Some health implications of globalization in Thailand.

Abstract

In recent years Thailand’s economy has becomeincreasingly dependent on international forces (1).Withthisexposurehavecomeadvancesinhealthcaretechnologyand improvements in living standards,aswell as increasing disparities between social groups(2) and exposure to health risks from other parts ofthe world (3, 4).Prior to 1997, when the economy was strong,there was intense competition for a share of thehealth market. Resources were invested in specu-lative markets with potential for large expansion.Private hospital beds increased from 8066 in 1982to 21 297 in 1992 and 34 973 in 1996. The numberof specialized doctors in private hospitals increased,leading to shortages in the public sector (5). Thecultureoffreeenterprisebroughtwithitanenlarged middle class, insurance coverage forhospitalization, tax incentives for private healthcare, heavy investment in advanced health technol-ogy for private sector use, and an internal ‘‘braindrain’’, at the expense of public health (5, 6).Aggressive promotion increased the demand forexpensive imported medicines and procedures (7,8). The cost of medical care for civil servants andstate employees has quadrupled in the last sevenyears, reflecting the lack of adequate governance inthe health care business sector (5, 9). Meanwhilethe share of the underprivileged in the country’soverall wealth was decreasing (4). The slump of1997, followed by devaluation of the baht, andrecession with its concomitant negative healthimpact, reflects the country’s overdependence oncheap labour and foreign investment, and conse-quent inability to control and protect its owneconomy.Direct health effectsPerhapsthemostimportant directeffectofglobaliza-tiononhealthinThailandisunequalaccesstomedicalcare by different social groups. The rise in importedsophisticated technologies has increased costs andnecessitated new training. An analysis made in 1996found that the average cost of medical care peradmission was 1558 bahts for health cardholders(rural) and 9981 bahts for civil servants (privileged), asixfold difference (10). If these facilities were treatingsimilar diseases, explanations are needed for the hugevariation. The economic gap might create demandunrelatedtoneedanddistortmarketcompetition.Theorganization of health service delivery was obscure,and there were no rules governing the payment ofproviders. Unequal access to care was reflected byunequal health status (2). Infant mortality in thepoorestregionswastwiceashighasintherichestones.Second, there are increasing problems ofenvironmental pollution. These include inadequatetreatmentofrawsewage(forinstance,intouristareas),and the notorious air pollution in Bangkok and otherbig cities(11).Environmentaldegradation anddisrup-tion of the ecosystem have led to frequent floods andchangesindisease vectorbehaviour.Theconstructionof a dam in the North-eastern region, financed by aloan from a development bank, has caused naturaldisasters affecting food production (12).Third, concerns about new infections and theresurgence of old ones have been on the rise.Internationaltradeandtravelareshapingthepatternsof epidemics. The plague scare in India had world-wide reverberations. The nipah virus outbreak inMalaysia caused concerns in Thailand (13). Choleraepidemics can inflict enormous costs on a countryandthisresultsinattemptstohidethembycallingthedisease‘‘severediarrhoea’’.Thecostsassociatedwithcontrolling HIV infection continue to rise. Fears offoot and mouth disease have affected meat con-sumption. The control of new dangers of this kindwill require global cooperation but many aspects ofcontrol have to be country-specific.Fourth, globalization has brought with itunhealthy lifestyles. Health has been damaged bythepromotionoffashionabledrugs,foodsandotherconsumer products such as tobacco, alcohol,melatonin and Viagra. Fifth and finally, globalizationbringswithitmanyconcernsabouthealthethics.Forinstance, the options for genetic manipulation andthepatentingofthetechnologieswillhavedirectandfar-reaching effects on health and social well-being.