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ASEANS MUTUAL RECOGNITION


ARRANGEMENT ON MEDICAL
DOCTORS FOR 2015

Freedom. The idea of freedom has been in the hearts and minds of
people and of countries for the duration of several years. Countries have
fought for this through literary works and others, through blood shed. Many
lives have been lost and many dreams have been shattered just to make the
idea of freedom turn into reality. Freedom can be personal. It could also be
economic or political. Although these have several definitions from different
sources, simply they are the freedom to exercise rights as citizens and rights
as a producer or a consumer in a globally competitive market. Countries in
the Southeast Asia region have struggled over the years for freedom. Their
diverse socioeconomic status, colonial history, political systems, health
systems, and health situation have been the barriers in achieving and
attaining freedom. The Southeast Asia region does not wish for more lives
lost. They have had enough over the years. They seek for freedom not
through swords and guns but through dialogue. By achieving peace, they
achieve freedom. They achieve personal, economic, and political freedom.
Southeast Asia is considered one of the most dynamic regions on earth
because of its great diversity among countries. These countries vary in size,
levels of development, resources both natural and human, histories, cultures,
languages, religions, races, politics and governance, economic and social
institutions, and values and traditions. The desire of these countries toward
economic growth, social progress and cultural development alongside peace
and stability paved the way for the establishment of the Association of
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This case was written by Maristella Divinagracia under the supervision of Dr. Kenneth Hartigan-Go, Asian
Institute of Management. All case materials are prepared solely for the purpose of class discussion. They
are neither designed nor intended to illustrate the correct or incorrect management of problems or issues
contained in the case.
Copyright 2012, Asian Institute of Management, Makati City, Philippines, http://www.aim.edu. No part of
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Southeast Asian Countries (ASEAN). This organization was formed on August


8, 1967 in Bangkok, Thailand. Its founding countries are Indonesia, Malaysia,
Philippines, Singapore and Thailand. Through time, its membership has
expanded to Brunei on January 7, 1984, Viet Nam on July 28, 1995, Laos
and Myanmar on July 23, 1997, and Cambodia on April 30, 1999. These ten
member states constitute the present ASEAN.
Economists continually state that economic freedom and political
freedom play an important role in the development of a country because they
promote economic growth. The ASEAN did just that. Because of that, many
have challenged its effectiveness.
To begin with, the ASEAN was founded in the midst of poverty and
conflict. Indonesia had a blood- shed confrontation with Malaysia. Malaysia
had gained its separation from Singapore. Singapore has had numerous race
riots. Malaysia underwent racial tensions that reached its climax in 1969. Viet
Nam faced civil conflict that caused the lives of people in major powers while
Laos and Cambodia indirectly suffered from such event. Former Indochinas
war posed a threat to the security of Thailand. Philippines and Malaysia were
in dispute over the island of Sabah. These external affairs of the countries
added more instability to the economic and social conditions of the countries
in Southeast Asia during the 1950s and the 1960s but all these were halted
after the ASEAN has been established. Indeed, its spectators have also been
stunned with the benefits of the said association. ASEAN has been proud to
show the positive trends in statistical averages among its members to prove
the economic benefits of the ASEAN. There has been an 8% economic growth
rate from 1992- 1997, 16.5% average annual increase in exports from 19931996, and an insurmountable increase in foreign direct investment. The list
may go on but what was significant was its impact on the people. There has
been a notable improvement in the lives of the people in Southeast Asia.
The average person in the first seven members of
ASEAN expected to live just slightly longer than fifty
years in the 1965- 1970 period. In the years from 1990
to 1995, the average person expected to live 64.7 years,
or an increase in life expectancy of 14.6 years in less
than thirty years. Related to this was the remarkable
decline in the mortality rate, with the crude death rate
dropping from 16 per thousand population in 1965- 1970
to 7.7 per thousand population in 1990- 1995. Access to
health care showed similar improvements, whether in
term of population- to- physician ratios, in terms of
population- to- hospital bed ratios, in terms of
percentage of births attended by trained health staff, or
in terms of infant immunizations. The per-capita calorie
supply for all nine present ASEAN members was
increased by more than 23 percent from 1965 to 1996.
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The average adult literacy rate for the six original ASEAN
members rose from 64 in 1970 to 83 in 1990, higher
than the world average and much better than the
average for the developing countries. 1
Indeed, such facts leave an impressive mark for the association. This
goes to show that the ASEAN, although it had a shaky take- off, its smooth
flight at present may attain its targeted goals and objectives after all.Or will
it? In a way, personal freedom has been achieved because people have the
right to live; to actually live long.
In spite the whopping record of the ASEAN, myriad of people have also
questioned the nature of it. There may be too much freedom among member
states because there are no governing body and set of rules for the ASEAN.
According to Rodolfo Severino, Jr, the Secretary General of ASEAN (19982002), the loose nature of the association, its informal style, and subtlety of
its processes have led many who write and speak superficially about ASEAN
to disparage it as a mere social club or talk- shop .To begin with, it does
not and it is not meant to have a supranational entity acting independently of
its members. In addition, it has no regional parliament, council of ministers,
law-making body, and no judicial system.With nothing holding all these
member states together, the member states seem to be hanging on a loose
thread. On the other hand, the ASEAN believes that there is nothing wrong in
being judged in that matter. Its member states believe that peace talk is the
best solution in arriving at solutions to quarrels. Cooperation is being called
to solve problems in order to generate understanding, agreement, and
friendship. Through friendship, enough investment is made to preserve peace
within the region. For them, this is enough to say that such club already has
a value. Looking at another perspective, relying on a friendly relationship
can work in the long run if people are living in an ideal world where everyone
is giving or sharing to others out of generosity and selflessness. People have
to remember that the world is in constant competition. Each country would
want to take the advantage of opportunities, goods, services, skilled labor
and everything else out in the market. As Paul Krugman stated in his
November/ December 1994 Foreign Affairs The Myth of Asias Miracle, he
did not doubt that East Asia would continue to grow at impressive rates; he
only expected that growth to slow down.
Amidst all this, the diversity of the ASEAN did not stop its
enlargement, rather it calls for a greater demand to keep ASEAN solidified
and strengthened. The member countries continue to aspire for freedom.
However, each member has increased eagerness to speak more freely to one
Severino, Rodolfo C. What ASEAN is and What it stands for. Asia Policy
Lecture. The Research Institute for Asia and the Pacific University of Sydney,
Australia. 22 October 1998.
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another. Ironically, such openness still has boundaries. The countries do not
hold the license to interfere with anothers internal affairs. This noninterference is the backbone of the ASEAN and it is that which makes it
unique. Dialogue among member states became more intensive and
interactions became more frequent. These conversations are held with
utmost caution and are put on a pedestal to cultivate cohesion rather than
cause more disputes.
ASEAN continues to strive to achieve its goals through the ASEAN
Economic Community (AEC) of having a single market and production base, a
competitive economic region, an equitable economic development, and
integration into the global economy. Indeed, economic freedom to promote
economic growth. ASEAN continues to characterize itself as a regional
association of free flowing goods, services, investment, skilled labor, and
capital. In addition, it is characterized by sound competition policy, consumer
protection,
intellectual
property
rights
protection,
infrastructure
development, competition in energy and mining, rationalized taxation, ecommerce and by small-medium enterprise (SME) development. Finally, it
continues to envision ASEANs centrality and participation in global networks.
All these should allow the association to benefit from efficiency while
boosting competitiveness. Also, it could strengthen institutions that will pave
the way for the regions socioeconomic development. ASEAN aims to
complete the AEC by 2015.
MUTUAL RECOGNITION ARRANGEMENT
Economic freedom is defined as the freedom of individuals to
specialize, exchange goods and services, compete in markets, and enjoy the
outcome they invested in2Economic freedom has pushed the ASEAN member
countries to facilitate the completion of AEC by 2015 and in line with the
ASEAN Framework Agreement on Services (AFAS), other terms of agreement
have been produced. A Mutual Recognition Arrangement (MRA) has been
proposed by the member countries to facilitate the free movement and
employment of qualified and certified professionals, particularly which of the
health care team members among the ASEAN countries. Led by the ASEAN
Tourism Task Force on Manpower Development and chaired by Indonesia,
this is achieved by reducing regulatory impediments to the movement of
goods, services, and in this case, of people.
The Healthcare sector is one of the twelve priority sectors that the
ASEAN leaders have identified for integration and creation of the AEC. This
Gwartney, James and Robert Lawson. Economic Freedom of the
World 2007 Annual Report, Philippine., ed. Lindsey Thomas Martin
(Fraser Institute, 2007), 7-37.
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sector is an integral part of the ASEAN Socio- Cultural Community that


should be given much focus and proper assessment because of the disparity
in health profiles of ASEAN member countries and the occurrence of
infectious diseases that go beyond geopolitical boundaries. Each member
country has its own standards, procedures, and regulations. It is that which
makes the creation of a single market and production base more complex.
Although the MRAs goal is to facilitate trade by making a smoother path in
negotiations between nations, conformity and competency standards must
still be called for. 3
Mutual Recognition Arrangements on three health professionals are
ongoing. Measures to facilitate movement among doctors, nurses, and dental
professionals are likely to increase the human resources for health among
the ASEAN region. An MRA for Medical Practitioners that was signed in 2008
is done in order to strengthen their professional capabilities to generate the
exchange of relevant information, expertise, experiences, and practices that
addresses the needs of the ASEAN member countries. The objectives of the
MRA are to (1) Facilitate mobility of medical practitioners within the ASEAN
(2) Exchange information and enhance cooperation in respect of mutual
recognition of medical practitioners (3) Promote adoption of best practices on
standards and qualifications (4) Provide opportunities for capacity building
and training of medical practitioners. Article III of the MRA allows ASEAN
medical practitioners who have had at least five years active practice as a
general practitioner or specialist in their country to apply for registration to
be qualified to practice medicine in another ASEAN state.

Schematic Outline on the MRA on Tourism Professional Mechanism

ASEAN Roadmap for the Integration of the Healthcare Sector. ASEAN- US


Technical Assistance and Training Facility. Executive Summary.
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Note:

TPCB, Tourism Professional Certification Board


NTPB, National Tourism Professional Board
ATPMC, ASEAN Tourism Professional Monitoring Committee
ATPRS, ASEAN Tourism Professional Registration System
Source: ASEAN Tourism Strategic Plan 2011- 2015
A Professional Medical Regulatory Authority (PMRA) is an authoritative
body by the government in each member country whose responsibilities are
to regulate and control medical practitioners as well as their practice in
medicine. This said body or relevant authorities issue domestic regulations.
These domestic regulations include laws, by-laws, regulations, rules, orders,
directives and policies to the practice of medicine. (Appendix A)
Once they are granted permission to practice their profession in
another member state, that medical professional will be bound by the
professional and ethical codes of the importing country or a host country.
The medical professional needs to possess a medical qualification recognized
by the PMRA of the exporting country or country of origin and its host
country. In addition, a valid certification to practice medicine, certification of
no violation of professional and ethical standards both local and international,
and a declaration of no pending legal proceeding against him in his country
of origin are also required. A medical professional working in the host country
will also need to adhere to the requirements of insurance liability. These
foreign medical professionals should respect the culture and religion of the
host country.4 The process does not end here. The PMRAs Domestic
Regulations of the host country still need to evaluate these medical doctors
qualifications, training, and experiences while imposing further requirement
or assessment. Language skills and technical competence are still to be
considered before the actual employment occurs. In the end, the freedom to
move by medical doctors does not immediately translate into employment
opportunities.
An integrated ASEAN market in healthcare consists of harmonized
standards, registration and evaluation, an operable post- marketing
surveillance mechanism, effective mutual recognition agreements and cross
border provision of healthcare services that are considered to be beneficial
for the people and the economy by means of improvement in technology,
increase in imports, and increase in available choices which in turn could
lower prices because of increase in competition.
There has been progress in the said Roadmap for Integration of the
Healthcare Sector however; measurable indicators are still not enough to
4

ASEAN Tourism Strategic Plan 2011- 2015

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prove its success. Suggestions have been made to make such harmonization
more applicable. First, ASEAN should adopt international standards in order
for ASEAN to expand their competition to the world market. Second, there is
a need to increase and expand public awareness to awaken the
consciousness of the industry, media, and public regarding the benefits of the
Roadmap to gather the support to hasten its implementation. Third, there is
a need to build capacity in regulatory authorities. Training and capacity
building should be held or coordinated at the ASEAN level and could include
exchange programs between ASEAN Member Country regulatory authorities.
Such cross visits would not only build trust and capacity among the regions
competent authorities, but would also create peer pressure for Member
Countries to improve their regulatory. 2Ironically again, for the ASEAN
Healthcare sector to become truly integrated, there is a call for liberalization
of healthcare services with limitation in respect to the nature of the
association in order to protect national interests.
People should keep in mind that the MRA shall not reduce,
eliminate, or modify the rights, power and authority of each ASEAN Member
State, its PMRA and other relevant authorities to regulate and control medical
practitioners and the practice of medicine. 5The question of preparedness of
each member country is being imposed given that the bottom line of having
to work in another country is due to the unequal distribution of health
workers causing the rural areas of the country to be understaffed. Even if
myriad of medical schools and trainings in both public and private facilities
are being set up in a country, the local employment opportunities are not
available to cater its production.
Population
(Millions)

of Density per 1,000


population/
Doctor
Brunei
0.4
400
1.1
Singapore
4.4
6380
1.5
Malaysia
26.6
17020
0.7
Thailand
63.9
31855
0.5
Philippines
88.0
90370
1.2
Indonesia
231.6
56938
0.2
Vietnam
87.4
43292
0.5
Laos
5.9
1863
0.3
Cambodia
14.4
2047
0.2
Myanmar
48.8
17791
0.4
ASEAN
571.4
266301
0.5
Global
6659.0
8404351
1.3
Table: Population Data and Health Professional Statistics 2000- 2007

Number
Doctors

MRA on Medical Practitioners

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Indonesia, Vietnam, Laos, Cambodia, and Myanmar are facing


shortages in medical doctors given their high population and low density per
1,000 population. Singapore has the highest density in doctors but the
country is said to be having shortages in the public sector because of the low
salary and long working hours compared to the private sector. Laos,
Cambodia, and Myanmar are reported to have poor resources that contribute
to the low production and employment opportunities. Singapore and Malaysia
produce eight doctors per 100,000 population. Philippines and Vietnam
produce four doctors. Indonesia and Thailand produce two while Laos and
Myanmar produce less than one.
Production capacity does not always translate to the availability of
health professionals. For example, the Philippines can produce around 3000
doctors given its population. Indonesia can produce only 5,500 doctors even
if its population is three times higher. Indonesia experiences shortages in the
national level. Due to the restricted capacity for employment because of the
decentralized health services in both Philippines and Indonesia, both
experience shortages at the sub-national level. Urban areas become the
areas of migration and outmigration of medical doctors. The figure below
shows the sub-national distribution of doctors in selected countries in
ASEAN.6

Figure: Sub-national distributions of doctors and nurses in selected ASEAN


countries
Jennifer Frances dela Rosa, et al. "Series: Human Resources for Health in
Southeast Asia: Shortages, Distributional Challenges, And International
Trade In Health Services." The Lancet 377.(2011): 769-781. Science Direct.
Web. 16 May 2012.
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The figure shows the deviation of medical doctors from the red line of
equality. The blue line represents the distribution of medical doctors while
the green line represents the distribution of nurses. The greater deviation of
the Lorenz curve from the red diagonal line shows a higher degree of
inequality which is also represented as a higher Gini coefficient indicated
within the parenthesis. Cambodia shows the greatest degree of inequality
followed by Thailand. Even if Thailand faces inequality at sub-national level,
this country still attracts many foreign patients for health services. This
situation has resulted to the brain- drain within the country where medical
doctors from the public areas move and work to private hospitals. In a
country poor in resources, there is difficulty in the production of more
doctors. Heavy reliance on medical doctors can increase the inequality of
distribution in the sub-national level. 5
By 2015, the medical doctors of the ASEAN will face a borderless
practice as dictated by the ASEAN harmonization. A freedom that presents
itself as a double- edged sword. Outmigration of health professionals will be
further enhanced. To certain individuals, myriad of opportunities abroad
await them. For some, it is the question of the impact of MRA to the health
systems of country members.
Health and health- care systems in ASEAN
ASEAN is a region presently facing public health challenges. Social,
political, and economic developments over the years have provided health
gains in some countries and minimal effects on some. Given the location of
the member countries, earthquakes, tsunamis, typhoons, and other natural
disasters pose a threat to the people. Public policies have social and
economic consequences that cannot be ignored.
The MRA on medical doctors addresses regional cooperation and is a
good public health strategy. These medical doctors, coming from different
countries in the ASEAN, can treat disease outbreaks, chronic disease
epidemics, communicable, and non- communicable diseases. 7

Chongsuvivatwong,Virasakdi, Kai Hong Phua, et al. Health and health- care


systems in southeast Asia: diversity and transitions. The Lancet 377: 429- 37
(2011). Web. 12 May 2012.
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Table: Basic demographic indicators


The table presents an inequitable socioeconomic development among
the ASEAN countries. Demographic transition in the countries is at its fastest
rates in the world in terms of fertility reduction, population ageing and rural
to urban migration. The urban to rural population ratio continues to increase
its gap. Epidemiological transition is occurring which is evidenced in the shift
of infectious to chronic disease. Newly emerging infectious diseases result in
the movement of people. Because of the outbreaks, regional cooperation in
information exchange and improvement in disease surveillance system pave
its way 7 Specializations are being called for in different areas and the
formation of MRA on medical doctors can facilitate in addressing disease
outbreaks.
In terms of health systems in the ASEAN, the article states four major
points:
1. Health systems in the region are a dynamic mix of public and private
delivery and financing, with new organizational forms such as
corporatized public hospitals, and innovative service delivery
responding to competitive private health- care markets and growing
medical tourism.
2. The health- care systems are highly diverse, ranging from dominant
tax based financing to social insurance and high out- of- pocket
payments across the region. There is a greater push for universal
coverage of the population, but more needs to be done to ensure
access to health services for the poor.
3. Private health expenditure is increasing relative to government
expenditure; where new forms of financing include user charges,
improved targeting subsidies, and greater cost recover. Health- care
financing could be further restructures in response to future
demographic shifts in age- dependency, as in introduction of medical
savings and social insurance for long- term care.
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4. There is potential for greater public- private participation with


economic growth through ASEAN integration and further regional
health collaboration, despite the current division of the region under
two WHO regional offices.
To dwell on health systems in taxation and financing is another
discussion to be done. The overview on the ASEANs diversity in the
health care system implies inequality even sub-nationally in the ASEAN
countries. The question therefore to be asked is if the inequitable
socioeconomic development and diverse health care system in the ASEAN
region provide equitable distribution and benefits for medical doctors in
the ASEAN? Will the establishment of the MRA further increase the gap
between the urban and rural population?
TECHNICAL BARRIERS TO TRADE (TBT)
In the side of Politics, ASEAN member countries are also diverse.
Countries are run by democracies, monarchies, military leaders, and
communism. Differences in the political government could impede economic
growth. All the ASEAN could hope for is for good relationship building among
its own members. To address the challenges and issues that the ASEAN is
undertaking, the leaders of the ASEAN proposed and enacted the ASEAN
Charter. This became crucial for the ASEAN because it is a threat to the
operation of the original association. The Charter could break the regions
tradition of non-interference and respect as it becomes more rules-based
instead of the mere friendly relationship. Before the formulation of the
Charter, the ASEAN lacked legal personality for forty years. Since there is no
supranational governing body, agreements among member countries
undertake a slow process of implementation as consensus among member
states are required.
If MRA is to become more applicable to the ASEAN, it was mentioned
earlier that there is need for standardization to increase harmonization.
Agreements are no longer made bilaterally but multilaterally among nations.
ASEAN can form its own identity and is distinct and separate among its
member countries. In order for there to be a standard in the education and
the profession of medical doctors in the ASEAN region, some level of
international law is needed. With the Charter, the rules-based provision can
bring legal personality with the ASEAN signaling important development for
the integration of the region. The question however is if the ASEAN is ready
to be under some level of international law even if its regional identity and
objectives are still not clearly defined? In the implementation of the MRA,
member countries should be aware of the common standards of conduct and
the basic principles that they should follow. Since the formation of the ASEAN
is based on geographic purposes that economic or political reasons, ASEAN
would struggle to set a common standard for all its members. The MRA
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contributes to the formation of the ASEAN regional identity because of the


free movement of people across borders making the people of different
nationalities become one.
According to Article V: Right to Regulate of the MRA on Medical
Practitioners, the ASEAN Member States, however, should undertake to
exercise their regulatory power reasonable and in good faith for this purpose
without creating any unnecessary barriers to the practice of medicine. Such
irony is present in the right since ASEANs history, ethnicity, religion, and
language are barriers to the MRA that cannot be avoided. According to
Lehman,
ASEAN exhibits the greatest degree of ethnic,
religious and linguistic diversity to be found
anywhere in the world. Whereas all Europeans share
a common heritage and hence a common value
system derived from Greek philosophy, Roman law
and the Judeo-Christian religion. ASEAN must
contend with interactions among predominantly
Christian Filipinos, Buddhist Thais, Muslim Malays
and Indonesians, not to mention the Confucians and
Taoist Chinese communities. These ASEAN- wide
heterogeneities are reflected in the national
composition of the individual member states:
Islamic minorities in Thailand and the Philippines,
apart from Chinese and Malays in Malaysia, there is
the 10% strong Hindu community, not to mention
the ethnic, religious and linguistic veritable tower of
Babel which is Indonesia.6
These differences in culture affect how medical doctors treat their
patients in a foreign land. There is a need for cultural sensitivity, cultural
awareness, and cultural competence. Medical doctors do not only need to
know the host countrys language. These doctors need to know politically
correct language in order to avoid any statements that may offend another
persons cultural beliefs. In addition, medical doctors should further stretch
their knowledge on the history, ancestry of the foreign land while
emphasizing an appreciation for its arts, music, crafts, celebrations,
traditions, and food. An attention to these particulars will enable the medical
doctor to become more one with the patients. To top these off, a medical
doctor should be equipped with the skills and knowledge to provide effective
treatment. Even if there are PMRAs that provide them with the go signal to
work in another ASEAN member country, to become culturally competent
these medical doctors should have an awareness of ones own culture and
not let it have an unwarranted influence on the patient. To avoid
stereotyping the population, the medical doctor has to have a specific
knowledge about the patients culture in order to avoid assumptions. What
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may be true for an ethnic group may not be applicable to a certain individual.
A medical doctor in a foreign land must understand the patients cultural
perspective. There is a call to respect and accept the patients way of life. On
the other hand, even if a medical doctor may have the knowledge about the
culture, there are still hindrances present. Ethnocentrism or the tendency of
man to think that their ways of behaving are right and that odd behaviors are
wrong and stereotyping can prevent appreciation for such cultural
differences.
As medical doctors practice their profession in a foreign land, they
gradually accept the new culture through a learning process. They accept
their own beliefs as well as the culture of the host country. Acculturation
occurs because the new member in the community must learn enough of the
new culture to survive. Although this could be seen as a positive effect, the
threat of cultural assimilation may occur. This is another challenge faced by
the medical doctor as he begins to gain a deeper knowledge on the scientific,
spiritual, or holistic health belief of his patient. This is indeed an undertaking
given that various countries in the West have colonized the countries in the
ASEAN. Singapore and Malaysia were colonized by Britain. Indo- china was
colonized by France while Philippines was colonized by the North Americans.
Parts of Indonesia have been under the Dutch and Germans.
Medical practitioners among ASEAN countries must make cultural
considerations. As mentioned, although the ASEAN countries are part of the
Asian/ Pacific Islanders, differences in religion and historical background may
cause the plan of treatment and approach to patients more individualized. As
an example, Philippines has been colonized by Spain and therefore has
additional or mixed beliefs and traditions with Asian/ Pacific Islanders.
COMPETENCY STANDARDS
There is competitiveness in terms of people as the region focuses on
building a global marketplace. This should mean that people are to be trained
through the acquisition of good education while upholding a healthy lifestyle.
Human resources and their capacity to produce are factors for economic
competitiveness especially in this day of age where everything becomes
knowledge-based and technologically advanced. Health then becomes an
important factor in the market although its relevance may differ for every
individual. People are consumers of healthcare services that constitute a
market. As consumers, they have varying purchasing powers. The question
now is the availability and accessibility of these goods and services.
People are consumers of healthcare services but their value as a
consumer differs from the time and the given circumstances. A consumer
functions poorly when one is ill. He may search for the best healthcare center
available or he may opt for a center that fits his budget. He may opt to go to
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a public hospital or a private one. He may become price insensitive by pulling


out all his financial resources in order to get well or he may opt to accept
inevitable fate and leave it all up to faith. Consumers of health have a wide
array of preferential options and beliefs to address their health concerns.
They seek for other alternatives. For example, others prefer to be treated
locally in their country for varying reasons. On the other hand, some opt to
travel to another country to seek better treatment. This could be a
manifestation of their belief that medical doctors in that country have longer
years of study and practice of medicine than their local country therefore
implying that they are more knowledgeable in the field.
Differences in the quality of education and training, licensing
requirements, language, and cultural dimensions of daily medical practices in
the ASEAN region makes the MRAs application more challenging. The
Medical Education Unit of the National University of Singapore conducted
comprehensive compilation on the educational processes of medical schools
among the ASEAN countries. The medical education systems are diverse
because of the colonial roots that governed their curriculum. Singapore and
Malaysia followed the British standards. Indo- china followed the French
standards while the Philippines followed that of the North Americans. Parts
of Indonesia followed the Dutch and German standards. Through the years,
notable changes in medical schools have been implemented by making the
learning more student-centered focusing on student assessment and staff
development to cater national priorities and needs. Medical schools in the
ASEAN face common challenges in finances, lack of human resources, and
faculty resistance to change although the common strengths in these medical
schools are that of tradition, good clinical and hospital support, and
supportive administrative. Tradition is seen in a positive light but then again,
the differences in curriculum may become a barrier to the application of MRA.
In addition, several disparities among medical schools in the ASEAN are
found. 8The key findings are as follows:
Variables
Gender Distribution

Key Findings
There are more female than male
medical students in 68% of the
schools, but proportionately more
male students in 16% of the schools.
The gender distribution is variable in
the remaining schools.

Amin, Zubair, Khoo Hoon Eng, et al. Medical education in Southeast Asia:
emerging issues, challenges and opportunities. Medical Education (2005)
39:8. Web. 14 May 2012.
8

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Integrated Curricula

Very few schools have a fully


integrated curriculum. Encouragingly,
many more are working towards
gradual integration, often using
problem-based learning (PBL) as an
avenue.

Problem- based Learning

In all, 50% of the responding schools


reported the presence of PBL in their
curricula. In most cases, PBL
represents
part
of
a
hybrid
curriculum and constitutes 2040%
of curricular time.

Clinical Training

Early clinical exposure, as defined by


direct patient contact before the
completion of Year 2, is implemented
in 40% of the schools. Nearly all
schools provide clinical training
beyond hospital settings.

Electives, self- study and research

A total of 46% of schools indicated


that they have provision for electives
and
self-study
time
in
their
curriculum,
while
70%
have
protected time for research and
project work.

Faculty Development

Nearly all schools (90%) indicated


that
they
conduct
faculty
development programs for their
teachers. Besides in-house programs,
many make use of regional and
international medical centers for this
purpose.

Student Assessment

Multiple-choice questions and oral


examinations
are
the
2
most
frequently used student assessment
instruments.
Selfand
peerassessments and portfolio- based
assessment are seldom used.

Curriculum Governance

All medical schools, except 1, have a


designated person in charge of their
curriculum. Medical schools in several
countries (e.g. Indonesia, Laos)

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follow their national curriculum.


Medical Education Unit

A total of 72% of responding schools


reported that they had a medical
education unit or similar structure in
place. The majority (76%) of these
medical
education
units
were
established during or since 1990.

Valuing Teaching

All medical schools reported that


teaching constitutes a component of
promotion criteria in their school. The
weighting given to teaching varied
widely; a few schools mentioned that
teaching constitutes the largest
component in promotion criteria.
Teaching is judged by a variety of
means that include both objective
and subjective criteria.

Curriculum Renewal

All except 1 of the responding


medical
schools
have
mission
statements and defined learning
objectives. In several schools these
were crafted from AAMCs Medical
Schools Objective Project (MSOP) or
the World Health Organizations
Five-Star Doctor.

The data given is merely a comprehensive report of 30 medical schools


in the ASEAN. Generalizations should not be made so as not to draw
conclusions regarding the quality of the school. The strengths of the study
are its focus on the process and practice of the education in medical schools
and important issues on the structure, organization, challenges, and
strengths of medical schools in the ASEAN. The differences in gender
distributions, integrated curricula, problem- based learning, clinical training,
electives, self- study and research, faculty development, student
assessment, curriculum governance, medical education unity, valuing
teaching, and curriculum renewal call for a standardized curriculum among
medical schools in the ASEAN. Standardization of these factors is a step in
harmonizing the ASEAN. In effect, the question of competency in medical
doctors may no longer be questionable. Consequently, not only is there a
need for agreement on competencies. There is a need to get the approval at
the national level among Ministries of Labors, Education, and Tourism and at
the regional level. This again is an undertaking among the ASEAN member
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countries because unlike the EU, there is no governing body in the ASEAN
that could implement laws. There is no supranational ASEAN government
that could dictate what should be done to achieve a standardized curriculum
for all medical schools in the ASEAN.
If the ASEAN continues to aspire for deeper integration, as evidenced
in the MRA, there is a need to establish stronger institutional structure that
has the right to enforce rules and regulation. The creation of the ASEAN
Secretariat in 1976 functions closely to that of an executive body that had no
authority to resolves arguments among the member countries. In addition,
the ASEAN Secretariat cannot authorize the final say in ASEAN agreements.
The position of a Secretary- General was created in 1992 and was given the
authority to initiate, advice, coordinate, and implement ASEAN activities. His
authority became questionable given that the ASEAN itself has no solid
regional identity. The Secretary- General cannot function at its fullest
because member states have no legally binding commitments to the ASEAN
itself.
If the MRA aims to have a standard on the education and professional
skills needed to be considered competent enough to work in another ASEAN
country, a deeper integration among member states with the call of a
supranational governing body is needed. The Council discusses different
issues with the ministers of the member states. It is the lack of decisionmaking power body that serves as a fatal weakness to the ASEAN
integration. Also, the ASEAN Charter has no recourse for the ASEAN
Secretariat should a member government be unable or unwilling to
implement agreements; that is, it lacks a supranational decision-making or
law-making organ for legislating community law, or for enforcing any ASEAN
protocols or resolution of disputes.9The system of the ASEAN itself makes
MRA challenging because there is no body that could dictate standard
measures that should be taken by the ASEAN members to create a win-win
situation for both the host country of the medical doctor and his country of
origin. In an ideal scenario, the age group, education, system of medical
schools, residency training exposure, licensure examination, board
certification for specialists, and earning range of doctors of all ASEAN
member countries are the same.
The absence of a supranational institution has caused no notable
damage to the ASEAN region throughout its history. The negotiation and
enactment of agreements and declarations have aimed at deeper integration
that was further strengthened by the signing of the ASEAN Charter. In terms
of economic issues, such negotiations and mere talks became technically
LIN Chun, Hung. "ASEAN Charter: Deeper Regional Integration Under
International Law?." Chinese Journal Of International Law 9.4 (2010): 821837. Academic Search Complete. Web. 16 May 2012.
9

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binding. This was evidenced in the 2009 ASEAN Trade in Goods Agreement,
the 2008 Manila Declaration on Intensifying ASEAN Minerals Cooperation,
and the 2009 ASEAN Comprehensive Investment Agreement.8 The region has
attained its economic freedom in the trade and movement of goods.
The MRA on medical doctors may need more than just negotiations
and mere talks because there are several stakeholders that come into play.
As the ASEAN aspires for a free trade area, there is a question of whether
health professionals are to be treated as a health commodity or a public
good. It can be argued that the health professionals should be distinguished
from the health services that they provide. Goods and services that benefit
everyone in the community characterize a public good. It is financed and
regulated by a governing body or a model. If the famous quote, Healthcare
is a human right! is to be applied, then it should be suffice to say that health
services are meant to be a public good. On the other hand, unlike a public
good such as food and clothing that is traded among member states, the
demand for healthcare cannot be predicted.Consumers avail of this good if
the time calls for it. There is now a shift in the perspective of how medical
doctors should be viewed. Medical doctors are now seen as commodities
instead of public goods because the product and the activity of production
that they produce are identical. In Talcott Parsons terms, there is a
collectivity-orientation, which distinguishes medicine and other professions
from business, where self- interest on the part of the participants is the
accepted norm.(American Economic Review of 1963)
The movement of medical doctors, being a commodity, takes a
different approach. Voluntary compliance with member countries are not
enough because there is no recourse for the ASEAN system on how State
governments should implement the measures. There are also no mechanisms
for calling Member States to account in case of non- compliance with binding
agreements.8The MRA may need to form central institutions to uphold
member countries compliance with its terms and standard however, unlike
the EU, the leaders of the ASEAN do not agree in having a supranational
institution because this would compromise their domestic sovereignty. As
stated,
due to nationalistic pressures, the ASEAN leaders
have to safeguard their domestic economies and protect
jobs first instead of pushing ahead with ASEAN
integration. With such pressures, there is a risk that the
budding endeavors for regional integration could turn
into
intense
competition
and
possible
political
confrontation rather than cooperation. To deter past
hostilities from creating present and future roadblocks,
to achieve regional identity and to ensure future
integration, there are still a multitude of steps to be
achieved among ASEAN members.8
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BRAIN DRAIN, CITIZENSHIP, MIGRATION, IDENTITIES


Free movement of people among ASEAN member countries may
increase the medical tourism in the host countries. Medical tourism, as the
name suggests, refers to patients that travel to another country to seek
health care while participating in leisure activities.

Figure: Intraregional and international flow of patients


Singapore, Thailand, and Malaysia have attracted 2 million foreign
patients in 2005- 2006 for health services. Thailand provided medical
treatment for 1.3M foreign patients in 2005 while Malaysia treated 300, 000
patients in 2006. Also, Singapore provided medical service for 400, 000
patients in the same year. Although there are no found statistics that could
indicate how many of these foreign patients come from other ASEAN member
countries. What is important to know right now is that these three ASEAN
countries have made a mark in the region as they become a destination for
health care treatment. Medical tourism has become an important source of
revenue. 6

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The effect of medical tourism in Thailand


The volume of international patients travelling to Thailand increased from half
a million in 2001 to 13 million in 2007 a 16% annual increase 36 and
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 financial incentives. Thus, the effect on the overall
shortage of doctors is not significant.
To provide services for international patients, however, highly specialized
staffs such as cardiologists, neurologists and neurosurgeons, intervention
radiologists, and oncologists are 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 effective measures to manage the outflow of senior
specialists from medical schools, the quality of medical training will suffer.
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.
The phenomenon could increase waiting times for surgery in the public
sector. Although the main beneficiaries 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 effectse.g., through the development of medical
expertise and improvements in quality control through hospital accreditation
and other processes. The challenge for Thailand and other countries that
engage in medical tourism is to put in place policies and approaches to
maximize benefits and manage health system risks. Even if this challenge is
met, whether the potential benefits will actually materialize, and whether
they are sufficient to make up for adverse effects on the health system,
remains to be seen.
Source: Jennifer Frances dela Rosa, et al. "Series: Human Resources For
Health In Southeast Asia: Shortages, Distributional Challenges, And
International Trade In Health Services." The Lancet 377.(2011): 769-781.
ScienceDirect. Web. 16 May 2012.

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The effect of medical tourism in Thailand remains to be unclear if it be


for the positive or the negative in the long- run. Thailands health care
facilities and services with low cost attract many patients worldwide and even
among ASEAN countries. Patients from the low- income group such as Laos,
Cambodia, and Myanmar cross their borders to avail of Thailands services.
An overview on the effect of medical tourism in Thailand serves as a model
that the demand for specialization in the field of medicine is being called for if
the MRA is to take its full effect on 2015. Will the benefit of the host country
to produce one specialized doctor outweigh its cost?
Foreign patients accounted for less than 1% of total patients in
Thailand compared to the 4345% in Singapore and Malaysia. Around 60%
of foreign patients in Thailand are working in Thailand or neighboring
countries or with other ASEAN countries. 10% are tourists who become
unwell and need health care, whereas only 30% are foreign patients who
come specifically to receive health care.This makes the effect of medical
tourism on the Thai health system small or even more so, relatively
insignificant. On other hand, the percentage of foreign patients attending
private hospitals is increasing. For example, 60% of patients at Bumrungrad
Hospital are foreigners, and in Piyavet Hospital a medium-sized private
hospital in Thailand foreign patients as a percentage of total patients
increased from less than 1% in 2003 to 14% in 2007. The increase in foreign
patients in the private sector is contributing to an internal brain drain of
highly specialized staff from the public sector to the private sector, and will
have an effect on the teaching hospitals where these specialists are working.6
Minimal effects are seen on domestic health systems but this has
become a contributing factor to the brain drain of medical doctors to private
hospitals serving these medical tourists. People cannot blame these medical
tourists for seeking healthcare in a foreign land if it entails receiving highquality medical services that are accredited by national accreditation systems
and by the Joint Commission International (JCI). Apart from the shortage of
medical doctors in their home countries, these accreditations make the
hospitals more attractive. At present, 38 hospitals in the ASEAN are JCI
accredited. Singapore has 16 of these hospitals, 11 hospitals are in Thailand,
6 hospitals are in Malaysia, 3 hospitals are in the Philippines, and Indonesia
and Vietnam each have 1 hospital. Since these hospitals are considered to be
competent enough to deliver excellent health service treatments, patients
opt to be treated in these ASEAN countries than the member countries of the
Organization for Economic Cooperation and Development (OECD) because
people get to save 90% of the cost. As an example, in the USA, a coronary
bypass operation costs US$130, 000. In Singapore, it costs $16, 500 and in
Thailand, it would only amount to $11,000. As a responsible consumer to
health treatment, it would be reasonable for the patient to seek such
operation in Singapore or in Thailand assuming that the patient is sensitive
to price. 6
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The revenues from foreign patients in the year 2005- 2006 in Thailand
reached US$1 billion. Similarly, Singapore targets 1 million foreign patients
in the year 2012 to reach US$2.3 billion. This goes to show that the increase
in qualified professionals in the host country in the ASEAN could attract more
people to the country to avail of its services. On the other hand, there are
several factors that contribute to these countries success medical tourism.
Excess health care has opened the countries doors to medical tourism. In
the case of the Philippines, providing adequate health services is still ongoing
and yet it has already opened its doors to medical tourism. Such incident
could produce a negative impact on the public health care system. Revenues
of the host country are forecasted to increase thus, contributing to economic
growth only if the government could see the MRA as both an opportunity and
a challenge. With appropriate interventions, countries that are coined as
factories of medical doctors could change the scenario by luring in more
ASEAN medical doctors and if possible, improve on the existing public health
care system at the same time.
As the MRA promotes medical tourism, it could further aggravate the
issue of brain drain among ASEAN countries. Brain drain, originally coined by
the London Evening Standard on January 7, 1963, is the term popularly used
when there is a migration of a university trained professional, in this case
that of medical doctors, from one country to another. The figure below shows
that Singapore and Malaysia import the medical doctors for both domestic
and international demand. Philippines and Indonesia are the main exporters
of medical doctors in the ASEAN region.

Figure: International flows of medical doctors in the ASEAN region


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Political and economic balances facilitate this phenomenon. With the


absence of barriers, which is proposed by the MRA, medical doctors can no
longer withstand the ties that they have with their place of origin. They seek
to practice medicine in countries where scientifically, technologically and
professionally favorable to their needs. Furthermore, they opt to migrate to
these countries.
There are several implications that could occur when there is free
movement among the ASEAN members. The host country compensates
financial losses in terms of the costs of education of these medical doctors
and their potential earnings either through the capacity of these medical
doctors or through the government. These medical doctors that were trained
either by the publics expense or not, involves great gains in the economic
and social welfare. Imbalances in the health care system occur because there
is a greater influx of medical doctors in countries where there is more
financial security involved. Some ASEAN countries, particularly Indonesia and
the Philippines, will turn out to be a factory of medical doctors supplying for
other ASEAN countries particularly, Singapore, Malaysia, and Thailand. These
hubs become an attraction of consumers of health within and outside of the
region. In the end, the factories that supplied the medical doctors will not
enjoy the fruits of their own investment. This could result in a widening gap
in the incomes among ASEAN member countries.
The brain drain among the ASEAN member states is a force that could
trigger migration of the medical doctors. Migration plays a pivotal role in the
ASEAN as the formal concept of citizenship is a problematic issue even as
close to it being non- existent. Struggles are prevalent among the member
states. There are various regimes ranging from a semidemocratic to a
dictatorship to an authoritarian. Majority of the member states are also
developing countries where mass poverty exists. Struggles for democracy,
equitable justice, and respect for human rights are still present. The
formulation of a free market and globalization has been transforming what it
is to become a citizen of a nation. The medical doctors are then perceived by
the host country as transient aliens and temporary workers who are
momentarily useful for various economic roles. They bear the obligation of
citizenship such as paying taxes but have only few or even no entitlement to
citizenship rights. Even more, migrant workers are seen as state offenders,
key to moral upheaval, an unnecessary burden on the state, carriers of
disease, and a threat to national security. These medical doctors could be
stereotyped based on their race or nationality.
Diverse reactions were received among people in the Philippines
regarding the full implementation of the MRA on 2015. Biasness for its
implementation is seen among medical doctors in the country as the MRA
presents more opportunities to work abroad. Others say that it presents an
opportunity for ASEAN medical doctors to practice in the Philippines given
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that the country uses English as its mode of instruction. Some say that the
public health institutions are not ready for it but this doesnt translate to the
hindered growth of the Philippine Medicine Industry. The downside however
is that the majority of medical doctors in the country are ignorant about the
implementation of MRA on 2015.
PHILIPPINES PERSPECTIVE
When Philippines had the MRA, the Department of Health (DOH) was
not primarily involved. It started with the side of the Department of Trade
and Industry (DTI). When DTI signed it, it was the only time that health
sector became involved with it.
It is the lack of understanding regarding the MRA which is the issue
now, states Dr. Kenneth G. Ronquillo, the Director IV of Health Human
Resource Development Bureau of the Department of Health (DOH). ASEAN is
hastening the full implementation of the MRA of health and tourism by 2015.
It lacks advocacy in the Philippines.
Looking at the MRAs, it is the Philippine Regulations Commission
(PRC), the regulatory body in the country that is responsible for these.
Apparently, even the PRC is not adept with the knowledge of what MRA is all
about including its terms and conditions. It is DOH that is attending the
meetings on behalf of PRC. Lately, with the new PRC chair, that was the only
time that the PRC Board of Medicine became involved. Even then, DOH is the
department giving out the information to the PRC Board of Medicine as well
as giving out advocacy to Philippine Medical Association (PMA). The PMA is
considered not to be a group that will provide information to all doctors
because it has no capacity to inform the whole members of PMA. In the
Board of Medicine, the PRC has no venue to advocate the MRA in the medical
industry. The knowledge has been limited. Because of its limitations, the
medical industries think that the country is bringing in foreign medical
doctors to practice in the Philippines. Medical industries do not see the
opportunity of medical doctors to go out of the country. In addition, these
industries also dont know that there is a structured process. The capacities
of each of the countries are first looked at. Also, the ASEAN is still in the
process of looking at the equivalences of medical doctors with other ASEAN
countries. Furthermore, the ASEAN checks which among the ten member
countries are prepared and ready for the full implementation of the MRA.
Philippines, Malaysia, Singapore, Brunei, and Thailand are the more
developed countries compared to the rest.
One of the reasons why the MRA is being pushed for is the opportunity
for the ASEAN member states, specifically the five less developed countries,
to be parallel or at par with the leading ASEAN countries. This was the start
of creating the roadmaps of each of the countries. The ASEAN secretary
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stated that each country should have a roadmap in order to implement the
MRAs. On the other hand, the five leading countries of the ASEAN have
different stance in the MRAs. Singapore, Brunei and Thailand, are already
accepting foreign medical specialists. Philippines, on the other hand, cannot
accept foreign medical specialists because its constitution dictates that only a
Filipino citizen can practice medicine in the country. Because of this, other
countries are questioning the involvement of the Philippines in the MRA. This
issue paved the way for the formulation of the ASEAN Roadmap. This was
created to know what is needed from each member states and what is
needed to formulate exchanges among member states that could be
beneficial for all parties involved.
The ASEAN Roadmap opened the transparency of member states
regarding the rules and regulations, education towards medicine, its
equivalence with other member countries, and what kind of exchanges could
happen. The creation of the ASEAN roadmap was the only time that doctors
in the ASEAN talked about the MRA on medical doctors. On the other hand,
when the issue was to be passed on to the Medical Association of the ASEAN,
they never talked about the MRA on medical doctors. They talked about
technology, improving their craft, conduct of ethics, but never talked about
the movement of people.
The level of MRA today is still in the process of comparing policies.
Member countries are still looking at equivalences as far as the medical
degrees are concerned. There are countries that do not have licensure
exams. There are countries that have their regulatory bodies under the
ministries of health unlike the Philippines that has a body called the
Professional Regulations Commission (PRC). Others do not have a PRC but
they have their councils. (Appendix A) Because of this, the ASEAN needs to
compare the regulatory bodies among the ASEAN states (ex. Is the PRC
equivalent to a countrys council?) Such step is still an ongoing process.
If the implementation is to begin in the Philippines in 2015, it has both
its advantages and disadvantages to the country. In the positive side, the
MRA will be able to expand its market. Filipinos will be all over the ASEAN
member states. Also, we will be able to improve the countrys technology
because Singapore and Thailand will be influencing the countrys health care
systems. In contrast to this, the country can lose Filipino doctors although
such impact is still unclear since we havent explored the possibility of having
other ASEAN medical doctors come in the country. There are Vietnamese and
Singaporean medical doctors that have expressed their desire and willingness
to practice in the Philippines. An exchange between the Philippines with these
countries is most likely to happen.
The issue is the terms and conditions that are to be discussed within
the MRAs implementing guidelines, states Dr. Ronquillo. This issue
however, has not yet been fixed. For example, the Philippines might not need
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surgeons from other countries because the country already has a lot of
surgeons but what the country may need is faculty. Also, since the country
only has a certain number of cancer specialists, Singapore can provide
Philippines with such in exchange for a certain specialty doctor that its
country needs. These are the exchanges that needed to be included in the
MRA. The MRA on medical doctors really depends on the terms and
conditions that are to be written within the framework of the MRA.
The full implementation of the MRA by 2015 does not imply to all
ASEAN member states. The ASEAN secretariat states that the
implementation of the MRA does not translate to all ten member countries at
once. If only five countries are ready for the MRAs full implementation, then
they would only be the member states that would first spearhead the
arrangement. Later on, when the other member states have been
upgraded, then they will follow on the implementation of the MRA. In Dr.
Ronquillos own personal view, Philippines is actually helping Cambodia with
its health care educational system. It will take time for Cambodia to be at par
with the Philippines. Within the framework of MRA, Cambodia might be left
behind. Cambodia may have the Philippines to help them but what happens
to other member states such as Laos PDR that are not getting any
assistance? The country is still asking for training and technical assistance.
At present, Brunei has no school of medicine but is currently
developing their school of nursing. Brunei has no existing universities but
they have the capacity to bring their citizens outside to study then to return
back to their home country. The Philippines can then have an agreement with
Brunei since they provide scholarships outside their country but never in
theirs. The country hopes of having a medical school sometime as well. For
now, Brunei is still sending people outside to study in order to create a
critical pool of medical doctors that could run their own medical school.
Philippines has universities that could cater to their need of training to
become a medical doctor back in their home country.
To avoid the threat that the Philippines becomes a factory of medical
doctors, there is a need to craft the rules and regulations of the framework
with care. Philippines can put quotas to medical schools by indicating a
certain percentage for foreign medical students. This should be properly
imposed because at present, Philippines is still in the stage of having an
open business. Myriad of medical schools in the country continue to accept
foreign students without having any limitations because of its profit
orientation. CHED has to come up with such policy once it reaches the full
implementation of the MRA.
Review of ASEAN member states equivalencies in education and
policies is the first step before full implementation. Although the targeted
year is at 2015, the readiness of the Philippines is still doubtful. The
implementation of the MRA may mean for example, just for oncologists,
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academe, or whichever specialization is in demand at the moment for an


exchange. It is important that the MRA for medical doctors does not translate
that the country is opening its doors for all specializations. What
specialization is needed by another ASEAN country in exchange for a
specialization in the Philippines is the only exchange that can happen. At
present, Philippines is rich in medical doctors whose expertise is in
community services. The countrys medical doctors have rich experience in
committee mobilization. This is the specialization that will most likely be in
demand among ASEAN member states.
The borderless practice that is imposed by the MRA is an issue that
needs to be clarified. First and foremost, ASEAN member states are not
ready for that. The provision of the MRA states that domestic regulation still
implies. The EU member countries took decades to build the European Union,
ASEAN is hastening its process of integration because it wants to come up
with its own tiger economy. This year, the member states are still working
on the ASEAN roadmap. The ASEAN secretariat was able to ask technical
assistance from New Zealand and Australia to fund operational research that
could complete the ASEAN Roadmap towards the implementation of the MRA.
Included in it is a complicated matrix that shows the requirements needed
from each of the member countries. Standardization is tried to be achieved.
Each country is required to fill up a checklist of what character or trait its
medical regulatory authority has. For certain characters or traits that the
regulatory body does not have, the country is required to indicate the plan
they are to undertake to achieve this. The checklist includes educational
system, medical degree competencies, establishment of Joint Coordinating
committees, etc This checklist will provide the needed direction to be taken
by an ASEAN member country. The setback of this is the time spent to finish
the checklist. English translations of policies were also needed from each
country to have transparencies among ASEAN member states. Because of
the long process being made, there is a big chance that only bilateral
arrangements will be made in 2015. This is could serve as an advantage
because exchanges could only occur based on countries capacities to make
requests and offers, and capacities of the helping and needing countries. In
addition, credentialing by the ASEAN itself is needed by medical doctors to
make the MRA more applicable. The ASEAN imposes these credentials that
are a measure of the level of competency among medical doctors. Such
credentialing by the ASEAN was already imposed in the field of engineering
but still does not exist in the health sector.
Medical tourism, although the country states that it is already ready
for it, has no existing framework for it until present. Although Philippines has
good hospitals and good places to visit, these components are not properly
threaded yet. Boracay is a good place to see but there is no existing good
hospital in the area. Medical tourism should be within a geographic area of a
tourist destination. Hospitals that joined medical tourism are found mostly in
Metro Manila while the sites to visit are located in the Southern area of
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Visayas and Mindanao. If Philippines is to be compared with Singapore and


Thailand, Philippines still has a long way to go to promote medical tourism.
In Singapore and Thailand, there are already tour packages that come with
the medical treatments for foreigners. Their hospitals already have medical
tourism departments or desks. When foreigners enter their hospitals, one is
already uncertain if he is in a hotel or in a hospital. In the country,
prioritization for health or tourism is still in question although it should be
health first since medical tourism targets treatment. Tourism in the country
should only be secondary. At present things, tourism has been highly
prioritized because it is that which actually sells. The Department of Health
(DOH) and the Department of Tourism (DOT) have not yet agreed on the
blueprint for medical tourism package.
To see the MRA as a benefit or as a threat to the Philippines depends
on what context we want to see it, states Dr. Ronquillo. If Filipinos see it in
the scales of economies, the MRA can be beneficial to the country. Countries
strive to be at par with other member countries. This makes the ASEAN more
integrated. If Filipinos are to see it in the context of health, people have to
think twice if the people are to benefit with the MRA. Philippines, without any
doubt, would want to be partnered off with better off countries such as
Singapore. If the framework of the ASEAN is to be designed in such a way
that the MRA will give the country what it needs, then this is beneficial. It
really depends on the framework in the context of health that the member
states and the ASEAN would want to formulate. The question of, What are
the member states the ASEAN want to help first? arises if there is an
outbreak of diseases within the ASEAN. It may be a loss for the Philippines if
the country decides not to participate in these reaching out programs. Other
member states may think that if the Philippines does not help in these trying
times, why then should the country have bilateral arrangements with it?
There is a need for cooperation with other member states even prior to the
full implementation of the MRA to gain its trust and friendship but even
within the technical groups, there are already politics present. The Philippines
has always been neutral with decision making choices but Malaysia and
Thailand are already campaigning themselves to the ASEAN.
CONCLUSION
Asia also has economic relations between countries known as the
Association for South East Asian Nations (ASEAN) countries. They have trade
relations but in most times, these relations only affect two countries. Bilateral
agreements are still made among ASEAN members. There are no common
economic policies that affect all member states. Agreements are only formed
through the building of relationships through talks that are said to create
friendship ties that maintain peace among the region. Although the ASEAN
has been labeled as a mere club, it continues to seek for deeper integration
through the formation of the Mutual Recognition Arrangement (MRA) that will
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have its full implementation by 2015. The MRA on medical doctors has been
made together with the nursing and dental professionals. The issue regarding
its application is questionable at present. Myriad of factors come into play if
harmonization is to take place in order to achieve an MRA that will benefit all
its stakeholders.
The implementation of the MRA speaks much of freedom. It is the
freedom of Economic freedom is defined as the freedom of individuals to
specialize, exchange goods and services, compete in markets, and enjoy the
outcome they invested in As ASEAN does not have a body that governs
domestic policies of each country, freedom does not spread as easily as that
in EU. In addition, countries in Asia do not share the same boundaries due to
geographic location that bodies of water hinder the movement of freedom
from one country to the other.
Freedom spreads from one country to the other. Such an idea came
about because of the domino theory wherein the economic standing, whether
prosperous or not, can infect countries successively either for its geographic
location or through trade proven by econometric model that used panel data.
the average level of economic freedom of a country's neighbors (or trading
partners) were to rise by one unit in the Summary Economic Ratings, the
country in question would experience a 0.2 unit increase units Economic
Freedom Rating (Gwartney and Lawson 2007, 30).
Trade is another medium for economic freedom to spread and this is
what the MRA stands for. For example, when a developed country
experiencing high economic freedom is able to export more products,
resources, or wealth, to other developing countries experiencing low
economic freedom, the receiving country experiencing the economic gains
will more likely increase their economic freedom domestically because they
would want to acquire more. When trade happens between these countries,
the country with high economic freedom influences the country with low
economic freedom to also to participate in domestic and international trade.
All countries undergo fallbacks or instability in the economy since they
are sometimes unavoidable but the policy that politicians implement to help
the country bounce back to a higher state is the important factor. The
implementation of the policy should not only take into account the positive
effects in the economy whether in the long run or short run but also the
weight that goes to the citizens since they are the producers and consumers
in the market.

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APPENDICES
Appendix A
ASEAN Mutual Recognition Arrangement on Medical Practitioners
PREAMBLE
The Governments of Brunei Darussalam, the Kingdom of Cambodia, the
Republic of Indonesia, the Lao Peoples Democratic Republic, Malaysia, the
Union of Myanmar, the Republic of the Philippines, the Republic of Singapore,
the Kingdom of Thailand, and the Socialist Republic of Viet Nam, Member
States of the Association of South East Asian Nations (hereinafter collectively
referred to as ASEAN or ASEAN Member States or singularly as ASEAN
Member State);
RECOGNISING the objectives of the ASEAN Framework Agreement on
Services (hereinafter referred to as AFAS), which are to enhance cooperation
in services amongst ASEAN Member States in order to improve the efficiency
and competitiveness, diversify production capacity and supply and
distribution of services of their services suppliers within and outside ASEAN;
to eliminate substantially the restrictions to trade in services amongst ASEAN
Member States; and to liberalise trade in services by expanding the depth
and scope of liberalisation beyond those undertaken by ASEAN Member
States under the General Agreement on Trade in Services (hereinafter
referred to as GATS) with the aim to realising free trade in services;
RECOGNISING the ASEAN Vision 2020 on Partnership in Dynamic
Development, approved on 14 June 1997, which charted towards the year
2020 for ASEAN the creation of a stable, prosperous and highly competitive
ASEAN Economic Region which would result in:

free flow of goods, services and investment;


equitable economic development, and reduced poverty and socioeconomic disparities; and
enhanced political, economic and social stability;

NOTING that Article V of AFAS provides that ASEAN Member States may
recognise the education or experience obtained, requirements met, or
licences or certifications granted in another ASEAN Member State, for the
purpose of licensing or certification of service suppliers;
NOTING the decision of the Bali Concord II adopted at the Ninth ASEAN
Summit held in 2003 calling for the completion of Mutual Recognition
Arrangements (hereinafter referred to as MRAs or singularly as MRA) for
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qualifications in major professional services by 2008 to facilitate free


movement of professionals/skilled labour/talents in ASEAN; and
PROVIDING an MRA for Medical Practitioners that would strengthen
professional capabilities by promoting the flow of relevant information and
exchange of expertise, experiences and best practices suited to the specific
needs of ASEAN Member States;
HAVE AGREED as follows:
ARTICLE I
OBJECTIVES
The objectives of this MRA are to:
1.1 facilitate mobility of medical practitioners within ASEAN;
1.2 exchange information and enhance cooperation in respect of mutual
recognition of medical practitioners;
1.3 promote adoption of best practices on standards and qualifications; and
1.4 provide opportunities for capacity building and training of medical
practitioners.
ARTICLE II
DEFINITIONS
In this MRA, unless the context otherwise requires:
2.1 Medical Practitioner refers to a natural person who has completed the
required professional medical training and conferred the professional medical
qualification; and has been registered and/or licensed by the Professional
Medical Regulatory Authority in the Country of Origin as being technically,
ethically and legally qualified to undertake professional medical practice.
2.2 Specialist refers to a Medical Practitioner who has the medical specialist
training and postgraduate qualification(s) that are recognised by the Country
of Origin and has been registered and/or licensed as a specialist if such
registration is applicable in the Country of Origin;
2.3 Foreign Medical Practitioner refers to a Medical Practitioner including
Specialist who holds the nationality of an ASEAN Member State, registered to
practise medicine in the Country of Origin and applying to be registered/
licensed to practise medicine in the Host Country.

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2.4 Registration refers to registering and/or certifying and/or licensing of the


Medical Practitioner within a jurisdiction or may refer to the issuance of a
certificate or licence to a Medical Practitioner who has met or complied with
specified requirements for registration to practise medicine in the Country of
Origin and/or Host Country.
2.5 Country of Origin refers to the ASEAN Member State where the Medical
Practitioner has a current and valid registration to practise medicine.
2.6 Host Country refers to the ASEAN Member State where a Foreign Medical
Practitioner applies for registration to practise medicine.
2.7 Professional Medical Regulatory Authority (hereinafter referred to as
PMRA) refers to a body vested with the authority by the government in each
ASEAN Member State to regulate and control Medical Practitioners and their
practice of medicine. PMRA in this context refers to the following:
MemberState

PMRA

BruneiDarussalam

BruneiMedical Board

Cambodia

Cambodian Medical Council and Ministry of


Health

Indonesia

Indonesian Medical Council and Ministry of


Health

Lao PDR

Ministry of Health

Malaysia

Malaysian Medical Council

Myanmar

MyanmarMedical Council, Ministry of


Health

Philippines

Professional Regulation Commission, Board


of Medicine and Philippine Medical
Association

Singapore

SingaporeMedical Council and Specialists


Accreditation Board

Thailand

ThailandMedical Council and Ministry of


Public Health

Viet Nam

Ministry of Health

2.8 Domestic Regulations include laws, by-laws, regulations, rules, orders,


directives and policies relating to the practice of medicine issued by the PMRA
and/or relevant authorities.

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2.9 Continuing Professional Development (hereinafter referred to as CPD) is


the means by which members of the medical profession maintain, develop or
improve their knowledge, skills and professional performance.
ARTICLE III
RECOGNITION AND ELIGIBILITY OF FOREIGN MEDICAL
PRACTITIONERS
3.1 Recognition of a Foreign Medical Practitioner
A Foreign Medical Practitioner may apply for registration in the Host Country
to be recognised as qualified to practise medicine in the Host Country in
accordance with its Domestic Regulations and subject to the following
conditions:
3.1.1 in possession of a medical qualification recognised by the PMRA of the
Country of Origin and Host Country;
3.1.2 in possession of a valid professional registration and current practising
certificate to practise medicine issued by the PMRA of the Country of Origin;
3.1.3 has been in active practice as a general Medical Practitioner or
specialist, as the case may be, for not less than five (5) continuous years in
the Country of Origin;
3.1.4 in compliance with CPD at satisfactory level in accordance with the
policy on CPD mandated by the PMRA of the Country of Origin;
3.1.5 has been certified by the PMRA of the Country of Origin of not having
violated any professional or ethical standards, local and international, in
relation to the practice of medicine in the Country of Origin and in other
countries as far as the PMRA is aware;
3.1.6 has declared that there is no investigation or legal proceeding pending
against him/her in the Country of Origin or another country; and
3.1.7 in compliance with any other assessment or requirement as may be
imposed on any such applicant for registration as deemed fit by the PMRA or
other relevant authorities of the Host Country.
3.2 Eligibility of a Foreign Medical Practitioner
A Foreign Medical Practitioner who satisfies the above conditions shall be
recognised as qualified to practise medicine in the Host Country.
3.3 Undertaking of a Foreign Medical Practitioner
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A Foreign Medical Practitioner who is allowed to practise medicine in the Host


Country shall be subjected to Domestic Regulations and conditions which
include but are not limited to the following:
3.3.1 to be bound by Professional and Ethical Codes of Conduct and
standards of medical practice imposed by the PMRA of the Host Country;
3.3.2 to be bound by prevailing laws of the Host Country;
3.3.3 to subscribe to any requirement for insurance liability scheme in the
Host Country; and
3.3.4 to respect the culture and religious practice of the Host Country.
ARTICLE IV
PROFESSIONAL MEDICAL REGULATORY AUTHORITY
4.1 Subject to Domestic Regulations, the PMRA of the Host Country shall:
4.1.1 evaluate the qualifications, training and experiences of the Foreign
Medical Practitioners;
4.1.2 impose any other requirement or assessment for registration where
applicable;
4.1.3 grant recognition and register eligible Foreign Medical Practitioners to
practise medicine in the Host Country;
4.1.4 monitor and assess the compliance of the registered Foreign Medical
Practitioners practice and conduct in accordance with the Professional and
Ethical Codes of Conduct and standards of medical practice of the Host
Country; and
4.1.5 take necessary actions in the event any registered Foreign Medical
Practitioner failed to practise in accordance with the Professional and Ethical
Codes of Conduct and standards of medical practice of the Host Country.
ARTICLE V
RIGHT TO REGULATE
This MRA shall not reduce, eliminate or modify the rights, power and
authority of each ASEAN Member State, its PMRA and other relevant
authorities to regulate and control medical practitioners and the practice of
medicine. ASEAN Member States, however, should undertake to exercise
their regulatory power reasonably and in good faith for this purpose without
creating any unnecessary barriers to the practice of medicine.
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ARTICLE VI
ASEAN JOINT COORDINATING COMMITTEE ON MEDICAL
PRACTITIONERS
6.1 An ASEAN Joint Coordinating Committee on Medical Practitioners
(hereinafter referred to as AJCCM) shall be established comprising of not
more than two (2) appointed representatives from the PMRA of each ASEAN
Member State with the following terms of reference:
6.1.1 to facilitate the implementation of this MRA through better
understanding of the Domestic Regulations applicable in each ASEAN Member
State and in the development of strategies for the implementation of this
MRA;
6.1.2 to encourage ASEAN Member States to standardise and adopt
mechanisms and procedures in the implementation of this MRA;
6.1.3 to encourage the exchange of information regarding laws, practices
and developments in the practice of medicine within the region with the view
of harmonisation in accordance with regional and/or international standards;
6.1.4 to develop mechanisms for continued information exchange as and
when needed;
6.1.5 to review the MRA every five (5) years or earlier, if necessary; and
6.1.6 to do any other matters related to this MRA.
6.2 The AJCCM shall formulate the mechanism to carry out its mandate.
ARTICLE VII
MUTUAL EXEMPTION
7.1 The ASEAN Member States recognise that any arrangement which would
confer exemption from further assessment by the PMRA of the Host Country
may be concluded only with the involvement and consent of that PMRA.
7.2 The ASEAN Member States note that the PMRA of the Host Country has
the statutory responsibility of protecting the health, safety, environment, and
welfare of the community within its jurisdiction, and may require the Foreign
Medical Practitioners seeking the right to practise in the Host Country to
submit themselves to some form of supplementary requirements or
assessment.

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7.3 The ASEAN Member States recognise that such requirements or


assessment shall provide the PMRA of the Host Country with a sufficient
degree of confidence that the Foreign Medical Practitioners concerned:
7.3.1 are equipped with the necessary skills and expertise consistent with the
medical practice, general and/or specialised, that they intend to carry out
and undertake in the Host Country;
7.3.2 understand the general principles behind applicable Professional and
Ethical Codes of Conduct and standards of medical practice in the Host
Country and demonstrate an ability to apply such principles in carrying out
medical practice in the Host Country; and
7.3.3 are familiar with the Domestic Regulations that govern the operation of
medical practice in the Host Country.
ARTICLE VIII
DISPUTE SETTLEMENT
8.1 ASEAN Member States shall
interpretation and application of
through communication, dialogue,
mutually satisfactory resolution
implementation of this MRA.

at all times endeavour to agree on the


this MRA and shall make every attempt
consultation and cooperation to arrive at a
of any matter that might affect the

8.2 The ASEAN Protocol on Enhanced Dispute Settlement Mechanism, done


at Vientiane, Lao PDR on 29 November 2004, shall apply to disputes
concerning the interpretation, implementation, and/or application of any of
the provisions under this MRA upon exhaustion of the mechanism in Article
8.1.
ARTICLE IX
AMENDMENTS
9.1 Any provision of this MRA may only be amended by mutual written
agreement by the Governments of all ASEAN Member States.
9.2 Notwithstanding Article 9.1, any ASEAN Member State may amend its
PMRA listed in Article 2.7 as and when necessary without the mutual
agreement of the other ASEAN Member States. Any amendment shall be
communicated to the other ASEAN Member States through the ASEAN
Secretariat in writing.

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ARTICLE X
FINAL PROVISIONS
10.1 The terms and definitions and other provisions of the GATS and AFAS
shall be referred to and shall apply to matters arising under this MRA for
which no specific provision has been made herein.
10.2 This MRA shall enter into force six (6) months after the signing of this
MRA by all ASEAN Member States. Any ASEAN Member State that wishes to
defer implementation of this MRA shall notify the ASEAN Secretariat in
writing of its intention within 6 months from the date of signature and the
ASEAN Secretariat shall thereafter notify the rest of the ASEAN Member
States. The deferment shall be effective upon notification by the ASEAN
Secretariat to the other ASEAN Member States.
10.3 Any ASEAN Member State which has, pursuant to Article 10.2 of this
MRA, given notice of deferment of its implementation, shall notify the ASEAN
Secretariat of the indicated date of implementation of this MRA, which shall
not be later than 1 January 2010. The ASEAN Secretariat shall thereafter
notify the rest of the ASEAN Member States of the indicated date of
implementation of this MRA. An ASEAN Member State which does not notify
the ASEAN Secretariat of its date of implementation by 1 January 2010 shall
be bound to implement this MRA on 1 January 2010.
10.4 This MRA shall be deposited with the ASEAN Secretariat, who shall
promptly furnish a certified copy thereof to each ASEAN Member State.
IN WITNESS WHEREOF, the undersigned, being duly authorised thereto by
their respective Governments, have signed this ASEAN Mutual Recognition
Arrangement on Medical Practitioners.
DONE at Cha-am, Thailand, this Twenty Sixth Day of February in the Year
Two Thousand and Nine, in a single original copy in the English Language

For Brunei Darussalam:


LIM JOCK SENG
Second Minister of Foreign Affairs and Trade

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For the Kingdom of Cambodia:


CHAM PRASIDH
Senior Minister and Minister of Commerce

For the Republic of Indonesia:


MARI ELKA PANGESTU
Minister of Trade

For the Lao Peoples Democratic Republic:


NAM VIYAKETH
Minister of Industry and Commerce

For Malaysia:

TAN SRI MUHYIDDIN YASSIN


Minister of International Trade and Industry

For the Union of Myanmar:

U SOE THA
Minister for National Planning and Economic Development

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AIM-X-XX-XXXX-XX
ASEANs Mutual Recognition Arrangement On Medical Doctors For 2015

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For the Republic of the Philippines:

PETER B. FAVILA
Secretary of Trade and Industry

For the Republic of Singapore:


LIM HNG KIANG
Minister for Trade and Industry

For the Kingdom of Thailand:


PORNTIVA NAKASAI
Minister of Commerce

For the Socialist Republic of Viet Nam:

VU HUY HOANG
Minister of Industry and Trade

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AIM Zuellig Center
2012