods, strengthened national capacity, norms and standards, and gold standard global reporting. The World Health Organizations many functions limit its capacity for global reporting, and a new global health monitoring organisation is needed to provide independent gold standard health information to the world

Regional Infectious Disease Surveillance Networks and their Potential to Facilitate the Implementation of the International Health Regulations

The International Health Regulations (IHR) 2005 present a challenge and opportunity for global surveillance and control of infectious diseases. This article examines the opportunity for regional networks to address this challenge. Two regional infectious disease surveillance networks, established in the Mekong Basin and the Middle East, are presented as case studies. The public-private partnerships in the networks have led to an upgrade in infectious disease surveillance systems in capacity building, purchasing technology equipment, sharing of information, and development of preparedness plans in combating avian influenza. These regional networks have become an appropriate infrastructure for the implementation of the IHR 2005.

International service trade and its implications for human resources for health: a case study of Thailand

This study aims at analysing the impact of international service trade on the health care system, particularly in terms of human resources for health (HRH), using Thailand as a case study. Information was gathered through a literature review and interviews of relevant experts, as well as a brainstorming session.It was found that international service trade has greatly affected the Thai health care system and its HRH. From 1965 to 1975 there was massive emigration of physicians from Thailand in response to increasing demand in the United States of America. The country lost about 1,500 physicians, 20% of its total number, during that period.External migration of health professionals occurred without relation to agreements on trade in services. It was also found that free trade in service sectors other than health could seriously affect the health care system and HRH. Free trade in financial services with free flow of low-interest foreign loans, which started in 1993 in Thailand, resulted in the mushrooming of urban private hospitals between 1994 and 1997. This was followed by intensive internal migration of health professionals from rural public to urban private hospitals.After the economic crisis in 1997, with the resulting downturn of the private health sector, reverse brain drain was evident. At the same time, foreign investors started to invest in the bankrupt private hospitals. Since 2001, the return of economic growth and the influx of foreign patients have started another round of internal brain drain.

Public stewardship of mixed health systems

Debate on the roles of public and private sectors in fi nancing and delivery of health services in developing countries has re-emerged. A formal agenda and resolution on the topic almost came to the fl oor at this year’s World Health Assembly until the infl uenza A H1N1 scare stole the show. The resolution will be scheduled for discussion next year. Public and private roles evoke strong views. Some advocate for government-run health systems as the best strategy to achieve health for all. Others argue that private provision of services is better. Although this values-driven discussion is important, we also have to pay attention to opportunities for progress in areas on which both sides can agree, focusing especially on the need for eff ective public stewardship of mixed health systems—that is, systems in which some of the actors are public and some are not. Proper stewardship—setting and enforcing the rules and incentives that defi ne the environment and guide the behaviours of health-system players—is a crucial state role. But many governments fall short because of political, administrative, and information constraints. Strengthening stewardship can diminish barriers that have long impeded eff orts to address the challenges and realise the opportunities of mixed health systems. This agenda is worth coalescing around. Practical steps can be taken, grounded in the reality that the nongovernmental players in mixed health systems are not going to fade away soon. What is driving all this? First, the vast and diverse universe of private players in the developing world— from private practitioners to health clinics run by nongovernmental organisations, to local drug shops, to traditional healers, to high-end for-profi t hospitals— has been poorly understood by many governments. Private providers, having grown up organically from origins that pre-date the creation of national health ministries, greatly outnumber their public counterparts in many countries. For example, in Madhya Pradesh, India, 75% of all providers operate in the private sector. Health-expenditure data show that, although the public and private mix varies substantially by country (and information to quantify this mix is scarce), more than half of total health spending is private out-of-pocket money in at least 19 countries in Asia and 15 countries in Africa, including many of the world’s most populous nations (China, India, Pakistan, Bangladesh, and Nigeria). Second, the current defi ciencies in stewardship are massive. Governmental monitoring of health markets is weak or non-existent in many countries. Regulation to control the extensive abuses that can be perpetrated by unmonitored providers (counterfeit drugs, excessive prices, inappropriate diagnosis and treatment) is also underdeveloped. At the same time, governments do little or nothing to harness the sizable private-sector resources and channel them more productively to support national health goals. And, as the persistence of high levels of out-of-pocket payment suggests, governments’ role in promoting fi nancial protection is still in its infancy. Other than a handful of donorsupported projects that harness private providers to deliver an important but narrow set of interventions (such as family planning, bednets, and tuberculosis treatment), the private health sector remains largely ignored by public authorities. How should countries begin to build better stewardship and constructively engage with a complex range of formal and informal providers? Several steps can be taken simultaneously. A logical fi rst step is to systematically and continuously collect detailed information about what kinds of providers exist, what types of services they provide, what types of patients they see, at what cost, and with what results. Without Published Online August 12, 2009 DOI:10.1016/S01406736(09)61241-1

Toward a Common Secure Future: Four Global Commissions in the Wake of Ebola

Lawrence Gostin and colleagues offer a set of priorities for global health preparedness and response for future infectious disease threats.

Addressing the internal brain drain of medical doctors in Thailand: the story and lesson learned

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The evolution and expansion of regional disease surveillance networks and their role in mitigating the threat of infectious disease outbreaks.

We examine the emergence, development, and value of regional infectious disease surveillance networks that neighboring countries worldwide are organizing to control cross-border outbreaks at their source. The regional perspective represented in the paper is intended to serve as an instructive framework for others who decide to launch such networks as new technologies and emerging threats bring countries even closer together. Distinct from more formal networks in geographic regions designated by the World Health Organization (WHO), these networks usually involve groupings of fewer countries chosen by national governments to optimize surveillance efforts. Sometimes referred to as sub-regional, these “self-organizing” networks complement national and local government recognition with informal relationships across borders among epidemiologists, scientists, ministry officials, health workers, border officers, and community members. Their development over time reflects both incremental learning and growing connections among network actors; and changing disease patterns, with infectious disease threats shifting over time from local to regional to global levels. Not only has this regional disease surveillance network model expanded across the globe, it has also expanded from a mostly practitioner-based network model to one that covers training, capacity-building, and multidisciplinary research. Today, several of these networks are linked through Connecting Organizations for Regional Disease Surveillance (CORDS). We explore how regional disease surveillance networks add value to global disease detection and response by complementing other systems and efforts, by harnessing their power to achieve other goals such as health and human security, and by helping countries adapt to complex challenges via multi-sectoral solutions. We note that governmental commitment and trust among participating individuals are critical to the success of regional infectious disease surveillance networks.

Smoking Behavior Among 84 315 Open-University Students in Thailand

The aim of this study was to estimate the prevalence of smoking among students in an open university in Thailand and to describe smoking patterns in relation to the personal and social characteristics of the sample. A self-administered questionnaire survey was conducted in 2005 with 87 134 open-university students in Thailand; the respondents aged 15 to 60 years (N = 84 315) are the participants in this study. We found a substantial difference in smoking prevalence by sex, with a much higher proportion of smoking male (20.9%) than female (1.0%) students in all sociodemographic categories. Smoking decreased among men with a higher level of education or income; in contrast, among women, higher incomes were associated with more smoking. Most of the smokers started smoking in high school. The findings provide evidence that future policy making should aim to reduce smoking among the younger population in Thailand, and in particular, they point to the need to preserve low smoking rates among women.

Southeast Asia: an emerging focus for global health

The Venetians monopolised it, then the Portuguese took control of it, and most European colonisers battled fi ercely in the 17th and 18th centuries for nutmeg, mace, and cloves—once grown only in the Spice Islands of Indonesia, the world’s largest tropical archipelago. Throughout its history, southeast Asia has witnessed the rise and fall of cultures, empires, colonial powers, and ideological regimes. Its natural environment mirrors its tumultuous past. Life-giving monsoons, so important for farming and sailing, also inundate and wreak destruction in local cities each year. Volcanic eruptions enrich and renew the topsoil, but also fl atten scores of villages and bury vulnerable villagers. The wet and hot jungles between the Tropics of Cancer and Capricorn, friendly to infections and insurgents alike, also sustain animal and plant life unequalled in biodiversity. Life in all its compact, congested richness is what distinguishes the region of southeast Asia— straddling the vast Asian geography between India to the west and China to the north. In many ways, southeast Asia is a microcosm of global health, providing an impetus for this Lancet Series on the health of the region. Although these countries share many elements of history and culture, the region teems with sociopolitical contrasts and contradictions. Economic powerhouses and agrarian economies, socialist and democratic regimes, and Muslim, Buddhist, Hindu, and Christian faiths—all of these lie within the reach of a brief plane ride. This diversity also plays out in contemporary health achievements: life expectancy ranges from 56 years in Myanmar to 81 years in Singapore. Southeast Asia presents daunting health challenges. Hosting complex animal–human interactions, the region has borne the brunt of several emerging and re-emerging infections, testing the responsiveness of local health authorities and the ability of the regional and global communities to cooperate to control diseases that cross national boundaries. Several strains of multidrug-resistant microbes of global signifi cance have also emerged from the region. Recently, artemisinin-resistant Plasmodium falciparum has been identifi ed on the Thailand–Cambodia border. Several countries in the region have pioneered successful HIV/AIDS control programmes. From vast archipelagos to Himalayan foothills, southeast Asia’s volatile geography and climate also challenge the region’s peoples and nations to respond to natural disasters. The 2004 Asian tsunami that devastated the coastlines of Thailand and Indonesia and cyclone Nargis in Myanmar drew attention to the region’s vulnerabilities, but also stimulated new models of disaster-manage ment partnerships between governments, multilateral agencies, and nongovernmental organisations. Reminiscent of its heritage of maritime commerce, southeast Asia is witnessing accelerating movements in trade, especially of health services, marked by infl ux of foreign patients and foreign direct investment in hospitals. What is distinctive about the region, however, is international health-related population movements. Thailand attracts more than 1·5 million patients per year for health tourism, with Singapore and Malaysia a bit behind. The Philippines and Indonesia have an aggressive policy of exporting health workers, especially nurses, to generate foreign exchange. These trends are likely to intensify as the ASEAN (Association of Southeast Asian Nations) Framework Agreement on Services comes into real action. Beyond health services, southeast Asia has several major exporters of food and agricultural products, with implications for global food security and safety. The number of migrants on the move in southeast Asia has risen substantially in recent decades, refl ecting Published Online January 25, 2011 DOI:10.1016/S01406736(10)61426-2