Trade and Health: The ASEAN Economic Community Blueprint

Ramon Lorenzo Luis R. Guinto University of the Philippines The Philippines is one of the founding members of the Association of Southeast Asian Nations (ASEAN), a regional bloc of 10 countries in Southeast Asia. For almost a decade, member nations of ASEAN have been discussing the full realization of regional economic integration by year 2020. In 2007, the heads of state signed the ASEAN Economic Community Blueprint that lays the steps towards the envisioned single market and production base in the region. In the blueprint, there were listed five core elements of economic integration: (i) free flow of goods; (ii) free flow of services; (iii) free flow of investment; (iv) freer flow of capital; and (v) free flow of skilled labour. The fifth element, free flow of skilled labor, exerts a potentially huge burden on the already-dismal state of the health workforce in the region. A recent Lancet series on Southeast Asia reports that although there is no shortage of health workers in the region overall, many countries in southeast Asia suffer from problems in the health workforce related to shortages, skill mix imbalances, and maldistribution of skilled staff. In the Philippines, for example, while six out of ten Filipinos die without seeing a health professional, the country suffers from overproduction, maldistribution, high out-migration, nil inmigration, and low return migration of health professionals. Healthcare sector integration in the ASEAN According to the document ASEAN Roadmap for Integration of the Healthcare Sector, which is based on the overarching economic blueprint, ASEAN countries will aim to increase the ability of skilled labor meaning, health professionals to provide services across border. It was recommended that arrangements for visa and work permits will be standardized to ease mobility of health professionals in the region. A mutual recognition arrangement (MRA) for nursing services has actually been already signed in December 2006 this is the first attempt to develop a common set of professional standards or competencies in medical services. Work is underway for a similar MRA on medical practitioners. According to the MRA, host countries still retain the right to recognize foreign nursing qualifications; foreign-trained nurses are required to work with local nurses and will still need to apply for a license to practice from the competent authority of the host-country. Over time, the ASEAN Joint Coordinating Committee on Nursing that was established under the MRA could explore further acceptance of home market credential and experience as members become more familiar with each others regimes and practices and skills converge at a high level. Regional economic integration versus national public health? This plan, which is already under way, poses both advantages and disadvantages. Allowing greater mobility of health professionals expands the space of opportunities for the regions doctors and nurses who may want to take other pursuits that are not available in their home countries. Furthermore, enabling health workers to practice in neighboring countries may enhance potential for joint learning through formal education and research activities. However, the potential dangers of this proposal to national health security are quite alarming. Such increase in mobility may lead to internal/regional brain drain. Doctors and nurses who are unsatisfied by

work conditions and limited opportunities in poorer countries in ASEAN, let us say Myanmar, will opt to transfer to more prosperous Brunei to practice their profession and receive higher salaries. Spots left unoccupied by doctors in urban areas will be replaced by doctors from rural areas, therefore leaving poor rural areas underserved. The country will be left with health workers of lower quality, since the highly qualified ones have gone for greener pastures in the richer ASEAN states. On the other hand, doctors from technologically advanced Singapore will look for lucrative opportunities to expand practice in countries with a thriving upper and growing middle class like the Philippines, in order to bring new technology and knowledge. Filipinos then might consider seeing instead Singaporean doctors in Manila, thereby displacing local doctors. Tensions may arise between local and foreign doctors who are competing for patients/customers. Such liberalization in the flow of health workers within the region may aggravate existing shortages in poorer countries, worsen maldistributions by bringing more doctors to the cities and to richer countries, decrease quality of health workforce in countries with high out-migration, and ultimately deepen inequities in access to health workers. It seems that these negative consequences have not been considered when the economic integration plan was devised and applied in the health sector. Consideration of health in trade agreements In 2008, the WHO Commission on Social Determinants of Health stated in its report that governments should institutionalize consideration of health and health equity impact in national and international economic agreements and policy-making. I hope the architects of the ASEAN Economic Community Blueprint and its accompanying policies pertaining to regional healthcare sector integration heed this call.