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www.thelancet.com Vol 377 February 26, 2011 769

Lancet 2011; 377: 76981

Published Online

January 25, 2011

DOI:10.1016/S0140-6736(10)62035-1

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377: 355, 534, and 619

See Online/Comment

DOI:10.1016/S0140-

6736(10)61923-X, and

DOI:10.1016/S0140-

6736(10)62140-X

This is the fi fth in a Series of

six papers about health in

southeast Asia

Mahidol University, Nakhon

Pathom, Thailand

(C Kanchanachitra PhD);

World Bank, Vientiane, Laos

(M Lindelow PhD); World Bank,

Phnom Penh, Cambodia

(T Johnston MPA); London

School of Hygiene and Tropical

Medicine, University of

London, London, UK

(P Hanvoravongchai MD);

University of the Philippines,

Manila, Philippines

(Prof F M Lorenzo DrPH);

Ministry of Health, Hanoi,

Vietnam (N L Huong MPH);

Gadjah Mada University,

Yogyakarta, Indonesia

(S A Wilopo MD); and University

of the Philippines, Manila,

Philippines (J F dela Rosa MSc)

Correspondence to:

Dr Churnrurtai Kanchanachitra,

Mahidol University, Institute for

Population and Social Research,

Phuttamonthon, Salaya,

Nakhon Pathom 73170, Thailand

[email protected]

Health in Southeast Asia 5

Human resources for health in southeast Asia: shortages,

distributional challenges, and international trade in

health services

Churnrurtai Kanchanachitra, Magnus Lindelow, Timothy Johnston, Piya Hanvoravongchai, Fely Marilyn Lorenzo, Nguyen Lan Huong,

Siswanto Agus Wilopo, Jennifer Frances dela Rosa

In this paper, we address the issues of shortage and maldistribution of health personnel in southeast Asia in the contextof the international trade in health services. Although there is no shortage of health workers in the region overall, whenanalysed separately, fi ve low-income countries have some defi cit. All countries in southeast Asia face problems of

maldistribution of health workers, and rural areas are often understaff ed. Despite a high capacity for medical andnursing training in both public and private facilities, there is weak coordination between production of health workersand capacity for employment. Regional experiences and policy responses to address these challenges can be used toinform future policy in the region and elsewhere. A distinctive feature of southeast Asia is its engagement in internationaltrade in health services. Singapore and Malaysia import health workers to meet domestic demand and to provide servicesto international patients. Thailand attracts many foreign patients for health services. This situation has resulted in theso-called brain drain of highly specialised staff from public medical schools to the private hospitals. The Philippines andIndonesia are the main exporters of doctors and nurses in the region. Agreements about mutual recognition ofprofessional qualifi cations for three groups of health workers under the Association of Southeast Asian NationsFramework Agreement on Services could result in increased movement within the region in the future. To ensure thatvital human resources for health are available to meet the needs of the populations that they serve, migration managementand retention strategies need to be integrated into ongoing eff orts to strengthen health systems in southeast Asia. Thereis 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.

IntroductionThe quality, composition, and distribution of the healthworkforce is widely recognised as a crucial determinantof health system performance1 and of maternal and childhealth outcomes.2 The ten countries in the Association ofSoutheast Asian Nations (ASEAN) region (Brunei,Cambodia, Indonesia, Laos, Malaysia, Myanmar, thePhilippines, Singapore, Thailand, and Vietnam) exhibit awide diversity in socioeconomic status, political systems,health systems, and health situation.3,4 As elsewhere inthe world, most countries in the region face problems ofhealth workforce shortages and maldistribution that

hamper progress towards the health MillenniumDevelopment Goals and contribute to inequalities inhealth 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 medicaltourism. Indeed, medical tourism has emerged as a keyeconomic strategy for several countries, notably Singapore,Malaysia, and Thailand.

We aimed to consider the shortage and maldistributionof health personnel in countries in southeast Asia in thecontext of the engagement of these countries in the inter-national trade in health services. We analyse the situationand identify factors contributing to shortages andmaldistribution that are experienced in many countries inthe region. Trade in health services is a recent venture for

Key messages

Like other regions, many countries in southeast Asia suff er

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, fi nancial barriers, and cultural factors. Because of

the low quality of services and training, migration ofhealth 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 diffi culties

in attracting health workers to remote areas, because of

fi scal constraints and inadequate fi nancial and

non-fi nancial 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.

(Continues on next page)



Series

770 www.thelancet.com Vol 377 February 26, 2011

some countries in southeast Asia, and the eff ect of theseinternational movements on the health workforce isdiscussed. Webappendix p 3 shows a conceptual frameworkof the issues and analysis discussed in this paper.

Although all groups of health personneldoctors,nurses, public health specialists, health administrators,and laboratory techniciansare essential in managementand provision of eff ective health services, we concentrate

on doctors, nurses, and midwives because comparable

data are most readily available for these groups.

Data and methodsWe sought to compile comparable data for stock,distribution, and production of health workers insoutheast Asia and for health-worker migration andmedical tourism (see panel for search strategy). ForCambodia, Indonesia, Laos, Thailand, and Vietnam, datafor the number of doctors, nurses, and midwives werecompiled from offi cial statistics to obtain more completeinformation. These data included both the public andprivate sectors, apart from Cambodia and Vietnam. Forthe other fi ve countries, data were compiled from WHOStatistical Information Systems.

Where subnational data were available, we producedLorenz curves and Gini indexes to depict geographicalinequality of doctor and nurse density. The Gini coeffi cientand Lorenz curve are among the most well knownmeasures of inequality and have been applied to previousstudies of health workforce inequality.6 Our inequalityanalysis was based on the density at the fi rst administrativedivision below national level, which is equivalent toprovince level in all countries apart from the Philippines(regional level). The analysis included only public-sectorhealth workers for all countries apart from Thailand, forwhich private-sector data were included. For trend analysisin the Philippines and Vietnam, where new regions orprovinces were established, data from newly created statesand provinces were aggregated with their originalcounterparts to maintain the same number ofadministrative level units across time and to ensure thatresults could be compared between periods.

Data from Ministry of Health documents andpublished sources were used in our analysis of health-worker production. Dependent on the reporting systemin each country, production capacity refers to either thetotal number of graduates or those passing requisiteexaminations. Data refl ect both public and privatesectors for all countries apart from Brunei, Cambodia,and Myanmar, for which data for production capacityfrom private medical and nursing schools were not

available. Data for migration of health workers andmedical tourism were obtained through the Organisationfor Economic Co-operation and Development (OECD),trade publications, and other published sources.

We encountered several diffi culties with respect to data.First, data for private-sector employment, remuneration,and training of health workers were not available or wereincomplete for most countries. In particular, the coverageof WHO Statistical Information Systems health workforcedata varies across countries, especially with respect to theprivate sector, but detailed information about data sourcesand issues is not available. Second, data for health-workermigration and medical tourism were available for mostcountries with middle and high incomes, but wereincomplete. Third, defi nitions and levels of training for

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 Co-operation and

Development, and the Association of Southeast Asian Nations. We focused our search on

issues related to human resources for health and international trade in health services,

including shortage, maldistribution, retention, migration of doctors and nurses, and eff ect

on human resources for health; search terms used were doctor rural retention,

distribution of doctors, trade in health services, medical hub, human resources for

health migration, and ASEAN mutual recognition arrangement. Grey literature included

ministry of health reports, health workforce planning documents, statistical yearbooks,

records from medical and nursing councils regarding the number and distributions of

members, and annual production data from training institutions. Detailed description of

these data sources is provided in webappendix pp 12, which includes the classifi cation of

diff erent types of health professional used in the study.

(Continued from previous page)

Although international trade in health services is not the

main cause of health-worker shortages or maldistribution

in southeast Asia, it clearly aff ects 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 eff ect 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 eff ects of medical tourism on domestichealth 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 benefi ts

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.



Series


nurses and doctors vary between countries. Fourth, fewstudies exist to compare the quality of medical training orclinical competence of health workers between countries.Finally, studies assessing the eff ectiveness of policyinterventions in the region were very scarce. With thislimitation of data, we focus on analysis of data from thepublic sector and of data that were available.

Outstanding challenges: shortages andmaldistributionThe stock of human resources for healthThe availability of a qualifi ed health workforce is acrucial determinant of a health systems capacity todeliver services to the population. Webappendix p 4shows the relation between health workforce densities

(measured by the number of doctors, nurses, andmidwives per 1000 population) and gross nationalincome per head in the ten countries in the ASEANregion. The aggregate level of human resources insoutheast Asia suggests no critical shortage, with aregional average of 27 doctors, nurses, and midwives(combined) per 1000 population (table 1).712 At a nationallevel, however, fi ve countries (Cambodia, Indonesia,Laos, Myanmar, and Vietnam) fall below the criticalshortage threshold of 228 doctors, nurses, andmidwives per 1000 population, as defi ned by WHO.1,13 Tomeet the WHO threshold in these fi ve countries, anestimated 884 868 health professionals would be needed,representing a shortfall of around 232 417 relative to thecurrent workforce.

Population

(millions)

Number Density per 1000 population Gap in health

workers*

Ratio of nurses and

midwives per doctor

Doctor Nurse and

midwife

Doctor Nurs e and

midwife

Combined

Brunei 04 400 2120 11 61 72 53

Singapore 44 6380 18 710 15 44 59 29

Malaysia 266 17 020 43 380 07 18 25 25

Thailand 639 31 855 140 404 05 22 27 46

Philippines 880 90 370 480 910 12 61 73 53

Indonesia 2316 56 938 387 458 02 17 19 83 652 68

Vietnam 874 43 292 77 233 05 08 14 78 747 18

Laos 59 1863 5363 03 09 12 6226 29

Cambodia 144 2047 11 125 02 09 11 19 660 54

Myanmar 488 17 791 49 341 04 10 14 44 132 28

ASEAN 5714 266 301 1 248 117 05 22 27 47Global 66590 8 404 351 17 651 585 13 28 41 21

Population data and health professional statistics for 200007 are from reference 7; data for health professionals from Thailand,8,9 Indonesia,10 Vietnam,11 and Laos12 are from

country sources. ASEAN=Association of Southeast Asian Nations. *Number of additional health workers needed to achieve the WHO threshold of 228 doctors, nurses, and

midwives per 1000 population; the total number of additional health workers needed in these fi ve critical shortage countries is 232 417 (for the ASEAN region overall, there is

no shortage). Authors calculation.

Table 1: Basic health professional statistics for countries in southeast Asia

Year Number of institutions or schools Annual production capacity Production per 100 000 population*

Doctors Nurses Midwives Doctors Nurses Midwives Doctors Nurses Midwives

Brunei 2010 1 1 1 17 146 11 4 38 3

Singapore 2010 2 3 NA 350 1347 NA 8 32 NA

Malaysia 2008 21 99 NA 2000 8153 NA 8 34 NA

Thailand 2009 12 69 NA 1305 7555 NA 2 12 NA

Philippines 2007 39 517 268 2930 60 199 3498 4 78 5

Indonesia 2008 52 682 465 5500 34 000 10 000 2 15 4

Vietnam 2008 14 14 ND 3520 860 4 1

Laos 2007 1 6 0 70 576 0 1 11 0

Cambodia 2008 2 6 6 290 410 398 3 4 4

Myanmar 2005 4 23 20 650 1200 1100 1 4 2

See webappendix pp 12 for data sources. NA=not applicable, since these countries no longer produced midwives. ND=no data. *Authors calculation. Only graduated from

Bachelor of Health Science (Medicine) 3-year programme in Brunei; did not include students who graduated from partner universities to complete the Doctor of Medicine

programme. Data are for 2009. Data are for nurses and midwives combined. Public only.

Table 2: Production capacity of doctors, nurses, and midwives in southeast Asian countries



Series


Although there is no international standard for nurse-to-doctor ratio, a low ratio could suggest ineffi ciencies inthe health system, since there might be scope to shiftsome tasks from higher paid doctors to nurses without adetrimental eff ect on quality. Moreover, training of doctorsis more expensive and takes longer than does training of

nurses, and positioning of doctors in rural areas is morediffi cult and expensive. So in a resource-poor country,production of more doctors can be diffi cult, and a highreliance on doctors might exacerbate urbanruralimbalances in the distribution of human resources forhealth. The ratio of nurses and midwives to doctors in

Figure 1: Subnational distributions of doctors and nurses in selected southeast Asian countries

Greater deviation of the Lorenz curve from the red diag onal line (line of equ ality) shows higher inequality ( which is refl ected in a higher Gini coeffi cient, with zeroindicating perfect equality). Green lines show the distribution of nurses an d blue lines show distrib ution of doctors. Gini coeffi cients are shown in pare ntheses in the

key of each fi gure.

Figure 2: Trends in Gini coeffi cients of doctor and nurse densi ties in the Philippi nes, Thailand, and Vietnam

Data are for the province level apart from for the Philippines, for which data are at a regional level. Only public sector staff are included, apart from for Thailand, for which

public and private staff data are included. Results are not fully comparable across countries becau se the administrative level units and data compo sition are diff erent.

1998 1999

Thailand (province)Vietnam (province)Philippines (region)

Doctors

05

0375

025

0125

0 0

01

02

03

Ginicoefficient

2000 2001 2002 2003

Year Year

2004 2005 2006 2007 2008 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Nurses

0

02

04

06

08

1 0 Nur se s (01 9)Doctors (050)

Cumulativeproportionofhealthworkers

Cumulativeproportionofhealthworkers

0 02 04 06 08 100

02

04

06

08

10

Cumulative population proportion

0 02 04 06 08 10


0 02 04 06 08 10


Cambodia (2008) Philippines (2006)

Vietnam (2008) Laos (2009)

Thailand (2008)

Nurses (019)Doctors (022) Nurses (011)Doctors (021)

Nurses (012)Doctors (017) Nurses (021)Doctors (037)



Series


southeast Asia is higher than the global average, but there

is substantial variation between countries. Indonesia hasthe highest ratio at 68 nurses and midwives per doctor,whereas Vietnam has only 18 nurses per doctor. Thesediff ering ratios might refl ect policy choicesfor example,some countries (eg, Thailand and Cambodia) explicitlyfocus on nurse-based primary care. However, diff erencesacross countries can also be a consequence of local labourmarket dynamics and trade in health services.

Aggregate ratios can conceal shortages in specifi c groupsof professionalsfor example, shortages of midwives inCambodia and Laos. Singapore has a high density ofdoctors, but also reports problems with shortages in thepublic sector, mainly due to the low pay and long workinghours compared with the private sector.14

Although a shortage of health workers can constrainaccess to services and coverage of health interventions,the adequacy of the workforce cannot be assessed inisolation of other factors aff ecting the demand for anduse of available services. For instance, even though Laosfalls below WHOs shortage threshold, the workforce isin many cases underemployed, with less than one patientper staff member per day in many district hospitals andhealth centres.15 This situation refl ects very low use ofpublic facilities, which in turn is a consequence offi nancial barriers, quality concerns, physical accessibility,and cultural factors.1618 In this context, measures toincrease the number of health workers are unlikely tolead to substantial improvements in health outcomeswithout complementary interventions.

Production and employmentLow production and employment capacities are closelyrelated to shortages of health workers in resource-poorcountries such as in Africa, as well as in Laos, Cambodia,and Myanmar.19 Production of doctors per 100 000 popul-ation ranged from a high of eight in Singapore andMalaysia, four in the Philippines and Vietnam, two inIndonesia and Thailand, to less than one in Laos andMyanmar. Annual nurse production per 100 000 (notincluding midwives) ranged from 78 in the Philippines,1115 in Laos, Thailand, and Indonesia, to about four in

Myanmar and Cambodia (table 2). The Khmer Rougeperiod in Cambodia (197579) and the Indochina warbefore the establishment of Laos in 1975 resulted insubstantial loss of health personnel and disrupted training.Moreover, medical training in Laos completely stoppedbetween 1976 and 1981, during the period of nationalreconstruction. Despite eff orts to increase production inrecent years, the medical school produced only 70 doctorsin 2007.20 In Cambodia, 290 doctors and 400 midwivesgraduated from the public medical school and trainingcentres in 2008,2124but because training of secondary mid-wives (a 3-year training course for secondary schoolgraduates) was stopped for 6 years between 1996 and 2002(because of delays in revising curricula), critical shortagesremain for this group of professionals.

Production capacity, however, does not always relate toavailability of health professionals. The Philippines, forexample, produced nearly 3000 doctors and more than60 000 licensed nurses in 2007, whereas Indonesia (witha population that is three times higher) produced5500 doctors and 34 000 nurses. Indonesia has shortagesat a national level, and both countries have shortages atsubnational levels, due to restricted capacity foremployment (health-service provision is highly decentral-ised in both countries), migration toward urban centres,and outmigration of health workers. This situation iscomparable to a diabetic status of human resourcesfor health, in which health systems cannot use theavailable human resources. Despite fairly low productionrelative to population, only half of the nurses whograduate in Indonesia can be employed, of whom halfgo to the public sector and half to the private sector.25There is little information about what those whoare unemployed are doing, whether working abroador leaving the profession. In 2009, an estimated400 000 licensed nurses in the Philippines were not

employed in the nursing profession.26Most governments in southeast Asia restrict production

from public training schools on the basis of projectedrecruitment into the public service. However, policycoordination between public producers and users is oftendiffi cult because training schools are in many casescentrally or regional managed, whereas recruitment islargely decentralised (as in the Philippines and Indonesia).Moreover, coordination with the private sector onemployment needs is often poor. Indonesia and particularlythe Philippines have developed market-driven, export-ledproduction of nurses and doctors that seeks to respond tointernational demand. In the Philippines, state universitiesdominated nursing education and production in the 1950s,but the global nursing shortage in the 1990s led private

Density of

doctors, nurses,and midwives per

1000 population

Cross-border

trade (mode 1)

Consumption

abroad(mode 2)

Commercial

presence(mode 3)

Temporary

movementof natural

persons

(mode 4)

Import Export Import Export Import Export Import Export

Brunei 72 0 0 + 0 0 0 +++ 0

Singapore 59 + 0 + +++ + ++++ ++++ +

Malaysia 25 0 0 + ++ + + ++ +

Thailand 27 0 0 + ++++ ++ ++ 0 +

Philippines 73 0 ++ + + + 0 0 ++++

Indonesia 19 0 0 + + + 0 0 ++

Vietnam 14 0 0 + + ++ 0 0 0

Laos 12 0 0 + 0 0 0 0 0

Cambodia 11 0 0 + 0 + 0 0 0

Myanmar 14 0 0 + 0 0 0 0 0

The greater the number of + in each cell, the greater the engagement of that country. Table adapted from references 25

and 32.

Table 3: Level of engagement in trade in health services in southeast Asian countries



Series


colleges to rapidly expand nursing programmes. Currently,more than 80% of nursing schools in the Philippines areprivate for-profi t and export-driven businesses that canfl exibly adjust production capacity to match globaldemands.27 Between 2005 and 2007years of highinternational demand for nursespublic and privatenursing colleges produced an average of 55 000 nurses peryear, which was more than seven times the productionduring 200004.26 Even though private schools do notreceive direct commissions from receiving countries orinstitutions, profi ts tend to be related to volume. There istherefore an incentive to maximise enrolment, irrespectiveof employment prospects for graduates.

Increased enrolment of medical and nursing studentsin the Philippines outpaced increases in faculty membersand sites for clinical and community training, which

compromised the quality of teaching, supervision, andstudent competency. In 2007, for example, less than halfof nursing graduates passed licensing examinations.

In low-income countries, the private sector plays asmaller part in training of medical professionals, butpublic-sector oversight is also poor. Cambodia has justone private medical school, and only recently allowedrecruitment of a small number of privately traineddoctors into the public service. The number of privatenursing schools is growing, however.

Inequality in distribution of the health workforceNational averages of health workforce density disguiseunderlying disparities in the distribution of health workers.Using methods and summary measures from the income

distribution literature, in particular the Lorenz curve andthe corresponding Gini coeffi cient, we show in fi gure 1 thesubnational distribution of doctors and nurses in fi vecountries for which data were available. In all fi ve countries,nurses are more equally distributed across subnationalregions than are doctors. Cambodia has the greatestsubnational inequalities in the distribution of doctors.

Figure 2 shows that inequality in the distribution ofdoctors has been falling over time in the three countriesfor which data were available for several years. Thedistribution of nurses has also become more equal inThailand and Vietnam, whereas the opposite is true forthe Philippines. However, these changes across timewere not statistically signifi cant.

Many factors contribute to the uneven distribution ofthe health workforce, including the distribution of

health facility infrastructure, poor working and livingconditions in rural areas, and the concentration ofincome-earning opportunities (eg, through secondaryemployment) in urban and more prosperous areas.Hence, doctors and nurses in Indonesia are reluctant torelocate to work in remote areas or isolated islands,28 insome cases because of an unwillingness to become localdistrict government employees.29 In Thailand andIndonesia, 6070% of public physicians work in privatepractices outside offi ce hours to earn additionalincome.10,30 In the Philippines, public doctors are allowedto treat private patients in addition to their publicpatients in an eff ort to retain them in public service.The eff ects of such practices on health systems andhealth provision have not yet been systematically

Figure 3: Intraregional and international fl ows of patients (mode 2)

ASEAN=Association of Southeast Asian Nations.

USA

UKGermany

ASEAN

Japan

Korea

ThailandMalaysia

Singapore

Australia

Middle East



Series


assessed, but they are likely to contribute to a preference

for employment in urban areas.

Trade in health servicesAn overview of trade in health services in southeast AsiaTrade in health services is substantial in many south-east Asian countries, and includes internationalmovement of both patients and health workers.31Singapore, Malaysia, and Thailand are importantmedical hubs, attracting patients from within andoutside the region, whereas Indonesia and thePhilippines export many doctors and nurses. In low-income countries such as Cambodia and Laos,movement of health workers is limited by languagebarriers and qualifi cations that are not recognised

outside the respective countries; however, similarly tomany of the middle-income countries in the region,there is a substantial fl ow of patients to facilities abroad.Although this fl ow consists mainly of better-off individuals who travel abroad for services that areeither unavailable locally or are perceived to be ofbetter quality, many patients from low-income segmentsof the population cross the borders from Laos,Cambodia, and Myanmar to access services in Thailandand Vietnam, or to use services as registered orunregistered migrants.

Table 3 shows countries engagement in diff erentmodes of trade in health services.25,32 These modes are:(1) cross-border trade (telemedicine and medical tran-scription); (2) consumption abroad (movement of foreignpatients); (3) commercial presence (foreign directinvestment); and (4) temporary movement of naturalpersons (migration of human resources for health). Inthis report we focus on the two modes of trade in healthservices in which countries in the region are activelyengagedmovement of patients (mode 2) and movementof health workers (mode 4). Engagement of the southeastAsian region in mode 1 (cross-border supply) and mode 3(foreign direct investment) remains limited. One exampleof mode 1 trade is the export of medical transcriptionservices from the Philippines to the USA. In terms offoreign direct investment in the region, only 1% of total

hospital beds in Indonesia are foreign owned, and 3% oftotal investment in private hospitals in Thailand is byforeign agencies.32

Medical tourismMedical tourism or health tourism refers to patientstravelling to other countries to seek health care. Theysometimes combine medical care with other leisureactivitieshence, medical tourism. Singapore, Thailand,and Malaysia have emerged as major destinations ofinternational patient fl ows (fi gure 3), with an estimated2 million foreign patients in 200506. 13 million foreignpatients came to Thailand for treatment in 2005, and300 000 and 400 000 patients entered Malaysia andSingapore, respectively, in 2006.3335 Foreign patients

accounted for less than 1% of total patients in Thailand,however, compared with 4345% in Singapore andMalaysia.32 Moreover, around 60% of foreign patients inThailand are working in Thailand or neighbouringcountries, 10% are tourists who become unwell and needhealth care, whereas only 30% are foreign patients whocome specifi cally to receive health care.36 Thus, the eff ect

of medical tourism on the Thai health system remainssmall (panel 1).3638 However, the percentage of foreignpatients attending private hospitals is increasing. Forexample, 60% of patients at Bumrungrad Hospital areforeigners, and in Piyavet Hospitala medium-sizedprivate hospital in Thailandforeign patients as apercentage of total patients increased from less than1% in 2003 to 14% in 2007. The increase in foreignpatients in the private sector is contributing to an internalbrain drain of highly specialised staff from the publicsector to the private sector, and will have an eff ect on theteaching hospitals where these specialists are working(panel 1).

Enabling factors for foreign patients seeking health carein southeast Asia are high-quality medical services

Panel 1: The eff ect of medical tourism in Thailand

The volume of international patients travelling to Thailand increased from half a million

in 2001 to 13 million in 2007a 16% annual increase36and generated US$13 billion

in 2007, with a forecast of $43 billion in 2012. Foreign investors, including Dubai

Istithmar and Singapore Temasek Holding, have purchased major shares in private

hospitals in Thailand.

If the annual increase of 16% in international patients is maintained between

2005 and 2015, additional doctors will be needed to meet this demand. Estimates range

from 176 to 909 additional doctors for 201415.36,37 Even the high estimates are 10% of

the total full-time equivalent of current Thai doctors, so in principle the increased demand

can be managed through overtime with additional fi nancial incentives. Thus, the eff ect on

the overall shortage of doctors is not signifi cant.

To provide services for international patients, however, highly specialised staff such as

cardiologists, neurologists and neurosurgeons, intervention radiologists, and oncologistsare needed. This need increases pressure on medical schools in particular because of a

shortage of teaching staff , with for example more than 300 specialists resigning to join

private hospitals during 200506.

In the absence of eff ective measures to manage the outfl ow of senior specialists from

medical schools, the quality of medical training will suff er. Even if specialists remain in

medical schools and teaching hospitals, secondary employment in the private sector could

compromise preparation and teaching time and reduce time for bedside teaching and

demonstration.38 The phenomenon could increase waiting times for surgery in the public

sector. Although the main benefi ciaries from the growth of medical tourism are the private

hospitals and their employees, the public sector will gain tax revenues. In principle, the

expansion of the high-end private sector could also have positive spillover eff ects

eg, through the development of medical expertise and improvements in quality control

through hospital accreditation and other processes. The challenge for Thailand and othercountries that engage in medical tourism is to put in place policies and approaches to

maximise benefi ts and manage health system risks. Even if this chal lenge is met, whether

the potential benefi ts will actually materialise, and whether they are suffi cient to make up

for adverse eff ects on the health system, remains to be seen.



Series


(accredited by national accreditation systems andincreasingly by Joint Commission International [JCI]),39long queues and supply shortage in home countries, lowcosts, and a strong focus on hospitality.31 Internationalhospital accreditation and medical tourism are mutuallyreinforcingcurrently, 38 hospitals in the ASEAN regionare JCI accredited (16 in Singapore, 11 in Thailand, six inMalaysia, three in the Philippines, and one each inIndonesia and Vietnam), with more than 70% accreditedsince 2007.39 Patients who seek health care in Asia cansave up to 90% compared with the cost in some OECDcountries.40 A coronary bypass operation in the USA costsup to US$130 000, compared with less than $11 000 inThailand and around $16 500 in Singapore.41 Theaff ordable cost of travel to the region creates a strongermarket for complex surgeries or elective procedures thatare not covered by insurance, which in turn increasesdemand for health workers in these specialties.35

In 200506, revenue from foreign patients wasestimated at US$1 billion in Thailand. Singapore has seta target of 1 million foreign patients in 2012. If the targetis reached, it would generate US$23 billion, while

creating 13 000 new jobs.42 Several countries haveestablished websites to promote medical tourism,and pricing suggests growing competition within theregion. The Philippines is vying to become the new hubof wellness and medical care in southeast Asia, off er-ing competitive prices as well as skilled and US-trained physicians.

Export of doctors and nursesMany health workers from the Philippines and Indonesiamigrate to countries within southeast Asia and to the restof the world. Malaysia also experiences outmigration ofhealth workers to Singapore, the Middle East, and OECDcountries. However, Malaysia and Singapore are alsopopular destinations for health workers in southeast Asia.

About 110 774 Filipino nurses were estimated to work

in OECD countries in 2000 (table 4).

43,44

In total, anestimated 163 756 Filipino nurses were working abroadin 2000.45 The number of Filipino nurses who migrateannually (to all destinations) increased from7683 in 2000, to 13 014 in 2009,46 with Saudi Arabia, theUSA, the UK, and the United Arab Emirates being thetop destinations (fi gure 4). Migration is in large partdriven by the substantial wage premium associated withoverseas employmenta nurse in Manila earnsUS$58115 per month, compared with $5000 a monthin the UK or USA.47

There are two types of health-worker migration.Temporary migration refers to health workers who havetime-restricted or contract work visas as are often seen

in Middle Eastern and ASEAN countries. Conversely,permanent migration refers to those whose stay indestination countries does not depend on workcontracts. In the early 1990s, permanent migration ofFilipino nurses was driven by relaxation of resident visarequirements, particularly in the USA and the UK.Temporary and permanent migration have diff eringimplications for the health system, since temporarymigrants are more likely to return to work in their homecountry and to send remittances to family than arepermanent migrants.

One of the potential benefi ts of migration of healthworkers are the remittances sent home by migrants totheir families. Such income can improve the economicstatus of migrant families while also having a positiveeff ect on the local economy.48 But migration also haspotential downsides. For instance, the recent upsurgein the demand for nurses abroad and opportunities forpermanent emigration to the USA resulted in Filipinodoctors retraining as nurses in order to seek overseasemployment as nurses.48 Roughly 2000 and 3000 doctorsin 2001 and 2003 were retrained as so-called nursemedics.48 These nurse medics sought to take advantageof opportunities open to nurse migrants.

The experience in the Philippines illustrates thecomplex interactions between global demand anddomestic supply and demand. By 2009, the global

recession had led to a drop in international demand formigration of nursing staff (including sharp reductionsin work visas for entry into the USA), even as nursingschools continued to produce new graduates. Nursesare typically required to have a licence as well as23 years experience in a referral hospital before theycan apply for overseas employment visas, and thisrequirement has emerged as a major bottleneck.In 2008, the Philippines Overseas EmploymentAdministration reportedly had 20 000 unfi lled job ordersfor nurses to the Middle East, Singapore, and Europe.49Thus, whereas some hospitals in the Philippineshavereportedly had to close wards because of loss ofexperienced staff and sometimes entire teams, otherhospitals have a backlog of junior nurses seeking

Number by country of birth

(2000)

Number by country

of training (2004)

Nurse Doctor Doctor

Brunei 129 94 42

Singapore 1913 1356 678

Malaysia 7569 4679 2552

Thailand 3050 1390 633

Philippines 110 774 15 859 10 181

Indonesia 3449 2773 480

Vietnam 5778 7591 2578

Laos 867 331 36

Cambodia 1119 669 76

Myanmar 418 1725 782

Data are from references 43 and 44. OECD=Organisation for Economic

Co-operation and Development.

Table 4: Number of doctors and nurses from southeast Asia w orking in

OECD countries, by country of birth and country of training



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internships. A survey of 200 public and private hospitalsfound that administrators had little diffi culty recruitingnurses with less than a years experience, but had morediffi culty recruiting experienced nurses, particularly inprivate hospitals, which off ered lower wages on averagethan did public hospitals.50 The Philippines is thushampered by its low capability to employ the new nursesit has produced, and is now in surplus.

Indonesia also exports many nurses. Muslim countriessuch as Saudi Arabia, the United Arab Emirates,Malaysia, and Singapore are the main destinations. Fewdata are available, however, either for migration oremployment in the domestic private sector. With lowerhealth-worker production capacity per population thanthat of the Philippines, outmigration of experienced andhighly skilled nursing and midwife staff creates great

challenges for the system, and exacerbates the problemsof shortage and quality of care in the Indonesian healthsystem.32

Singapore is the major importer of doctors in southeastAsia. In 2009, a recruiting target was set of up to1000 foreign trained doctors. The Ministry of Health hasa webpage to advertise the benefi ts of migration toSingapore. Recent statistics show that two-thirds ofdoctors in the country and a third of doctors in the publicsector are foreign-educated (including those Singaporeandoctors who trained abroad).14 Singapore also importsnurses from other countriesan estimated 30% of allnurses working in the country are foreigners.

Recent years have seen a tendency for recruitmentpatterns to shift from individual applications or

institution recruitment to bilateral and multilateralformal agreements between origin and destinationgovernments. For instance, the Philippines andIndonesia have entered into bilateral agreements withseveral countries. The UKPhilippines agreement,signed in 2002, resulted in the recruitment of225 experienced Filipino nurses from 2002 to 2006. Theagreement came to a close in 2006, when the UKdeclared that nurse shortage was no longer a concern.51

Japan and Canada also entered into agreements with thePhilippines and Indonesia to provide skilled nurses.

At the regional level, the ASEAN Framework Agreementon Services, signed in 1995, progressively liberalises tradein services, with health being one of the 11 priority sectors.In 2001, members began negotiating mutual recognitionarrangements to facilitate fl ow of professionals, as agreed

by the Framework Agreement, with the expectation ofachieving free fl ow of health workers by 2010. Theagreements call for mutual recognition of qualifi cationsand professional licences across ASEAN countries. Amutual recognition arrangement on nursing services wassigned in 2006, followed by an agreement for medicalpractitioners in 2008. The diversity of the ASEAN region,including diff erences in the quality of education andtraining, licensing requirements, language, and culturaldimensions of daily medical practices between countries,makes implementation of these agreements challenging.15These barriers, as well as additional requirements of3 years of work experience for nurses and 5 years fordoctors, have posed diffi culties for the free fl ow of healthprofessionals in southeast Asia.

Figure 4: Internat ional fl ows of doctors and nur ses (mode 4)

Japan

Philippines

Indonesia

SingaporeMalaysia

Saudi Arabia

UK

USA

United ArabEmirates


http:///reader/full/humanresourcesforhealthin-southeastasia-shortagesdistributionalchallengesandinternationaltra 10/13

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DiscussionSoutheast Asian countries face diverse health workforcechallenges. Although there is not an aggregate shortage

of health workers at the regional level, fi ve countries inthe ASEAN region (Indonesia, Vietnam, Laos, Cambodia,and Myanmar) fall below the WHO threshold of228 doctors, nurses, and midwives per 1000 population.Thailand and Malaysia have low densities of healthworkers in view of their level of economic development,whereas the Philippines, Singapore, and Brunei havehigh densities.

Irrespective of how health-worker density relates tointernational norms, most countries in the region facepressures to increase the availability of qualifi ed andmotivated health workers in order to meet the needs ofthe population. Increased production of health workersclearly has an important part to play in addressing thischallenge. However, in many southeast Asian countries,

fi scal capacity restricts the scope for expansion of

public-sector employment, and many graduatingdoctors and nurses are not able to fi nd jobs in the healthsector. This problem points to the need to strengthenthe link between production and use or deployment oftrained workers through health workforce planning andeff ective engagement (and regulation) of medicaleducation providers.

One approach to improving the availability of staff withlimited resources is to shift some clinical functions andother responsibilities to lower level staff . This processoften referred to as taskshifting or substitutionhasbeen found to be a cost-eff ective solution to increaseaccess to services in various settings, although theevidence from middle-income countries is scarce.5254

Taskshifting can also entail increased reliance oncommunity-level workers, such as the communitymidwives that are widely deployed in Myanmar, whichmight be particularly helpful in contexts with underuseof facility-based services.

However, a high health workforce density does notnecessarily translate into improved availability of services,in particular for poor and rural populations. As elsewherein the world, many countries in southeast Asia facepersistent challenges in deployment (and retention) ofdoctors, nurses, and midwives to rural and remote areas,resulting in a high degree of inequality in the distributionof the health workforce (particularly doctors) acrossprovinces and regions. Many countries are also havingdiffi culty retaining staff in the public sector, withpotentially adverse implications for the availability ofservices for the poor and near-poor populations, whotend to be less likely to use private formal providers.Some countries in the region have had success inaddressing these challenges (panel 2), but imbalancesremain substantial. Although there are signifi cant gapsin the evidence base with respect to how best to addressthese imbalances, there is growing consensus on the mixof approaches that countries should consider to improvedeployment and retention.59,60 Experiences in specifi ccountries show that comprehensive strategies are moreeff ective than a single approach (panel 2). However,

countries need to be able to respond to changingsituations to ensure sustainable outcomes.

Of course, low health workforce density is by no meansthe only constraint to meeting population health needs.In many of the low-income countries in southeast Asiawith low health-worker density (critical shortage), use ofhealth services is often also low. Scarcity of humanresources is one factor in this situation, but poor-qualityservices, fi nancial barriers, and other factors might bemore important. Hence, eff orts to expand the healthworkforce in these contexts need to go hand-in-hand withcomplementary measures to reduce fi nancial and otherbarriers to service use.

We have also drawn attention to the growing trade inhealth services, and the signifi cance that this trade has for

Panel 2: Experiences of coping with shortage, maldistribution, and retention of

health workers in southeast Asia

In reponse to a shortage of midwives in Cambodia, the government established in 2003 a

1-year primary midwife programme, recruiting local students with grade 7 education. The

programme was scaled up nationwide in 2005, including recruitment of grade 10

students to improve quality. The governments goal of one primary midwife in each

health centre was achieved in 2009. In Laos, a low-grade auxiliary nurse training

programme was implemented between 1960 and 2002, after which a 3-year nursing and

midwifery programme was adopted to ensure standards. These programmes have

increased access to midwives in rural areas, but recent midwifery assessments concluded

that most of these midwives lacked basic lifesaving skills.20 Both Cambodia and Laos have

introduced Health Equity Funds to increase access for poor patients and to generate

additional revenue for health workers. Cambodia also piloted performance-based

contracting through non-governmental organisations, which improved availability of

health workers and reduced absenteeism.

Myanmar linked licensing of medical doctors with rural area practice. Nurses are obliged

to work for the public sector for 3 years, otherwise their licences to practise will be

withdrawn.55 Compulsory rural practice has a short-term eff ect, however, so other

measures were introduced in parallel, including fi nancial and non-fi nancial incentives

such as social recognition and career advancement.56

Vietnam requires 4 additional years of training for existing assistant doctors in health

centres at commune level to qualify as a medical doctor. Additionally, Vietnam increased

student recruitment from local areas and for ethnic minorities in disadvantaged isolated

communities (without entrance examination requirements), improved collaboration

between local hospitals and medical schools to accelerate in-service training, expanded

the 4-year community doctor training programme for grassroots-level staff , and rotated

high-level staff to work in low-level facilities.

Thailand responded with integrated approaches for rural retention, including recruitment

of local students, local training, and home-town placement of nurses and doctors.

Mandatory government bonding was initiated in the 1970s, and both fi nancial and

non-fi nancial incentives or motivation were subsequently provided for doctors in rural

practice.57 This measure reduced the gap in density of doctors between the poorest

northeast region and Bangkok from 21 times in 1979 to 94 times in 2000. Despite these

eff orts, retention of doctors in rural areas beyond the bonding period is diffi cultimpeding

factors include preferences among physicians for urban practice and specialisation training. 58



Series


health systems and policies for human resources for

health in the ASEAN region. High-income and middle-income countries are participating more actively in thistrade than are those with low incomes, with fl ows of bothpatients and health workers. Indonesia and the Philippinesboth export many doctors and nurses, although from verydiff erent starting points in terms of the organisation ofmedical education and training. Thailand and Malaysiaare actively involved in provision of health services toforeign patients, but have little involvement in the exportof health personnel. Singapore and Brunei are the mainimporters of foreign health workers, and Singapore is alsoengaged in medical tourism. Conversely, low-incomecountries in the region (Cambodia, Laos, Myanmar, andVietnam) are not engaged extensively in the trade in health

services, except with respect to wealthier patients seekingcare in middle-income and high-income countries.

Trade in health services is likely to continue to grow.Many countries are actively promoting medical tourism.For instance, the Thai Government is promoting Thailandas a major medical hub in Asia as part of an eff ort toexpand and diversify exports. Moreover, the ongoingprocess of regional (ASEAN) integration, which hasalready led to mutual recognition arrangements for threegroups of health professionals (doctors, nurses, anddental practitioners) and other measures to facilitate themovement of labour, is likely to result in increasedmovements of human resources for health within theregion. However, in practice, language skills and technicalcompetence will remain key criteria for potentialemployers, so the freedom to move will not necessarilytranslate into employment opportunities for healthworkers, in particular those from low-income countries.

Medical tourism and remittances from overseas workerscan generate substantial economic benefi ts, and potentiallygenerate broader benefi ts for patients and health workersthrough investments in facilities and health-workertraining, increased competition, and strengthenedaccreditation and quality standards. But these benefi ts areby no means automatic, and trade in health services alsohas many potential downsides. Although the evidencesuggests that trade in health services is not the main

driving force behind health-worker shortages ormaldistribution in the ASEAN region, this trade clearlyaff ects health-worker production and employmentpatterns, particularly in middle-income and high-incomecountries. Migration can deplete the domestic stock ofhealth workers, particularly specialist doctors andexperienced nurses, with eff ects on the quality andavailability of services. Similarly, medical tourism canexacerbate inequalities in access to health care because ofa brain drain of highly skilled health professionals frompublic to private hospitals and from rural to urban areas.37Medical tourism can also lead to a rapid expansion ofhigh-end, technology-intensive health care, which mightnot be sustainable over time and can distort practices andpriorities in the broader health system.

Although the growing trade in health services is clearly

an important policy challenge for countries in the region,how countries should respond to this challenge is lessclear. What can countries do to maximise benefi ts fromthe trade in health services? Can the risks be mitigated ormanaged? How should benefi ts, risks, and the interestsof sending and receiving countries be balanced? So far,the evidence base to answer these questions is weak, inpart because the way in which trade in health servicesaff ects health systems is highly context-specifi c. Withrespect to movement of health workers, banning ofmigration is widely recognised as neither possible norethical.61 One route to addressing this challenge hastherefore been to establish codes of practice for theinternational recruitment of health personnel. One such

code of practice was adopted by the 2010 World HealthAssembly, which aims to lay down principles for ethicalrecruitment of health personnel to maximise benefi ts andmitigate negative eff ects on countries while maintainingthe rights of migrant health personnel.62 However, thecode is voluntary in nature, and in view of the complexityof migration as an international occurrence, itsimplementation will inevitably be challenging.

Another route to address the challenge of migration isthrough bilateral agreements covering agreed numbersof migrants, but potentially also allowing for technicalassistance and capacity buildingmeasures that shouldallow the return of migrants to their home countries totrain and to teach, provide compensation where necessary,and forge partnerships between hospitals from sendingand receiving countries.63 Experiences from other regionssuggest positive results. For example, the UK and SouthAfrica signed a memorandum of understanding in 2003that established time-limited placements betweencountries and a framework for ethical recruitment ofhealth personnel. This memorandum has resulted in adecrease in the number of South African nurses andmidwives working in the UK, and the twinning policy hasimproved quality of health personnel in South Africa.63

So far, there has been less experience with similarmeasures implemented to balance the benefi ts and risksassociated with medical tourismfor example, through

local agreements, agreements between the public sectorand providers or associations engaged in the provision ofservices for international patients, or codes of goodpractice. Such measures could have potential, inparticular if accompanied by strengthening of qualityand accreditation throughout the health system, tostimulate transfer of capacity and good practice fromprivate providers through partnerships with medicaleducation institutions, and to reallocate benefi ts fromtrade in health services to public sectors, especially torural areas that might have been aff ected by internalbrain drain.

More generally, the eff ects of trade in health services onhealth systems hinge on how the supply of health workersresponds to a growth in migration and medical tourism.



Series


The supply of health workers, in turn, depends on how

the health education system is organised and regulated.Countries in southeast Asia off er very diff erent modelsin this respect. The rapid growth of export-orientedprivate training in the Philippines and Indonesia hasmitigated the eff ect of migration on the total stock ofhealth workers, but poor regulation of private traininghas compromised quality and contributed to over-production of health workers with scarce employmentprospects. Thailand on the other hand has no policy oftraining for the purposes of working abroad, and theprivate sector plays a very small part. Strong oversight isneeded to ensure quality and to regulate output in thePhilippines and Indonesia, whereas training policiesespecially for highly specialised staff in Thailand might

need to take into consideration the projected growth ofmedical tourism.

A fi nal point to emerge from our report concerns data.Despite the importance of human resources for health,there is little investment in collection of accurate andtimely data that could improve understanding of thesituation and inform policy. Data gaps are most notablein relation to the private sector. As a result, Ministries ofHealth in southeast Asia are in many cases not able tomonitor public and private production and employmentin the health sector. In countries where professionalorganisations such as medical and nurse councils areauthorised to register and to license professionals, thesecouncils can regularly update data for the stock of healthprofessionals. Data for workers in part-time and full-timeemployment by public and private sectors as well asindependent practitioners are more diffi cult to captureand to update. Moreover, data for salaries and income ofdiff erent health-worker groups are necessary to helppolicy makers to make decisions about compensationand incentive policies. Tackling of this problem willnecessitate country-specifi c design of eff ective data-capturing systems, and sharing between the public andprivate sectors. Finally, few comparative data are availablefor the quality of training and health services in southeastAsia. Such comparative information about quality couldbe gathered through specifi c studies, or through regional

eff orts to develop common quality indicators, monitoringtools, and possibly regional accreditation standards.

Contributors

CK set the conceptual framework of the paper, undertook the literaturesearch, compiled data from country authors, verifi ed data, and wasresponsible for data analysis, data interpretation, and writing of thepaper. PH set the conceptual framework of the paper together with CK,and contributed to data analysis, production of tables and fi gures, datainterpretation, and writing of the paper together with CK. ML (Laos) andTJ (Cambodia) set the conceptual framework of the paper together withCK, provided country data, verifi ed data, and edited and gave commentson the draft. FML (the Philippines) set the conceptual framework of thepaper together with CK, provided country data, provided information oncountry migration situation, verifi ed data and gave comments on thedraft. SAW (Indonesia), NLH (Vietnam), and JFdR (the Philippines)provided country data, verifi ed data for those countries in the paper, and

gave comments on the framework and on general content of the draft.

Confl icts of int erest

We declare that we have no confl icts of interest.

Acknowledgments

The paper is part of a Series funded by the China Medical Board, theRockefeller Foundation, and Atlantic Philanthropies. We thank thesteering committee of this Series on health in southeast Asia, inparticular Lincoln Chen and Suwit Wibulpolprasert for providinginvaluable comments on the framework and draft paper. We also thankThein Thein Htey (Department of Health, Myanmar) for providinginformation about the human resources for health situation inMyanmar, Manuel M Dayrit (WHO) and German Palabyab (ProfessionalRegulation Commission, Republic of Philippines) for providing data forproduction capacity in the Philippines, Ann Robins (Human Resourcesfor Health Advisor, WHO/Cambodia) for her contribution of data onhuman resources for health in Cambodia, and Khampasong Theppanyafrom the Department of Health (Ministry of Health, Laos) for assistingwith data for the Laos health workforce. We also appreciate thecomments from fi ve anonymous reviewers who have greatly helped

shape the content of the paper.References1 WHO. World health report 2006. Geneva, Switzerland:

World Health Organization, 2006.

2 Anand S, Brnighausen T. Human resources and healthoutcomes: cross-country econometric study. Lancet2004;364: 160309.

3 Chongsuvivatwong V, Phua KH, Yap MT, et al. Health andhealth-care systems in southeast Asia: diversity and transitions.Lancet2011; published online Jan 25. DOI:10.1016/S0140-6736(10)61507-3.

4 Tangcharoensathien V, Patcharanarumol W, Ir P, et al.Health-fi nancing reforms in southeast Asia: challenges inachieving universal coverage. Lancet2011; published onlineJan 25. DOI:10.1016/S0140-6736(10)61890-9.

5 Chen L, Evans T, Anand S, et al. Human resources for health:overcoming the crisis. Lancet2004; 364: 198490.

6 WHO. Measuring health workforce inequalities: methods andapplication to China and India. Human Resources for HealthObserver, 5. Geneva, Switzerland: World Health Organization,2010.

7 WHO. World health statistics 2009. Geneva, Switzerland:World Health Organization, 2009.

8 Suwannaki T, Sirikanokwilai N, Wibulpolprasert S. Supplyprojection for physician in Thailand over the next 25 years(19962020 AD). http://www.who.int/hrh/en/HRDJ_2_2_04.pdf(accessed Nov 27, 2010).

9 Srisuphan W, Senaratana W, Kunaviktikul W, Tonmukayakul O,Charoenyuth C, Sirikanokwilai N. Supply and requirementprojection of professional nurses in Thailand over the next twodecades (19952015 A.D.). http://www.who.int/hrh/en/HRDJ_2_3_05.pdf (accessed Nov 27, 2010).

10 The World Bank. Indonesias doctors, midwives, and nurses:current stock, increasing needs, future challenges and options.Jakarta, Indonesia: World Bank, 2009.

11 Vietnam Ministry of Health. Health statistics yearbook 2008.Hanoi, Vietnam: Ministry of Health, 2009.

12 Department of Personnel and Organization, Ministry of Health,Lao PDR, 2009. Human resources for health report, 2009,Vientiane, Lao PDR.

13 McCoy D, McPake B, Mwapasa V. The double burden ofhuman resource and HIV crises: a case study of Malawi.Hum Resour Health 2008; 6: 16.

14 The Temasek Review. Two out of three doctors in Singapore areforeign-trained, Jan 12, 2010. http://www.temasekreview.com/2010/01/12/two-out-of-three-doctors-in-singapore-are-foreign-trained/ (accessed June 25, 2010).

15 Ministry of Health, Laos PDR. Human resources for health:analysis of the situation in Lao PDR. Vientiane, Laos: Ministryof Health, Laos PDR, 2007.

16 Hemmings J, Sakulku S, Siphakanlaya S. Reproductive health atthe margins: results from PEER studies in southern Laos.Vientiane, Laos: United Nations Population Fund, 2008.

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