Three decades of a lesson learned from Thailand: compulsory service for dentist workforce distribution

The CS program in Thailand had been implemented for about three decades, initially targeting physicians (1967–1987) and later both physicians and dentists (1988 to the present). The background of the policy development and its action from the past to the present are shown in Table 1. In 1961, the first National Economic and Social Development Plan of Thailand was launched to define the country's strategic plan, which includes a plan for building up the health system. Concurrently, the National Health Plan of Thailand was established, aiming to increase the number of infirmaries across the country [7, 8]. During that time, however, Thailand faced the external brain drain phenomenon because several hundred Thai physicians moved from Thailand to foreign countries for working purposes [3]. The government tackled this challenge by laying down several directive policies to minimize the emigration of physicians and increase their distributions to rural areas where healthcare personnel were lacking.

In 1967, the official directive policy was launched including enforcement measures dictating that all medical students should receive financial subsidies from the Thai government during their 6-year undergraduate education. Therefore, the newly medical graduates had to enroll in the CS program as mandated physicians in public hospitals for 3 years [4]. Later on, a fine for not properly enrolling into the program, including the refusal or early resignation from the CS program, was strongly implemented [5].

In 1968, the number of medical schools and medical students per year was raised to increase the physician production rate. Public hospitals also increased to support mandated physicians [9]. To control medical profession standards, core curriculum and central examination were applied to all institutions [10]. In 1973, a maximum fine increased from 200 000 to 400 000 baht (~ 6285 to ~ 12 571 USD) [11]. This fine was lowered according to the number of attended years in the CS program.

In 1978, the government established the “Project of Increased Rural Physician Production” (PIRPP) to increase the physician distribution in rural areas [12, 13]. Data reported that the proportion of physicians completing the 3-year CS program were more likely from this project than from other application tracks. We believe this had occurred because the PIRPP project included additional restrictions in the CS program such as an option to select predetermined provinces for compulsory work that were somehow linked with the hometown of the applicants (e.g., nearby provinces adjacent to their home residence) [14‐16].

In 1982, a similar policy was applied to newly dental graduates. This enforcement for Thai dental students was established upon the condition that they would receive financial subsidies partially provided by the government during their 6-year undergraduate education. Therefore, the newly qualified dental graduates would have to enroll in the CS program in public hospitals for at least 3 years. Otherwise, newly graduates would be fined 400 000 baht as a form of reimbursement, and such fine would be adjusted according to the number of attended years in the CS program alike the policies for the medical graduates [17, 18].

During a period of sustained economic growth in Thailand (~ 1987–1996), several private health care facilities had emerged. The government encountered at this time “internal brain drains” from public to private health care facilities. During 1994–1995, the “Collaborative Project to Increase Production of Rural Doctors (CPIRD)” was established to increase the retention rate of mandated physicians in rural areas [19]. In 2005, the government extended the CPIRD model to dentists to increase their production numbers and distribution to rural areas, and called this one the “Project of Increase Rural Dentist Production”, which was approved and implemented for a period of 10 years (2005–2014) [20, 21].

Since dentist workforce production is linked to the educational output from Thai universities, the academic admission process should be analyzed for allocating and distributing the newly dental graduates.

Dental workforce production in Thailand was officially implemented in 1940 by the first Faculty of Dentistry in the Kingdom which was created at Chulalongkorn University. To date, there are 16 dental schools (12 public and 4 private schools) distributed across 4 regions; 4 Northern, 2 North-eastern, 1 Southern, and 9 Central, covering Bangkok and adjacent provinces.

Some differences between public and private dental schools are noted. Because public dental schools receive financial support partially from the government, their tuition fee is lower and more fundings are offered to the students in public dental schools compared with those in private dental schools. Meanwhile, students in private dental schools tend to afford educational and living expenses. In addition, the strategies of public dental schools rather depend on and follow the government policies such as the number of new students and admission tracks.

The undergraduate dental education in Thailand offers a 6-year curriculum with the Doctor of Dental Surgery (DDS) degree. Preclinical courses must be completed within the first 3 years, and clinical courses start on the 4th and end on the 6th year. To obtain a dental practicing license, all dental undergraduates must pass a national standard examination [22].

Globally, there are 3 types of CS programs: (1) the state employment program, (2) CS program without incentives, and (3) CS program with incentives [26]. CS program with bundled incentives is adopted in Thailand, including educational, employment-related, and living provisions. Both state employees and civil servants working in public hospitals can be under the supervision of different institutions. Thus, different employment benefit packages are offered to dentists according to each institution (Table 2).

Benefits for civil servants include salary and welfare, comprising financial and non-financial compensations. In addition to the monthly salary, 4 types of financial welfare exist: (1) a professional allowance that increases depending on the highest educational degree of the civil servant; (2) a non-private practice allowance, a fixed amount for dentists who do not carry out private practice after regular working hours; (3) an allowance for dentists in rural areas that is different across the provincial areas (certain provinces will have extra benefits according to government policies for that specific fiscal year) and (4) a shift allowance that relies on either the working duration or hours of workload [27, 28].

Non-financial compensation for civil servants includes higher education, employment, and living provision. Oral health practitioners in public hospitals who leave for study still receive a monthly salary during study duration, but after graduation, they are required to go back to work at those affiliated hospitals for a specific amount of time. Other employment incentives include free dormitory, financial support for their children’s tuition, and a civil servant medical benefits scheme that covers not only the civil servants, but their family members also [29, 30].

Each university admission track establishes the conditions of Dentistry applicants and future graduates to enter the CS program. The future dentists from the quota track must undergo CS program in the predetermined provinces, commonly located around their hometown places. Recent compiled data from Academic Affairs at Faculty of Dentistry, Chulalongkorn University showed that the dentists arising from the “Quota admission track” completed the full 3-year CS working program in higher proportion rates and had lower resignation rates during the first working year, when compared with other admission tracks (Figs. 2 and  3). This data is consistent with data from medical graduates and it indicates that the “Quota admission track” tends to reduce the disparities in the number of dentists across the country [31, 32].

The public institutions recruit junior dentists to become state employees via face-to-face interviews during the last academic year of undergraduate education. Then, the MoPH allocates junior dentists to become civil servants at the end of the academic year by drawing and casting lots. Thus, these graduates may not get to work in their expected areas in the CS program due to a potentially limited quota for each province.

According to CS program data from the Human Resource Management Department under MoPH, the dentist allocation process by drawing lots through an online platform showed that 25.6% and 26.2% of newly dental graduates failed in getting to work on their expected areas in 2020 and 2021, respectively. In addition, 0.60% and 1.13% of them, in 2020 and 2021, respectively, refused to enter the CS program and were willing to pay the fine [33, 34]. A further longitudinal study is needed to identify whether the newly dental graduates in the CS program who get to work in their expected locations of interest have longer retention rates than those who were not so lucky with the draw.

An intense policy enforcement for newly medical graduates who decided not to enter the CS program was proposed in 1968 and 1973, including a higher fine and the completion of the full 3-year CS program. These medical graduates were able to receive a graduation certificate and passport after the 3-year CS program, though an early resignation would result in the withdrawal of the medical license [35]. At present, however, the only official directive and enforced policy mandates a maximum fine of 400 000 baht (~ 12 571 USD) if not attending the CS program. To increase dentist retention in public hospitals, several financial and non-financial compensations are also provided for oral health practitioners.

These directive measures and working compensation schemes may help increase the number of dentists in rural areas. However, an unequal dentist distribution between public and private health care facilities, between Bangkok and other regions, and between urban and rural areas persist for the last three decades [36‐38]. These shortcomings should carefully be analyzed to tackle the root of these oral health inequalities. Regardless of the selected academic admission track, any newly dental graduate can choose to pay the fine to drop out of the CS program. Therefore, the “quota track”, which is the only admission track created to reduce imbalances on the dentist workforce across the country, can be circumvented and this generates important shortcomings in tackling oral health inequalities. The CS program’s drop out or resignation fine should have been revised once every 5 years following real socio-economic changes, however, such fines remained the same during the last 32 years. If one assumes an average Thailand inflation rate for the last 32 years (BE 2532–2563) at 2.61% [39], then a 2.10 inflation coefficient value should be computed, and the maximum fine should have been 840 000 baht (400 000-baht × 2.10) or ~ 25 142 USD at the present time (Additional file 1: Table S1). However, additional adjustments to the fine may be necessary after considering other factors such as academic tuition fee, financial support from the government/academia, and opinions of the different universities and hospitals.

Despite the existence of provisions by several public welfare schemes, the monthly income of Thai oral health practitioners in public hospitals is approximately 40.9–59.7% lower than those in private practice [40]. Dentists in public hospitals commonly have an additional workload that goes beyond their clinical responsibilities, such as hospital management and excessive administration bureaucracy along the decision-making chain. Meanwhile, private dentists can stay focus mainly on their oral health care responsibility. Moreover, the government disbursement system for dentists in public hospitals is relatively delayed especially the monthly allowance as it mainly depends on the financial liquidity of each local hospital; conversely, disbursement of allowance for dentists in private hospitals are generally punctual. Since income is one of the major employment concerns among junior dentists, disparities between income and ultimate workload affects dentists’ early resignation from public hospitals [41].

In addition to financial welfare, access to higher education is also one of the factors negatively affecting dentist retention rates in public hospitals. The Thai government supports only a monthly income for CS-mandated dentists during their enrollment in continuing education programs, ignoring tuition expenses borne by junior dentists. In addition, types of dental specialties for the purpose of continuing education are limited by directive management policies of local hospitals. Consequently, junior dentists often resign from public hospitals or change their hospital affiliation whenever their continuing education aspirations do not meet their employer’s policies. Unlike in medical programs, several postgraduate dental education programs do not impose applicants to have a public institution affiliation and/or working experience in public hospitals as prerequisites to enter in such programs. Thus, the current educational benefits scheme may not be sufficient to attract the junior dentists and retain them in public hospitals.

The dentist workforce production strategy should consider not only a target number of newly graduated dentists per year, but also specific characteristics that meet the requirements and demands of the different stakeholders. This strategy will ultimately make such dentist distribution more equal across the country. Establishing dental labor market needs by committees would be essential in order to annually identify the number and criteria of undergraduate dental applicants, as well as to improve the predoctoral and postdoctoral curriculum to fulfill market and public health demands. This labor market committee would be responsible for setting up a dentist production plan for a 6-year time frame (as per current predoctoral curriculum duration), which could be adjusted by dental schools. Since newly dental and medical graduates prefer selecting workplaces that are located close to their hometowns [14, 15, 42], determining such workplace locations will have an impact on their retention by public hospitals. Universities may also have an important role in this strategy and should consider increasing the number of students in the “Quota admission track” to augment their retention in public hospitals and promote an even distribution between urban and rural areas. This can be achieved through the CS program because they have to undertake such program in public hospitals located in their hometowns, or in rural areas nearby or in adjacent provinces.

Determining underlying causes for dentists’ retention or resignation from public hospitals is necessary to set up policies for the various stakeholders. According to Herzberg's Motivation Theory [43], working motivation is divided into hygiene and motivation factors. Motivation factors, including work success, acceptability, and work progress directly affect working. Meanwhile, hygiene factors including welfare, medical benefits, and interpersonal relations, do not lead to positive motivation in the long term, however, they can prevent dissatisfaction. Presently, the established public policy increases dentist retention by promoting hygiene factors and medical benefits. Further directions should include a policy that promotes motivation factors to improve long-term dentist retention in public hospitals.