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Part 3. Brain Theft

Double Movement: Health Professionals and Patients in Southeast Asia

Nicola Suyin Pocock

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1Against a backdrop of widespread privatization of health systems, medical tourism and health-worker migration, commonly referred to as medical brain drain (MBD), are highly contested phenomena globally. Countries in Southeast Asia have been at the forefront of developing medical tourism as an industry, whilst dually restructuring their health systems and expanding health coverage to their own citizens. Simultaneously, thousands of health-workers trained in the region are migrating across borders to seek opportunities in Southeast Asia and beyond. Conceptually the links between these interrelated trends are not well understood. In this paper, I draw on descriptive data, prior conceptual work, and ecological studies to assess where medical tourism, health coverage, and health-worker migration converge, and outline the implications for health equity among local health-care users, particularly those who rely on public health systems.

Introduction

2A core concern at the nexus of medical tourism (MT), health coverage, and health-worker migration (HWM) is ensuring that citizens, especially users of public systems, are not disadvantaged by these trends. Arguably before MT becomes entrenched in a health system, as we observe in Thailand, Singapore, and Malaysia, universal coverage for the population should be achieved. A second concern is the satisfaction and well-being of health-workers themselves, including those that choose to emigrate. Ultimately, we care about better health status in origin countries, with our main research question focused on whether MT, and/or HWM, adversely affects health status.

3Southeast Asia, like many regions, faces challenges of shortages of skilled health-workers, maldistribution within countries, skill mix imbalances and, for some countries, high levels of out-migration without adequate in-migration to compensate. Reasons for low health-worker densities include inadequate production capacity for medical staff, restricted capacity for employment of graduates, and low pay in the public sector (Kanchanachitra et al. 2011). Figure 1 shows health-worker densities in the region.

Figure 1. Health-worker density per 1,000 population, 2000–2007 (latest year) (data from WHO 2009, first published in Pocock and Phua 2011b).

Figure 1. Health-worker density per 1,000 population, 2000–2007 (latest year) (data from WHO 2009, first published in Pocock and Phua 2011b).

4Although the total number of health-workers (doctors, nurses, and midwives) in the region is 1.6 million, with an average density of 3.2 doctors, nurses, and midwives per 1,000 population, above the World Health Organization (WHO) minimum threshold of 2.28 health-workers per 1,000 population, intraregional inequalities are severe. Five countries record health-worker densities below the WHO threshold, including Myanmar, Vietnam (1.4), Laos (1.3), Cambodia (1.1), and Indonesia (0.9) (WHO 2006; WHO 2009). Importantly, the differing ratios above likely reflect policy choices, e. g., Cambodia and Thailand focus on nurse-based primary care (Kanchanachitra et al. 2011). Dual practice is common in the region.

5Health-workers are concentrated in urban areas in most countries, resulting in inequitable national distribution. According to a recent analysis, however, the distribution of doctors in the Philippines, Thailand, and Vietnam over time is becoming more equitable between regions, and nurse distribution is becoming more equal in Thailand and Vietnam, but more unequal in the Philippines (Kanchanachitra et al. 2011).

6There is a clear relationship between poor human resources for health (HRH) policies and low use of health services, especially in the public sector. Potential users are deterred because of poor quality services and training of medical staff, financial barriers, and cultural factors (Kanchanachitra et al. 2011). Precisely because of poor quality services and training of health-workers, outmigration of health-workers is not an issue for lower-income countries, yet. As noted in migration research on general skills shortages in developing countries, “low demand and low supply reinforce each other, and educational quality is often very low” (Clemens 2013, 3). At heart of the problem is improving the supply side, including health-worker training and health infrastructure.

Health-worker migration

Physician emigration

7The medical brain drain (MBD) dataset provides estimates of physician emigration from 191 source countries to Organisation for Economic Co-operation and Development (OECD) countries between 1991 to 2004 (Bhargava, Docquier, and Moullan 2010). Physician emigration from Association of Southeast Asian Nations (ASEAN) to OECD countries (defined as the percentage of doctors trained in country who migrated that year), remained relatively consistent between 1996 to 2004, although there is a slight upward trend for Singapore and Thailand. Globally, Southeast Asian countries have far less MBD than countries in Africa and the Caribbean, and other small countries.

8In 2004, the latest year for which data are available, we see that Singapore and the Philippines have the highest rates of physician emigration (17% of physicians trained in country migrated), followed by Thailand (12%), Burma (11%), and Malaysia (10%) (Figure 2). Since then, government strategies to increase medical tourism have proliferated in Singapore, Malaysia, and Thailand and, to an extent, the Philippines (Pocock and Phua 2011a). Developing the MT industry can be seen as a tactic to reduce international emigration of health-workers, particularly of specialists. Anecdotal research from Thailand indicates that medical graduates, having acquired specialized medical degrees abroad, are finding it lucrative and more satisfying to stay in their home country (UNESCAP 2007). Politicians in Singapore have reasoned that, in order to recruit and retain specialists in a country with a small local population, the country must attract a high volume of medical tourists. However, within countries, the growth of medical tourism may exacerbate public to private sector brain drain, notably of specialists who provide elective surgeries demanded by foreign patients (Pocock and Phua 2011a).

Figure 2. Physician emigration rates from ASEAN countries, 2004 (Bhargava, Docquier, and Moullan 2010).

Figure 2. Physician emigration rates from ASEAN countries, 2004 (Bhargava, Docquier, and Moullan 2010).

9Among Thai emigrating physicians, 97% opted for the United States (US), along with 94% of Filipino doctors, and 52% of Burmese doctors, whilst 74% of Malaysian doctors opted to migrate to Australia. This may be linked to country of training. Eligibility of medical qualifications and English as the main language likely play a role in choice of destination country. Language has been shown to be a key determinant in the migration decision, with emigration rates higher amongst countries whose languages are more similar (Adsera and Pytlikova 2012).

What induces doctors to leave or to stay?

10Health-workers leave for well-known reasons, including higher wages, better training opportunities and better working conditions, as well as for personal reasons including family ties abroad and better education for children (Henderson and Tulloch 2008). In source countries, inadequate supplies/equipment, mismatch between skills and tasks, and poor supervision and management can provide incentives to migrate. Political instability and risk of violence can also be push factors for migration, in a sector where skills are highly portable (Henderson and Tulloch 2008). Higher HIV prevalence rates may prompt doctors to migrate (via the mechanism of increased transmission risk) (Bhargava and Docquier 2008). This is corroborated in studies whereby doctors are also not compensated for this additional risk (Bhargava and Docquier 2008).

11A longitudinal analysis of MBD from 31 sub-Saharan African (SSA) countries to the United Kingdom (UK) and US found economic conditions in source countries to be a determinant of physician emigration. A 1% decline in GDP per capita increased MBD by 0.3% in the next period (Okeke 2013). In a cross-sectional study of physician emigration from 141 countries to the US, Canada, Australia, and the UK, better-endowed origin countries with more health-workers, more economic and developmental progress, and better health status lost proportionately more physicians than more disadvantaged countries (Arah, Ogbu, and Okeke 2008). Singapore, the Philippines, Thailand, and Malaysia, as relatively better-endowed ASEAN countries, do appear to have higher MBD rates, as shown in Figure 2. As countries become richer, retention strategies for physicians become much more important, whereas poorer countries should focus on training policies (Arah, Ogbu, and Okeke 2008).

12The finding that better-endowed countries lose more doctors is less surprising when we consider macro migration trends. Using World Bank and United Nations (UN) data between 2005 and 2013, the Pew Research Center finds that international migrants are increasingly living in high-income countries (57% in 2005 to 69% in 2013), but were born in middle-income countries (48% in 2005 to 58% in 2013), whilst the share of migrants born in low-income countries (18% to 15%) and high-income countries (31% to 24%) has declined (Pew Research Center 2013).

13In a longitudinal analysis of health development assistance (health ODA) and physician emigration from 50 countries to OECD countries, changes in the physician emigration rate were negatively related to health ODA—that is, higher health ODA reduced growth in physician emigration rates in the long term, through the likely improvement in working conditions (facilities, equipment, technical expertise) (Moullan 2013, 12). Surprisingly, wages in destination country had a small, insignificant effect (3.8%) on physician emigration—corroborating prior findings that wages are not the most important factor in the migration decision for doctors or for the highly skilled overall (Gibson and McKenzie 2011b; Vujicic, Zurn, Diallo, Adams, and Dal Poz 2004). Consistent with studies on overall skilled migration, Moullan (2013) found that smaller countries (<2.5 million population) have higher physician emigration rates than larger countries (Docquier, Lohest, and Marfouk 2007; Moullan 2013). Smaller population sizes may indicate fewer opportunities for career progression or greater competition for such opportunities, especially among surgeons with highly specialized skills.

What do we know from studies of migration of the highly skilled?

14A rich literature on the migration of the highly skilled contradicts conventional thinking on causes and consequences of outmigration. As Clemens (2013) points out, “skill shortages in developing countries are the result of a complex mix of structural factors, which persist whether workers stay or emigrate.” These factors are numerous and include: low returns to education in an impoverished economy, the effect of poor nutrition on cognition, cronyism in school placements, inadequate tax revenue for good quality public education, corruption in public training systems, and other barriers to private education. In most cases, preventing the movement of skilled workers will not address these problems (Clemens 2013, 3).

15Furthermore, Clemens contends that the financial effects of highskilled emigration are exaggerated—he finds that the costs of training a skilled worker are far outweighed by ODA flows to developing countries (Clemens 2013). Besides development assistance, a study of Tongan and Samoan nurses in Australia found that remittances more than compensated for the cost of their training (Connell and Brown 2004). However, besides overall development needs, ODA flows must be funneled into the appropriate direction in the health sector also—by training health-workers, raising salaries in the public sector, funding essential health infrastructure and medicines—in order to compensate for MBD. Whilst it makes sense that overall development in a country may induce the highly skilled (and lesser skilled) to stay, health-sector-specific funding must also be mobilized to improve human resources for health.

16Further benefits accrue from skilled migration. Empirical studies find that there are three brain gain mechanisms: increased investment in education in source countries from remittances, the return migration of skilled migrants (Gibson and McKenzie 2011a), and the “incentive effect”—those in home countries will opt to improve their education levels in response to potential gains via migration, but not all will actually migrate, leaving a net brain gain effect (Collier 2013).

17Gibson and Mackenzie find a significant role of non-financial incentives in emigration and return migration decisions of the highest skilled in Pacific Island countries—specifically related to opportunities for progression—to be working amongst leaders in the profession, over and above financial incentives (Gibson and McKenzie 2011b).

18With better health status as the ultimate concern, whether stopping health-workers from emigrating will improve health status in source countries, as much as rises in incomes, better housing and schooling, and well-run institutions becomes a central research question demanding further study (Clemens 2013). This article cannot answer this question, but instead outlines the implications for health equity among health-care users when MT, health coverage, and HWM converge.

Consequences of physician emigration

19There are several possible consequences of physician emigration. The incentive effect posits that more individuals enter medical school in countries with a higher physician emigration rate, such as in the Philippines (Bhargava, Docquier, and Moullan 2011). In a sample of health professionals and policymakers in six African countries, respondents observed a link between HWM and deterioration of teaching quality in medical schools (Awases, Gbary, Nyoni, and Chatora 2004). In Thailand, medical faculty in public teaching hospitals have been observed to shift to the private sector, associated with medical tourism (Phyu and Chotbenjakul 2010).

20There have been mixed results on how physician emigration affects health status, likely due to the explanatory and dependent variables used. One study finds that MBD did not significantly hamper vaccination rates nor affect child mortality—two important indicators of health coverage (Bhargava et al. 2011). Yet, another finds that a 1% increase in MBD led to a 0.5% increase for child and infant mortality respectively (Chauvet, Gubert, and Mesplé-Somps 2008). However, when considering AIDs mortality, a third study found that, when HIV prevalence was above 3%, a doubling of MBD implied a 20% increase in the number of adult deaths from AIDs (Bhargava and Docquier 2008). Given the mixed evidence, we can at least conclude that MBD does not have positive effects on health status—it is at best neutral (when countries have sufficient HRH already) or negative (when countries have severe health-worker shortages).

Health-workers and health coverage

21In studies of health-worker densities and health coverage, nurse density was found to positively impact measles, diphtheria, and polio vaccination rates, whereas doctor density has no effect. Health-workers not only provide vaccination services directly—the presence of health-workers can increase demand for health services by educating potential users about the benefits of vaccination and by training unskilled volunteers to perform vaccinations (Anand and Bärnighausen 2007, 1283). Health-worker densities have been found to have a positive impact on mortality rates, particularly via doctor densities, with the greatest impacts on maternal mortality compared to child mortality. This may be because qualified health-workers “are able to address a larger proportion of conditions that put mothers at immediate risk of death compared with infants or children” (Anand and Bärnighausen 2004, 1607). These findings are corroborated elsewhere, with healthworker density significantly and positively associated with skilled birth attendance, as well as measles immunization (Kruk, Prescott, de Pinho, and Galea 2009, 5).

22High health-worker densities have clear positive impacts on health service coverage. So where does HWM fit into the equation? In theory, if a country trains sufficient health-workers for its domestic needs, with additional health-workers trained to compensate for those that migrate, health status may not be adversely affected (although intracountry differences may persist, owing to rural-urban migration and health inequities that may result from public to private brain drain). However, the main question for health equity arises when a country has a shortage of health-workers for domestic needs, but medium to high levels of MBD. This dynamic requires policies that may involve expanding training opportunities, recruitment, and retention strategies.

Private sector—unclear role in health outcomes and physician emigration

23As none of the analyses examining health outcomes and health-worker densities control for the proportion of health-workers in the private sector, we have little idea about how the public/private split affects health outcomes. Case studies of physician emigration and health systems in India, Ghana, and Peru found that private health-care delivery and financing per capita appeared to decrease physician emigration (Loh, Ugarte-Gil, and Darko 2013).

24Generally, little is known about the role of private-sector health-workers in providing essential public services. A recent literature review found that non-profit private-sector workers can contribute to immunization provision in low-income countries, whilst for-profit providers facilitated the adoption of new vaccines before mass public sector roll out (Levin and Kaddar 2011). Beyond this, the author found no further studies on the private sector’s role in health coverage.

25Of the three countries where medical tourism is most popular, Thailand retains the largest share of health-workers in the public system, as seen in Figure 3 (the proportion for nurses is similar across the three countries). But as Figure 3 also shows, the internal distribution of Thai doctors varies considerably, with public sector doctors most concentrated in provinces outside of Bangkok. In general, wealthier patients in cities can afford private health services, whereas those in rural areas may not be able to, the public sector being a positive leveling force for health equity. However, health-worker densities in less urban areas must also be sufficient to have positive effects for health equity.

Figure 3. Proportion of doctors in public/private sector, latest year—Proportion of doctors by agency and region in Thailand, 2008 (MOH Malaysia 2012; MOPH Thailand 2010; Singstat 2012; adapted with some data from MOPH Thailand 2010).

Figure 3. Proportion of doctors in public/private sector, latest year—Proportion of doctors by agency and region in Thailand, 2008 (MOH Malaysia 2012; MOPH Thailand 2010; Singstat 2012; adapted with some data from MOPH Thailand 2010).

26A key issue in Southeast Asia is regulating dual practice (DP). In Indonesia, reportedly nearly all public-sector specialists engage in DP (Meliala, Hort, and Trisnantoro 2013). In the Philippines, doctors are legally permitted to treat private patients in an effort to retain them in the public sector (Kanchanachitra et al. 2011). This is also the case in Thailand, where an estimated 55% of doctors’total earnings come from private practice (García-Prado and González 2011). A recent review of dual practice in East and South Asia finds a lack of research in this area despite the rise of dual practice in line with increasing demand for private health-care. Rapid private sector growth and weak regulation in the region raises the risk that dual practitioners will ignore the poor. However, the authors suggest that DP can improve health service access and the range of services offered and increase doctors’ satisfaction when it is appropriately regulated (Hipgrave and Hort 2013).

Retention strategies for the public sector—Thailand’s experience

27To retain health-workers in the public sector in understaffed rural areas, Thailand has implemented various policy measures including public service bonds, a specialized rural track recruitment program for medical schools, rural service prerequisites for specialized training, founding of medical schools in rural areas, special salary rates for rural physicians, and general shifting of resources from urban to rural areas (Wanchaijiraboon 2012; Wiwanitkit 2011).

28Unlike other countries in Southeast Asia, Thailand has restricted the entry of private, for-profit medical schools, instead permitting only non-profit private medical schools. Private school graduates must pass the national licensing exam, compared to automatic licensing in public schools (Wibulpolprasert and Pengpaibon 2003). To date, there is only one private institution (Rangsit University) among 21 public medical schools (Saereeporncharenkul 2011).

29A new round of internal drain to the private sector in Thailand is observed as partly attributed to medical tourism—however, Wibulpolprasert and Pachanee (2008) note that increased demand from the wealthy urban Thai population for private health services is a bigger driver, along with rising social and income inequality. Emigration of health professionals in Thailand has not been a major problem, partly due to decent income, good working conditions and opportunities for progression, and limited English language skills (Wibulpolprasert and Pachanee 2008). Approval by the Medical Council to one of the public universities to introduce an English language medical school program was met with staunch criticism from the National Health Personnel Committee, due to concerns that this would exacerbate public to private brain drain within Thailand, despite assurances that graduates would still be bonded for three years or have to pay compensation (Bangkok Post 2010). Language has also been a determinant of incoming HWM, as all doctors who wish to practice in Thailand must pass the medical exam in Thai. Some private, MT-driven hospitals have been excluded from this policy, if they are only serving foreign patients.

Growth in medical tourism in Southeast Asia

30Medical tourism has been defined to involve “the organized travel outside one’s natural health-care jurisdiction for the enhancement or restoration of the individual’s health through medical intervention,” using but not limited to invasive technology (Carrera and Bridges 2006, 1). This definition takes into account the territorially bounded nature of health systems, where service access is often but not always limited to national boundaries (Pocock and Phua 2011a). Medical tourism is growing rapidly in Southeast Asia—Malaysia alone saw a doubling of medical tourism revenue, from 254 million ringgit in 2007 to 511 million ringgit in 2011 (Chee 2010).

31Anecdotally, many medical tourists in Southeast Asia appear to be from neighboring countries, reflecting inequities in service provision at home, either via unavailability of quality services or underinsurance (Pocock and Phua 2011a). For example, in Singapore and Malaysia, it is claimed that most medical tourists are from ASEAN countries, whilst Thailand’s consumers are often from outside the region, with the Japanese accounting for the largest share of foreign patients (UNESCAP 2007). In 2011, 47.2% of Singapore’s and 57% of Malaysia’s medical tourists were Indonesians (Pocock and Phua 2011a). Low-quality public and private health provision at home forces those who can afford it to undergo treatment overseas, with Malaysian, Singaporean, and Thai hospitals offering specialized services unavailable in other, especially poorer, ASEAN countries (Arunanondchai and Fink 2007; UNESCAP 2007).

32Yet, a recent Gallup poll with a sample of over 17,000 adults aged 15 and above in selected Asian countries found that most people travel domestically for health-care, rather than regionally or internationally. For example, 12% of Malaysians had traveled within the country to seek treatment, with just 1% traveling overseas for treatment. Among respondents from Cambodia, Indonesia, Malaysia, the Philippines, Singapore, and Vietnam, between 0–2% had traveled internationally for health-care (Gallup 2010). Even though anecdotally ASEAN countries are well represented as medical tourists according to Singapore and Malaysia, it may be that those who travel for health-care are wealthier groups from poorer countries who overall comprise a much smaller percentage of their domestic population.

Potential costs of medical tourism to health systems

33The policy implications of medical tourism reach beyond the potential to crowd out consumption by locals. As Chee (2010) points out, when middle-class fee-paying patients decide to undertake treatment abroad, their domestic health systems lose out, not only financially but in terms of the political pressure that these potential consumers could exert to improve the health system that poorer consumers rely upon (Chee 2010). The possibility to “exit” low-quality health systems gives the middle class little incentive to exert pressure for quality improvement (Hirschman 1970). This equally applies to domestic users of private health services—as noted in Thailand, demand from wealthy urbanites is likely the largest driver of internal public to private brain drain (Wibulpolprasert and Pachanee 2008).

34Although driven by the private for-profit sector, the public sector is accommodating medical tourists by constructing private wings in hospitals, as is evident in Singapore’s corporatized public hospitals. At least when hospitals are publicly owned, revenues from medical tourism are taxable and thus can be reinvested back into the public sector by the government, which is not necessarily the case for private hospitals, depending on tax incentives offered (Pocock and Phua 2011a).

Is medical tourism a retention strategy for emigration of health-workers?

35A recent study on medical tourism in Singapore, Thailand, and Malaysia compared private hospitals and their role in medical tourism. The authors found that excess capacity in private hospitals could be used for the population at large, and that private-sector stakeholders seemed interested in contributing to medical education, which could help ease present HRH shortages (Herberholz and Supakankunti 2013). This raises the question of whether private-sector capacity could be leveraged for the public good, and coupled with DP regulation, whether international HWM and public-to-private flight could be discouraged.

36To date, hampered by a paucity of data on MT and data quality issues such as double counting of medical tourists, there are no studies examining how an increase in MT or DP regulation might retain health-workers within a country, or within the public system. Herberholz and Supakankunti’s (2013) study alludes to the possibility that growth of MT could be leveraged for wider gains to the public health system, but there has been no documentation of specific policies to that broad end.

Discussion

37This paper has charted the intersection of health-worker migration, health coverage, and medical tourism in Southeast Asia, where a rapidly growing private sector and public-to-private flight without regulatory oversight has emerged. The implications for health equity at home are not straightforward. At the nexus of these phenomena, we can conclude that health-worker densities are important for health-service coverage, and that geographic and public/private distribution of health-workers also affects health equity at home. Retention strategies in the public sector matter for health equity, as demonstrated in the case of Thailand. MBD is not a positive force for better health status, although it may be neutral in instances where a country already has sufficient health-worker densities (with adequate staffing in the public sector). Yet when a country experiences health-worker shortages, MBD is likely to be a negative force to leveling health inequities domestically. There is a dearth of research on the private sector’s role in health coverage, with no studies evaluating its effects on equity. Finally, doctors are induced to leave based on a variety of reasons, including those related to the health sector (e.g., poor hospital infrastructure, lack of career progression opportunities) as well as broader development challenges (e.g., education of children). But this does not reveal the full picture of the nexus.

38Key questions and knowledge gaps remain beyond the Southeast Asian context. These include:

  • How do HWM and MT affect health status?
  • How do HWM and MT affect health coverage?
  • Does MT discourage international HWM?
  • Could DP regulation discourage public-to-private flight?
  • Are lower HWM rates associated with improved health status?
  • What is the role of the private sector in providing essential health services (if any)?

39An overarching question is whether public-private, rural-urban HWM, in the face of increased demand, is the bigger issue, rather than international HWM or MT. It is clear that we need more and better evidence of MT’s impact. As elaborated elsewhere:

“Access to health-care in developing countries, the main destinations of medical tourists, is notoriously uneven, and often becoming more so. Medical tourism, urban bias and privatisation have combined to exacerbate this trend. This is exemplified in both Thailand and India, where regional areas have been disadvantaged by the migration of health-care workers to hospitals focusing on medical tourism, neoliberal national financial provision for medical tourism (and related tourism campaigns) and evidence of trickle-down gains is lacking.” (Connell 2011)

40To ensure affordability and equity between medical tourists (or private fee-paying users generally) and local citizens, policies are needed to ensure that public services are readily available and subsidized—i. e., there needs to be a redistribution mechanism in financing regardless of the levels of MT or private health provision in an economy. Dual practice has policy potential—coupled with excess capacity in private hospitals—to ensure that citizens’ access to health services is safeguarded, particularly access to specialists, who from observation are more likely to be lost to the private sector. Finally, perhaps governments should consider restrictions on private hospital building—after years of tax breaks and financial incentives, slowing private-sector growth would enable health authorities to work on regulation of this sector.

41As for HWM, we might consider emerging empirical work considering the benefits of emigration of the highly skilled, a.k.a. “skill flow.” Before jumping to the conclusion that HWM is inherently bad for health systems, we may need a more constructive approach that includes mobility of health-workers as a reality, and recognition that the broader challenges of development may affect health status more than HWM might.

42As the Thai case illustrates, policy responses to public-to-private flight of health-workers are likely to be more effective when targeted to potential health-workers in provinces with critical HRH shortages. Having a package of tailored retention policies is increasingly important for low-and middle-income countries which, as they grow richer, may lose proportionately more health-workers than less well-endowed countries. Policymakers must heed the message “health is wealth” and invest in health systems that are socially equitable and of benefit to the entire population.

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Table des illustrations

Titre Figure 1. Health-worker density per 1,000 population, 2000–2007 (latest year) (data from WHO 2009, first published in Pocock and Phua 2011b).
URL http://books.openedition.org/editionsmsh/docannexe/image/10763/img-1.jpg
Fichier image/jpeg, 66k
Titre Figure 2. Physician emigration rates from ASEAN countries, 2004 (Bhargava, Docquier, and Moullan 2010).
URL http://books.openedition.org/editionsmsh/docannexe/image/10763/img-2.jpg
Fichier image/jpeg, 69k
Titre Figure 3. Proportion of doctors in public/private sector, latest year—Proportion of doctors by agency and region in Thailand, 2008 (MOH Malaysia 2012; MOPH Thailand 2010; Singstat 2012; adapted with some data from MOPH Thailand 2010).
URL http://books.openedition.org/editionsmsh/docannexe/image/10763/img-3.jpg
Fichier image/jpeg, 98k

Auteur

Doctoral student at the Gender Violence and Health Centre at the London School of Hygiene and Tropical Medicine (LSHTM). Her thesis explores the health needs of men trafficked for commercial fishing in Thailand. Prior to her studies at LSHTM, Nicola was the health systems researcher at the Asian Trends Monitoring Bulletin, a Rockefeller-foundation-funded project on pro-poor development based at the Lee Kuan Yew School of Public Policy, National University of Singapore.

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