Spotlight Interview
With Suwit Wibulpolprasert Conducted May 2008
Dr Suwit Wibulpolprasert is a Senior Advisor on Disease Control at the Ministry of Public Health, Thailand. He has extensive experience in the area of human resources for health (HRH) and has published widely on the subject. Dr Wibulpolprasert is chair of the Asia-Pacific Action Alliance on Human Resources for Health (AAAH) and also sits on the Board of the Global Health Workforce Alliance (GHWA) as the Chair of the Policy and Planning Committee.
	ICHRN: As a member of the GHWA, what do you see as the most pressing challenges confronting health human resource policy makers in the Asia-Pacific region? Do these differ from priorities in other regions? If so, in what way?
Suwit Wibulpolprasert: The most pressing challenge is the shortage and maldistribution of staff. I do not think that it is much different from other regions, especially on the issue of maldistribution. This is a complex issue which relates to the adequacy of numbers, trade in health services and the incentives available for staff.
	ICHRN: What is the GHWA doing to address this key set of challenges in Asia-Pacific?
Suwit Wibulpolprasert: The most important issue for GHWA in Asia-Pacific is to work closely with its partners, including AAAH, the World Health Organization, the World Bank and governments, to build up long-term institutional capacity within the countries in order to collect up-to-date and accurate information, and to analyse and synthesize or formulate – as well as implement/assess – appropriate policies to solve the HRH problems. Without this capacity, problems will not be easily realised and policies will not be formulated or implemented based on evidence.
	ICHRN: What are the priority HRH challenges of the health system in Thailand?
Suwit Wibulpolprasert: Thailand has the same problems as there are generally in the region: shortage and maldistribution, complicated by the massive influx of foreign patients in the past decade. Last year it was estimated that we had around two million foreign patients and this number is increasing at more than 10 % per year _ the highest among all Asian countries that have foreign patients and “health tourists”. The growth of the private sector and the increased demand from foreign patients has drained a sizeable portion of the limited numbers of health workers from the rural public sector to the urban private health facilities. This is not an external brain drain _ the “brains” are still in Thailand _ but they are now serving foreigners. I call this a ‘virtual’ brain drain. It is better than the real brain drain in the sense that the money gained by providing care to health tourists is retained within the country. However, we have to import a huge amount of technology, including patented drugs. We either have to produce more nurses and doctors or import from other countries. We choose to produce more.
	ICHRN: The inequitable distribution of nurses between rural and urban areas is an issue faced by nearly all health care systems, including Thailand's. What strategies are in place to promote the distribution of nurses to rural and under serviced areas in your country?
Suwit Wibulpolprasert: We have used several strategies at different times. We started, since more than half a century ago, by producing lower level nurses and midwives, who did not have a license to practise in the private sector, so they had to stay only in the public sector. With the country's development and more demand for better care, this training system was stopped more than 10 years ago. We also used the so-called “rural recruitment, local training and hometown placement” strategy. We provided special quotas for each rural province, district or even sub district. Students with permanent residence in those areas were eligible for recruitment under the quota. So students in the rural districts would have a higher chance to be recruited as there is less competition. They were trained in the local provincial and district hospitals, including rural health centres, where they were familiar with the way of life and the health care systems. After graduation, they worked at rural health centres and district hospitals near home. This strategy proved to be quite effective until the coming of the public sector reform with the limitation on civil servant posts and the mushrooming of the private sector, as mentioned earlier. Previously, all graduates from 36 nursing colleges in the Ministry of Public Health worked with us. Nowadays, we lose 30 per cent of them to the private sector, right on the first day that they graduate. We are now working closely with the local governments to mobilize their resources to send local students to nursing college and to be hired by these local governments when they graduate. In addition to that, many financial and non financial incentives have been applied.
	ICHRN: Health tourism, travelling to another country to obtain health care, is a rapidly growing industry in Thailand. Can you briefly describe the practice? How does it affect the workforce?
Suwit Wibulpolprasert: This has been described above. The latest development is the growing business of long term care. This will require many more nurses and specialist doctors. The Thai government, since the mid 1980s, provides tax incentives for investment in private hospitals, including long term care. Thai ladies are usually very kind with excellent hospitality so Thai nurses usually provide very good nursing care services. The medical technologies and skills of the medical professions are also excellent. In the last 5 years, the public tertiary care hospitals lost around 500 well trained specialists to the private sector. Many of those who are still in the public facilities work in private hospitals during non-official hours. To recruit new nurses, many private hospitals go to the nursing colleges and schools to meet with the 3rd or 4th year nursing students. They offer scholarship in exchange for a period of contracted work with the private hospitals after graduation.
	ICHRN: Thailand has joined with other countries in the Association of South East Asian Nations (ASEAN) to promote mutual recognition of nursing qualifications in the region. What do you think the impact of this agreement will be?
Suwit Wibulpolprasert: There will be little impact as it is not really mutual recognition. Each country still retains its right to issue its own regulation on licensing. The degrees are also not automatically recognized. In order to move to practice in other countries in the region, nurses will be required to have three years of working experience, after graduation. If implemented this condition makers it more difficult for nurse to move. So it is different from the Mutual Recognition Agreement (MRA) in the EU or in other regions. This MRA was developed to satisfy the country leaders who have agreed on the mandate and was designed by the nursing professional bodies in the ASEAN countries who are not supportive of the MRA. They have reasons for that, mainly due to the difference in the nursing standard among the 10 countries. We may need another 20 years to have a real MRA. After all, the EU spent 50 years or more to achieve theirs.
	ICHRN: Within Asia, Thailand has been less affected by the out migration of nurses. Why do you think this is?
Suwit Wibulpolprasert: Firstly, many Thais do not speak good English, and those that do speak good English have often not entered nurse training. Secondly, because our systems pay them quite well, in both the public and private sectors, we retain them. Thirdly, there is an adequate working environment. And because of the excellent working spirit and care, Thai nursing care has attracted many foreign patients which has drained the limited resources from the rural public facilities.
	ICHRN: Can you briefly describe for our readers what the AAAH is and how is it working to improve HRH in the region?
Suwit Wibulpolprasert: AAAH stands for Asian Action Alliance on HRH. It is a network of HRH coordinators and those who are interested in HRH in the Asia-Pacific region. We started with only 10 countries in the first year and expanded to 15 in the second year. We are continuing to expand. The main purpose of AAAH is networking, knowledge and skill sharing, capacity building, and advocacy. More details can be retrieved from our website at www.aaahrh.org.
	ICHRN: Is there anything further you would like to communicate to our readers interested in HRH issues?
Suwit Wibulpolprasert: HRH problems are complex and need long-term solutions supported by strong institutional and human capacity for policy development and implementation. A programme based on outside consultants will not work and will not be sustainable in the long run. Multiple strategies, both demand and supply side, need to be integrated and implemented in a well coordinated manner with multi-sectoral support in order to be effective. The Kampala Declaration and Agenda for Global Action, endorsed at the First GHWA Forum on 5 March in Kampala, Uganda, is a very good tool for each country to consider applying to their needs.