Doctors Allocation Policies on Equitable Distribution of Doctors in Thailand | Health human resources

Ensuring an adequate supply and equitable distribution of health workers is critical to achieving effective universal health coverage and the Sustainable Development Goals. Equitable geographic distribution of physicians is a recurring challenge to the global health workforce and has been part of the health policy debate for decades. Studies have shown that a higher density of physicians is associated with better health outcomes such as increased life expectancy and lower standardized death rates [1,2,3,4,5]. Concentration of physicians in one region at the expense of others, such as high concentrations of physicians in large cities and urban areas, has led to unequal access to health care in many countries. [6]. Moreover, social and cultural changes and the increasing incidence of chronic diseases among the aging population increase the demand for health care much faster than the supply of physicians. [1]which effectively widens the gaps of unfair distribution of the labor force.

Thailand is an upper-middle-income country that implemented a universal health coverage plan in 2002, and by 2017, 99.84% of the Thai population had some form of health coverage. [7]. Available health facilities that provide services to people can be classified according to a three-tiered service system consisting of primary, secondary and tertiary care facilities. Primary health care facilities provide services that include treatment of common ailments, health promotion, disease prevention, rehabilitation and community health interventions. This type of health facility includes health centers that are mostly under the control of the Ministry of Public Health. Secondary health care facilities provide curative care after referral from primary care facilities. These health facilities include district hospitals run by the Ministry of Public Health, other public hospitals, and private hospitals. Tertiary healthcare facilities provide specialized care, usually after referral from primary or secondary healthcare facilities. These facilities include public and regional hospitals run by the Ministry of Public Health, university hospitals, other public hospitals, and private hospitals. [7]. Many health facilities are concentrated in the capital, Bangkok, which has a population of 5,487,876. Among the general hospitals in Bangkok in 2017, 5 were medical school hospitals, 18 were specialty hospitals, 26 were general hospitals, and 137 were medical centres. In addition, 108 of the country’s 308 private hospitals (35%) were located in Bangkok in 2017. [7]. At the provincial level, covering 76 provinces excluding Bangkok, there were 6 medical school hospitals, 49 specialty hospitals, and 28 provincial hospitals in 2017. At the provincial level, health facilities included general or regional hospitals, district hospitals, and health centers. In 2017, there were 88 general hospitals covering all governorates, 780 district hospitals covering 88.8% of districts, and 9,777 health centers, operating as primary healthcare facilities, covering all sub-districts. [7]. Almost all health facilities at the provincial level fall under the responsibility of the Ministry of Public Health, but private hospitals are also found in large regional centres.

The number of physicians, including general practitioners and all specialist physicians, was 41,746 in 2013, and the ratio of physicians per 1,000 population was 0.65. [8]. Annual output of general practitioners from all medical schools in Thailand increased from 1,676 in 2013 to 3,218 in 2017 [7]However, the density of doctors in Thailand is still much lower than the average density of doctors in Southeast Asian countries (1.1 / 1000 people) and Europe (2.9 / 1000 people). [9]Which indicates a shortage of doctors. In addition, doctors in Thailand are not equitably distributed between rural and urban areas or between provinces with lower economic status and wealthier provinces. [4], which impedes the effective provision of health care services by the Thai health system. The Thai government has implemented a multi-pronged intervention strategy for decades to attract and retain doctors in underprivileged areas. To increase the number of doctors serving rural areas, a special track for recruiting and training students has been implemented that enrolls students with rural backgrounds, provides training in medical colleges and Ministry of Public Health hospitals close to their hometowns, and obliges them to return to their home provinces upon graduation. These interventions help increase the likelihood of medical graduates choosing to work and remain in rural areas [10,11,12]. This particular track currently accounts for 47% of the total number of fresh graduates (General Practitioners) recruited to work in MOPH facilities annually [10, 11]. In addition, financial and non-financial incentives to attract and retain physicians to MOPH facilities have been implemented, details of which can be seen in the reviews of Wibulpolprasert el al. [13] and Pagaiya and Noree [14]. However, as the general health needs of the population continue to increase due to the increasing proportion of elderly patients and the increasing incidence of chronic diseases, more health workers are needed. The current situation combines a general shortage of doctors with a growing demand, which has exacerbated the poor distribution of doctors.

In a strategy to address misallocation of physicians, the Ministry of Public Health began allocating newly graduated general practitioners according to the use of health services in 2017. [15]. With this approach, physician requirements for each hospital were determined in 2017 based on service utilization at that hospital in 2016. The services were outpatient visits, inpatient days, operation services, delivery services, and accident and emergency services. In addition, in each hospital, the ratio of one physician per five health centers was used to estimate the number of physicians required for a primary health care service, and the physician per health center ratio was based on service utilization in health center facilities. [15]. The total number of physicians required for all MOPH facilities in 2017-2021 was expected to be 20,053 – 24,668 physicians. To achieve this goal, newly graduated general practitioners were allocated to each governorate during the period 2017-2021 according to the use of the service and the number of health centers in the region. It is important that the distribution of doctors be fair, so that people get accessible, qualified and effective health services. Therefore, this study aimed to assess the effects of allocating physicians by the Ministry of Public Health in relation to the distribution of shareholders’ equity.