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The Socio Economic Impact of Medical Tourism/ Medical Travel

By Amado Alejandro Baez | 03 May, 2015

Medical Tourism is a multi billion dollar industry. The ethical and socio-economic impact of this business practice has yet to be fully analyzed. Some believe that the international standards of care, quality, knowledge transfer and system funding related to medical tourism leads to improved systems of care and an overall positive impact on quality of care delivered in developing countries. On this GHD forum we would like to create a global discussion on the etics and social impact of medical travel.

Replies

 

David Citrin Replied at 10:00 PM, 3 May 2015

Thank you for starting this important conversation. As a former medical voluntourist myself, this form of modern medical travel in any form (international medical rotations, medical missions, health camps, short-term disaster relief work) requires constant reflection.

I'm writing from rural Nepal, where I hear from colleagues working in/with the ministry about the influx of international relief organizations and aid cowboys who, despite their good intentions, are struggling to add value right now in the aftermath of the earthquake. The potential impacts here - in both senses of the word - are great. Of course, the response to a "natural disaster" and choosing to go on a global health medical elective are different forms of engagement. Outside of natural disasters, medical voluntourism often seems set up to respond to less spectacular forms of everyday sickness and suffering in more diffuse settings; places that Peter Redfield (2010: 191) suggests are closer to the “verge of crisis” where “the emergency remains emergent, its temporal form an ‘almost now,’ rather than a vital present of pure action.”

But, arguably the conditions of a post-earthquake Nepal only further invite that 'state of medical exception' where healthcare and livelihood-saving decisions are reconstituted by a briefly present, mostly foreign "non-governmental government" (Ferguson and Gupta 2002). The late Nepali anthropologist Saubhagya Shah (2002: 156) referred to this as a veritable "NGOdom."

I also work for an international healthcare NGO in Nepal, so I must be upfront. I do not presume to have all the answers here, but am excited to see this discussion space for compassionate and honest discussion. This is a really important discussion. All of this is very context-specific.

Here, I humbly offer a few pieces I've written on the potential long-term unintended consequences of short-term care, and a bibliography I've compiled with readings on the topic:

(1) A recent piece on helping in the aftermath of the Nepal earthquake: http://www.humanosphere.org/basics/2015/04/from-remote-nepal-a-warning-agains...

(2) The Anatomy of Ephemeral Healthcare: http://hsdg.partners.org/wp-content/uploads/2014/10/Citrin-2010-SINHAS.pdf

(3) My thesis, "Paul Farmer Made Me Do It": https://www.academia.edu/2762283/_MPH_Thesis_Paul_Farmer_Made_Me_Do_It_A_Qual...

(4) a TEDx talk (apologies for the poor A/V quality): https://www.youtube.com/watch?v=jGrKaeoIEOU

(5) Bibliography (attached)

Citations:

1. Redfield, Peter. 2010. The Verge of Crisis: Doctors Without Borders in Uganda. In Contemporary States of Emergency: The Politics of Military
and Humanitarian Interventions. Didier Fassin and Mariella Pandolfi, eds. New York: Zone Books. Pp: 173-196.
2. Shah, Saubhagya. 2002. From Evil State to Civil Society. In State of Nepal. Kanak Mani Dixit and Shastri Ramachandaran, eds., pp. 137-160. Kathmandu: Himal Books.

Attached resource:

Heidi Sampang Replied at 10:46 PM, 3 May 2015

Thank you David for sharing some of your work with the group. I am a medical voluntourist and I see the value of the service to the community. But I'm also seeing issues when the missions are not integrated with the local health system. The missions should strengthen the health system and not foster dependency on external aid. And do you think the same ethical concerns should apply during disaster and on scheduled short term medical outreach programs?

Amado Alejandro Baez Replied at 10:57 PM, 3 May 2015

This is an interesting side to medical travel. The volunteer convergence of "disaster tourists", difficult to assess credentials and quality of care, where good intentions is not enough I saw this first hand in our Haiti field hospitals.

How about thoughts on non-disaster medical travel? where patients leave their geography to seek better quality and often cheaper medical care?

Michele Sare Replied at 11:01 PM, 3 May 2015

​For the question about 'during a disaster': So many considerations. I was
in the quake in Haiti in Leogane - and can say that the problem w/ outside
aid (when it did finally arrive) was that it 'ran-over' the local efforts
and didn't take a minute to see what was built: For example - ​there were
young men teaching, managing clean H20, 'ambulance' men (carrying people in
& out of our 'lawn hospital), etc. The only aid organization that seemed to
'get' the awareness of uplifting local and not running over was JICA.

Jessica Evert Replied at 11:18 PM, 3 May 2015

Hi All,

I totally agree with these challenges (and importance of local health systems integration of outsiders activities, even if that 'system' isn't familiar based on the visitors reference point of view) and I'm attaching two articles here that might be of interest around ethics of short-term medical activities and a study of placing students in a 'brigade' type setting that parachutes in and sets up medical services outside of existing health systems and one that integrates into existing health systems.

I think the integration into existing health systems is essential for sustainability, local empowerment, and asset-based development. CFHI (www.cfhi.org) only integrates students in this way and it really impacts their impression of 'global health' and seeing outsiders as enablers of local capacity rather than replacements for it. Also, see this blog about when 'service' becomes a 'dis-service": www.globalsl.org/cfhi

Glad we are discussing.



Best, Jessica

Attached resources:

Tara Russell Replied at 11:33 PM, 3 May 2015

Hi,
Could the moderator please clarify if this topic is about medical tourism, or voluntourism?
I was following this topic for insight on medical tourism, as I am working in Thailand -
http://www.globalizationandhealth.com/content/7/1/12
And if we wanted to reflect on Nepal -
http://www.globalizationandhealth.com/content/7/1/12
Tara Russell
Technical Advisor, Health Systems Strengthening Working Group, Eastern Burma

Rakesh Biswas MD Replied at 12:06 AM, 4 May 2015

Thanks Tara, The topic to me appears to be about both or can be
extended to both and is a broad overview on strategies to promote
global health.

I am interested in this discussion from my vantage point where i
actively promote 'Global Health Electives' (click on:
http://promotions.bmj.com/jnl/bmj-case-reports-student-electives/)
from a medical education and practice perspective where we try to
address,"less spectacular forms of everyday sickness and suffering in
more diffuse settings; places that Peter Redfield (2010: 191) suggests
are closer to the “verge of crisis” where “the emergency remains
emergent" quoting David (in the second email of this thread).

best,

rb

Margaret Chirgwin Replied at 5:36 AM, 4 May 2015

There are many aspects to this discussion and I wonder if there is a place that the migration of the health workforce from the poor nations to the rich is being discussed? I have just returned from working in Sierra Leone on Ebola - my first experience of the emergency medical response world but have previous experience in the development end of working in poor nations - I was the only doctor in North-eastern Cambodia for a couple of years training semi-literate community health workers and local midwives for a small NGO and then worked for DfID in Bolivia and Nigeria. I do not have any answers but did have the opportunity to go back to Cambodia 10 years after I left and there was NOTHING to show for the work we had done which had not been integrated with the local health system. I also went back to Nigeria 10 years after working there and the systems we had developed with the local health system were still there and being rolled out across Nigeria - I believe because the systems had been owned by Nigerians. But I have stopped working in the aid world because I concluded it was part of the problem not the solution.

For me the endless supply of willing rich country health staff (usually either at the beginning or end of their career or for short breaks) available to work in poor counties does not do anything more than provide a sticking plaster - it does not give any real sustainable improvement in health for these populations - it does save individual lives and improve the quality of life of others and it definitely educates those who do it in a good way creating a cohort of people who have some understanding of the problem. Sierra Leone a - a country of over 6 million had 167 doctors before Ebola - lost 33 to Ebola - so now has 134 (1 doctor for 45,000 population). Yet when I talk with people about the need to support the training of lots more local doctors the response is - there is no point because they will not stay. Where will they go? To England, to the US, to Canada, to Australia, to New Zealand ..... so we prefer to train Community Health workers or medical assistants because this workforce will stay because we will not tempt/steal them away. For me some how helping nurses and doctors to stay and work in their countries of origin is going to be much more effective than medical tourism/travel. There needs to be a concerted effort to stop this kind of medical travel from poor nations to rich. I know this is complex and difficult and we all understand why it happens and we sympathise with both the migrating doctors and nurses and the receiving countries but this is the only long term solution.

The issue of how to behave in an emergency relief situation - cowboys, those who wish to send what they wish to send even when the WHO/those with experience say please only send the following things.... has been a feature of all major disasters over many many years. Coordination of all the "good will" a well known problem. I believe it is getting better but I do not know how much better - the media is saying the same things for Nepal that have always been said- too slow, lacking coordination etc. Medical travel/tourism will always be needed to supplement local staff when something large scale like this happens - having teams on standby with basic training and lead by those who have done it before will save lives but I am not sure if there is any positive role for the longer term medical travel/tourism - though perhaps it is better than nothing! I would really like a coalition of people trying to stop the movement of nurses and doctors from poor countries to rich and an intense programme to train more doctors and nurse incentivised to stay rather than medical travel/tourism filling the gap.

Thanks for all the attachments - lots of reading to be done!

Margaret

Amado Alejandro Baez Replied at 7:27 AM, 4 May 2015

As the moderator I posted the discussion originally to focus on Medical
Tourism: http://www.cdc.gov/features/medicaltourism/
But then realized that traveling for medical purposes (humanitarian,
disaster tourism etc...) is an interesting subset of this important issue.
I would like for us to continue this discussion on disaster/humanitarian
volunteer missions as I think are somewhat related to the original ethics
and socio-economic discussion. But also, kindly look at Medical Tourism I
will add a few resources and links soon to shift the discussion.

Deborah McSmith Replied at 8:33 AM, 4 May 2015

I am interested to hear how colleagues think coordination of emergency
medical support in a disaster situation could take place. If several
country teams are flying into Nepal to assist, and each is setting up its
own treatment centers and triage protocols, and bringing its own limited
medical supplies, what coordination is possible? Should one agency be
chosen to collaborate with government for coordination? When communication
infrastructure is down or limited, how might coordination take place?



--
Deborah McSmith, MPH
Global Health - Capacity Development, Systems Strengthening, Technical

Amado Alejandro Baez Replied at 11:04 AM, 4 May 2015

One of the key common elements in the discussion of disaster volunteerism and medical tourism is the capacity building piece and day to day operations in "normality", most studies demostrate that low healthcare GDP countries do much worse in a disaster and humanitarian crisis response perspective (Chile vs Haiti quake). So one has to wonder if efforts and funds can be allocated for long term system improvements, not just responding to a disaster, a sort of " teach a man how to fish" approach.

alejandro cambiaso Replied at 11:16 AM, 4 May 2015

Thanks Dr. Alejandro Baez for this forum: Im Dr. Alejandro Cambiaso, president of the Dominican Republic Health Tourism Association, that is a not-for-profit organization that promotes the Dominican Republic for medical tourism, given its geographical position, cost-effective medical services, supporting the best practices, quality and security of medical care.

Not everybody should be a candidate to offer medical tourism services, as international criteria must be met. First, you have to comply with local criteria, such that the center needs to be licensed by the Ministry of Public Health and the professionals should be part of the medical college and their medical specialty society. In addition, the hospital should be certified and accredited and have international departments that manage the entire patient experience.

Medical Turism in the Dominican Republic is raising the bar on quality and safety, the need for certifications and international accreditations will positively impact locals and health indicators. This will also create new jobs and attract foreign investment to the country, and will promote knowledge transfer, and sustained medical education, creating new opportunities for the local community.

There are key factors to take into consideration when deciding where to receive health services or which companies, insurers and medical facilitators to recommend for international patients, among which are the guarantee of quality, ethical and legal aspects.

For this reason, it is a priority to create a local hallmark in order to identify qualified-guaranteed service providers who meet quality standards, and to prepare a destination guide, which identifies health centers with logistical capacity, language support, disease prevention, patient-centered care, continued care, diseases management protocols, as well as respect for the International Patients’ Bill of Right and Responsibilities established by the American Medical Association to assure safety and sustainability of a health tourism in the Dominican Republic.

In addition, international accreditation with the Joint Commission International, ISQUA, Canada International and certification by international departments today play a leading role in this market. Besides the quality and safety of the medical care, legal aspects play an important role, because they provide standards and rules considered as best practices and they guarantee transparency, ethics and effective communication in a low-regulated market.

Likewise, patients must know their rights and their duties, clear informed consent and if a dispute occurs, it must be clearly determined where the conflict resolution will be performed. In the Dominican Republic it is a favorable option the Center for Alternative Dispute Resolution of the Santo Domingo Chamber of Commerce, since conciliation options and arbitration are confidential, dialogue and more expeditious solutions are offered.

The Dominican Republic has undergone major transformations in the economic and social orders as a result of globalization. The health sector is not an exception to this reality, and it is vital to respect and modernize the existing national legislation, framed in the General Health Law and other regulations, and to encourage the creation of regulatory framework of the health tourism, in order to have clearer ethical rules, regulations, protocols, as well as special incentives for the development of medical tourism in the benefit of local and international patients.

Margaret Chirgwin Replied at 11:42 AM, 4 May 2015

The comment on the emergency response again comes back to how do you have a better functioning local health system - better able to deal with any future disaster - teaching a man to fish is for me not such a good way to look at this - we can teach as many men and women to fish as we want but if they leave this does nothing. If we insist we only train lower level health workers because they will stay we will still not have a high functioning health system. Cuba has one doctor per 170 and very good health outcomes (life expectancy 78 years. In 2012, infant mortality 4.83 deaths per 1,000 live births compared with 6.0 for the United States and just behind Canada with 4.8 ) and only spend approx. $250/capita. I would definitely second the idea that when a natural disaster strikes lets try to put some of the funds that suddenly become available into training doctors and nurses. The Ebola response put huge amounts of money into the affect countries - just the ETC where I worked received £12.6 million and I think the UK put £56 million or some such into Sierra Leone for the Ebola response - when did the UK put this kind of money into the health system in Sierra Leone? Never. People in the UK have been very generous for the earth quake victims in Nepal.

I do think that the example of Dominican Republic attracting patients rather than their health professionals going to the countries the patients come from is a great model.

Margaret

Heidi Sampang Replied at 11:59 AM, 4 May 2015

The UN-OCHA with its cluster system is the lead agency to coordinate the foreign aid agencies. But I saw the system breakdown during the super typhoon relief in the Philippines in November 2013. There was lack of interagency coordination and poor communication. And also the National Disaster Risk Reduction and Management Council (NDRRMC) of the Philippines was not strong enough to take charge of the situation. But since then the NDRRMC had undergone some restructuring and with its new leader, USec. Pama, the council is focusing on disaster mitigation and resilience and also a more active role in coordinating the aid agencies entering the country. It's not a perfect system yet but at least the country recognized the need to take charge of their own disaster planning and be able to coordinate aid agencies effectively.

Anyway, do you know of any programs by aid agencies that has a good track record in strengthening the host nation's health system and encouraging sustainability?

Massimo Manzi Replied at 12:46 PM, 4 May 2015

At the Council for the International Promotion of Costa Rica Medicine - PROMED we see medical travel as a segment of a much broader industry called "Global Healthcare". Global Healthcare as an economic activity and a development opportunity for countries like Costa Rica, Dominica Republic and others that have a competitive advantage in terms of provision of a number of health related services: surgeries and dental treatments (medical travel), services outsourcing (Healthcare BPO), clinical studies abroad (in countries with good healthcare services and similar epidemiologic profiles), medical education (due to the cost of attending a medical school in other countries).
Since we are speaking about healthcare countries are called to comply with international standards of quality and patient safety in order to offer trust to their potential visitors. In Costa Rica we established the international accreditation of CMS deeming authorities like Joint Commission, AAAASF and AAAHC as the mandatory requirement in order to participate to official promotional initiatives.
Even if this is the "business" or "private" side of healthcare, still the benefit for a country healthcare system are important: development of international best practices, quality controls on private healthcare providers, new opportunities for healthcare professionals (in Costa Rica we have an oversupply of 3500 denstists that see in "medical tourism" a unique opportunity to develop their practice")

Amado Alejandro Baez Replied at 2:03 PM, 4 May 2015

Medical tourism is a worldwide, multibillion-dollar phenomenon that is expected to grow substantially in the next 5–10 years. "Medical tourism” is the term commonly used to describe people traveling outside their home country for medical treatment. Quality, technologies and cost have been important drivers to MT.
Traditionally, international medical travel involved patients from less-developed countries traveling to a medical center in a developed country for treatment that was not available in their home country. In the United States, the term “medical tourism” generally refers to people traveling to less-developed countries for medical care.

Studies using different definitions and methods have estimated there are 60,000–750,000 medical tourists annually from around the world.

I would like for us to focus this GHD discussion on understanding the forces that drive Medical Tourism Globally (access to quality care, technologies, cost reduction) and see how these could be having an effect on developed countries systems of care by perhaps preventing brain-drain, inyecting needed funds to the system and creating international quality standards.
Also, perhaps comment on the needs for a regularoty framework and ethics of this practice to control what some call" the dark side of MT", as without it we are witnessing unnecesary procedures, organ transplant markets and even euthanasia.

Some links on MT:

http://www.oecd.org/els/health-systems/48723982.pdf

http://en.m.wikipedia.org/wiki/Medical_tourism
http://www.washingtonpost.com/wp-dyn/content/article/2006/11/02/AR20061102007...
http://abcnews.go.com/Business/IndustryInfo/story?id=2320839&page=1

Amado Alejandro Baez Replied at 6:20 PM, 4 May 2015

So we have reviewed experiences in Costa Rica and Dominican Republic, also an interesting discussion on disaster volunteerism. Wonder if some of our US-Based forum participants have opinions on medical tourism into the US. The US is considered the biggest player in the MT market, yet it has the most expenssive healthcare system 1:7 USD of the GDP. So clearly patients are traveling to seek technologies and advanced care not otherwise seen in their home country.

Can Medical Tourism become an important source of healthcare funds in developing countries to generate quality care systems, and technology investments? and once available can these translate into the care of all patients (local and international)?

Doris McNeill Replied at 8:54 PM, 4 May 2015

The question posed of medical tourism being of any benefit to a developing country can have two answers.

1) Yes, the developing country will benefit from the hard currency being paid by foreigners for this service. Generally speaking, any foreigner travelling for medical procedures of any kind to a country outside of their native one will be paying for that medical service in cash. So, in that respect it is a benefit in terms of providing a new stream of revenue for the country. Assuming the funds are used for the country in question. That is a big "if" since it may be unclear who is actually receiving the payments, the government or a private entity.

2) The drawback to this medical tourism is that the brightest and most talented medical providers may be more likely to practice in these new medical facilities instead of practicing in areas of their country that are in desperate need of medical services. There is a larger incentive to work where the compensation is higher.

I researched Cuba just recently for a class (I am working on completing my Global Health Certificate at the graduate level) and what I found was that there is a marked difference in what the world sees as their health care system and what their reality is. Cuba has two systems in place right now, though it only advertises one. There is The National Health Care system for all of its citizens which is founded on the preventive and primary models of medicine; and the other one is for those who can pay for services with hard currency. The observation is too many physicians are either shipped out to other countries in exchange for hard currency, or are recruited to work in the "spa" like medical facilities that cater to an elite foreign clientele visiting Cuba. While this new business strategy may enhance the humanitarian look Cuba is going for in shipping out of physicians to countries who need them (Brazil, Argentina, etc), and attracting foreigners for services they can provide and receive payment for is beneficial for their very desperate economy - the citizens of Cuba are left with too few physicians left to care for their needs. There are long waits for service, not enough medicine to go around on a regular basis, very little new technology and the facilities are in desperate need of repair and upgrading.

So, while medical tourism can be a great boon for a developing country's economy, there must be a balance so that the native population is still well cared for. And there is always the question of who exactly is profiting from this business - the private sector or the public sector.

Doris McNeill

Margaret Chirgwin Replied at 4:44 AM, 5 May 2015

Doris I find your statements about Cuba quite difficult to take - they have lower infant mortality than the USA (who have an even more two tier system) so your judgement of their system - that "reality" is not what they claim or some such is quite offensive to me. They have limited resources (because of a US embargo) and have amazingly good health outcomes - I find it hard to know how to write something helpful here - you might want to imagine what it has been like for Cuba behind the embargo and recognise that what they have achieved for their population (compared in particular to what your country has achieved for its population) is amazing - why do you feel the need to stand in such negative judgement? They are supporting many countries by training doctors and also by sending their medical brigades. Their response to Ebola was exemplary - there were more Cuban Doctors and Nurses in the 3 affected countries than any other country - over 460 arrived at the beginning of October and stayed for 6 months - until the epidemic was over in Liberia and nearly over in Sierra Leone. I believe some are still in Guinea. This was the largest number of health professionals from one country - from a small country of only 11 million people. They put their lives on the line - two deaths (from malaria) and one case of ebola (survived). Because of their large medical workforce they are in a good position to export medical staff unlike most poor countries. For them investment in equipment and facilities for medical tourism will generally be helping an economy which is still struggling from the long term consequences of the US embargo - they are selling those things they have to sell and their population is healthier than yours.

I think the questions raised on the possible impact of medical tourism on poorer countries health systems are really interesting. Generally aid has been very resistant to allowing countries to use money on developing the higher end of the health care system - focussing on primary care models (a la Cuba). I have had interesting discussions in a number of countries about how low income countries might attract back medical staff but also other highly qualified nationals - potential business people, accountants, IT people etc etc. These discussions include the need for the availability of high quality medical services in country - would you take your family to live in a country where you need to fly them out to get what you would consider a safe operation? Can you develop your medical skills in a system with only the very basic equipment and investigations? For most people the answer is no (some of us do take our families and we have access to medical evacuations but many consider these risks unacceptable once they are used to what is available to their families in the UK or US) . Can a low income country support the cost of a first world style and quality hospital and should they when there is not an adequate primary care system? The answer is clearly No. But perhaps through medical tourism the country could have such a hospital - this would attract doctors and nurses back and also be able to provide services to rich returning families. Yes there would be a two tiered system but I do think it will have good consequences for the whole health system in a country and for the country more generally.

It might be useful to look at this across the different levels of income of a country. Which High Income countries do it and for what? US - from all over the world for very expensive experimental stuff??? UK - we get rich families from low income nations in particular. I am not sure which middle income countries are doing this at scale - I think Jordan does it, clearly Dominican Republic, from what is said here probably Cuba, India, South Africa, Thailand. In this group India is I think the poorest (only lower middle income country?). Do not think that any low income country does this at the moment? It would be interesting to look at the health outcomes for the population of a country that has significant Medical Tourism to see if we could show any positive (or negative) impact of the development of Medical Tourism.

Doris brings up the issue of mal-distribution of health personnel - this is already present - many of the brightest and best are not even in the country - so getting them and their families back into the country would be a good start. Most countries are struggling with how to get health professionals to spend any significant period working out in the rural areas - Australia is a good example - hard to get health professionals to work in Alice Springs or the Northern Territory with their Aboriginal populations out in remote areas etc etc.

I see the development of strong relationships between Medical Institutions in high income countries with ones in middle and low income countries as a possibly model to ensure that quality of the institutions are those that the health tourist expects - I believe this is how some of this is structured already - a branch of a famous institution... however may be this is actually just continuing a model of domination???? So maybe not! I have thought that rotating staff between a hospital in the UK or maybe South Africa or ??? and one in say Nigeria would be a way to develop an institution in Nigeria that would quickly have the same quality of service provision. Would there be enough private money to support such an institution in Nigeria? Perhaps but maybe medical tourism would make it more financially viable. I work in development and I know there are those who would feel this will increase the gap between the rich and the poor - this divide is already huge - think it would increase the middle class access and support the development of the economy ...

Margaret
Margaret

Mamsallah Faal-Omisore Replied at 10:09 AM, 5 May 2015

A very interesting topic.
I would like to focus on the impact that medical tourism has on the economies of participating countries. For India, Thailand, Malaysia etc there has been unprecedented growth in the medical tourism industry which appears to have benefited the players but not necessarily the most needy as the population health related indices particularly those linked to socio-economic factors have not changed much. In a sense creating a two-tier system whereby the masses may still rely on basic and not advanced health care. How this will play out in the long-term is not clear. Furthermore, how the medical tourism industry can be of social benefit is not apparent. Primarily because it is profit driven and perhaps in a way not aligned to national health policy/systems.
I work in Nigeria where medical tourism is a viable and thriving concern, with reported losses to the economy of anything from $200million annually. How has this come about?
Due to a decaying health care system and lack of social trust in government institutions significant numbers of Nigerians go abroad to seek healthcare. This includes locally to South Africa and further afield primarily to India. Undoubtedly on an individual level this means huge costs. Parallel to this, there has also been growth in so-called intermediaries who liaise between the patient and the receiving doctor(s)/hospital often without local medical input.
What this means in real terms for a Nigerian doctor is that we see patients make their own medical arrangements, travel abroad and return for continued review often without the supporting documents that allows us to make an informed decision on how to manage these patients going forward.
As medical tourism is here to stay, then I would like to see provider countries enter into trade agreements with 'patient-sending' countries and consider medical tourism as a traded service. This allows for the creation of terms of reference for this kind of trade to occur and will address such issues as the regulatory framework for the provision of such services, medico-legal aspects of health care provision particularly when things go wrong and levels and quality of care that is provided.
Furthermore, ironically, as it is again the countries that can least afford to engage in medical tourism in this manner that appear to be contributing most to its growth; I think it is important as part of trade agreement negotiations for provider countries to contribute to the strengthening of health systems of sender countries by participating in the development of the often inadequate human resources for health through training and telemedicine services which can augment local care provision.
Finally, this is a global issue which transcends national or indeed regional health systems and in an ideal world should be addressed at that level. The question is which global body is ultimately responsible for the oversight function of medical tourism as a profit making enterprise involving health - is it the WHO or WTO or both?

Margaret Chirgwin Replied at 10:56 AM, 5 May 2015

Mamsallah

Are there not enough Nigerian doctors in Nigeria or willing to work there to set up a private hospital that could keep much of the $200 million in Nigeria? If it was set up right it could have a commitment to using some proportion of profits for improvement of the health of the poorest? Just a wild thought though I do know a reasonably wealthy Nigerian based in Lagos who has been discussing this with friends .... I feel the NHS might also have an incentive to support this/be involved in this.

I think however your question of who might be able to police this international trade is important. WHO I think is never anything more than advisory so I guess it might be the WTO - it is a legal question. Maybe it actually has to be bilateral between the countries. What might be most useful would be to develop some best practice guidelines for industry - involving sending country clinicians in the process seems key as they will have at least some of the background information and will have to manage the patient on return. Sharing the patients records would of course require patient consent but ensuring that the patient is safe in the hands of this industry will be about safe sharing of patient information between clinicians in different countries as will some guarantee of quality of care (Dominican Republic seems to have a system for this? Maybe there should be an international kite/quality mark. Best practice guidelines would be helpful to users ie the medical tourists as would a recognised quality mark. If we do want the whole country to benefit from medical tourism we could also recommend to the tourists that they use providers who show that they are helping to develop either the health system of the sending country or the provider country!

Margaret

Amado Alejandro Baez Replied at 12:12 PM, 5 May 2015

About Medical Tourism with Social Responsability

I very much enjoy all your posts, thank you. In the Dominican Rep we have looked at various models for a Medical Tourism platform. From fully independent Medical Free Zones to dedicated "International Services". I now see that Medical Tourism to be sustainable and of high impact, it needs to have a strong social quota. The idea is to have MT inject funds to the HC system, promote quality care based on international standards, transparency, access to medical technologies, so that this MT "layer" actually allows and fosters better care to everyone, specially locals. We have are calling Medical Tourism with Social Responsability.

Luis Azpurua Replied at 5:50 PM, 5 May 2015

Amado,

I was going to suggest the social responsibility issue. There are a lot of economical incentives that shift the health professionals from the public to the private settings. Specially hard currency in middle income countries.

One idea would be that these professionals, as part of the MT working agreement, would dedicate a part of their time working on those public settings. In this way MT could subsidize the public healthcare sector.

Margaret, my aim is not to be polemic. But have you ever been in Cuba? I have not. But we have thousands of cuban medical phycicians in my country (Venezuela). Talking to them some refer in their proper words what Doris stated in her comment. I am aware that Cuba has made a great effort in primary care but there is a technological health care system divide and a medicine shortage over there.

Doris McNeill Replied at 10:14 PM, 5 May 2015

Thank you Louis. Margaret, it was not my intent to speak badly about Cuba. I was simply sharing some of the information that I found with regard to their health care system.

I think the Cuban basic model should be copied because it makes sense to set up a health care system using the tools and methods we know will produce the outcomes we desire at the least possible financial expense. The Castro regime, with the design set up by Che Guevara (who was himself a physician from Argentina) wanted a system that would cover all of the people of Cuba regardless of socio-economic status. And they did in fact implement such a system which yielded very impressive health outcomes. But, when the former Soviet Union collapsed, Cuba had to look for an alternative way of funding its health care system (along with many other social services the government was trying to provide). I will not get into a political discussion here, but merely want to express how it all started. It is a system based on some common sense that is also cost effective - primary and preventive first, which should lead to lower needs for curative care (at least lower cost care), and massive amounts of education on safe and hygienic personal care practices. And Cuba has a way of working on epidemics, that while criticized by many, works. I will add that physicians are required to work where they are assigned upon graduation. That is one way the Cuban government has of trying to have the health care where it is needed. However, Cuba still sends many more abroad (than those who stay) and many do end up defecting to other countries and not returning to Cuba.

The issue with Cuba is that the statistics that are provided to organizations such as WHO, UNICEF and PAHO (Pan-American Health Organization) are provided by Cuba itself. There have been no independent parties verifying their statistics. And that has been a problem with Cuba. Until now. In March 2015 PAHO and Cuba moved to the second phase of a project monitoring the transmission rates of mother-to-infant HIV and syphilis to gain information on how to duplicate Cuba's success rate elsewhere in the Latin American regions. This second stage involves an independent investigative group from PAHO to inspect the records/statistics of Cuba. If all is well, Cuba will receive formal validation from PAHO of its work. That is very impressive. And hopefully that will open the doors to other such works so that the rest of the world can use what they can from the experiences of Cuba. I have my fingers crossed that it goes well for Cuba!
As a side note, I was able to find a study done in Chile with regard to infant mortality - comparing Chile's antenatal program to Cuba's. The issue was that they wanted to find out why Cuba had better published statistics in this benchmark. The investigators concluded that the only possible way to have better numbers (they found their systems almost identical) was to use selective eugenic abortion. (Donoso & Carvajal, 2012)

With respect to Cuba's venture into the Medical Tourism business (back to the focus of this discussion), I think it is an ingenious way of using their natural resources (medical professionals) to bring much needed revenue to a country that needs it. There is a great deal going on in Cuba these days and it is worth staying tuned-in to what and how they are doing things. Health care is considered a right there, so it is not likely to become a forgotten project by the Cuban government.

I have noticed also, that Puerto Rico (a commonwealth of the US) is also entering this Medical Tourism business. That island has begun setting up organizations to promote the new business for patients and to entice medical professionals to stay there or move there. Puerto Rico has been suffering from a tremendous "brain drain" in the medical fields since their economic recession began in 2008. For even though it is essentially part of the US, the reimbursement rate for programs such as Medicaid/Medicare (public health insurance) and private health insurances are far below what the rate is in the continental US. So, many medical professionals have moved elsewhere (predominately to the US) for better compensation. From what I can tell of the situation in Puerto Rico, it appears to be a private business venture. While the government there may be supporting the venture as a way of boosting the economy to attract investors and patients, it does not look like the government is doing anything else, therefore not directly receiving any of the revenues from this venture (except maybe in the form of taxes if collected). The island is advertising surgical procedures at deep discount rates from the US. I can tell you that an oral procedure I was considering here in the US with a cost of $8000 would be $2000 in Puerto Rico. Of course that figure does not take into account expenses such as airfare, lodging, food and transportation. But, as you can see, there is a great difference in cost between the US and Puerto Rico for the same procedure from qualified professionals.


Donoso S, Enrique, & Carvajal C, Jorge A. (2012). El aborto eugenésico podría explicar la menor mortalidad infantil existente en Cuba comparada con la de Chile. Revista médica de Chile, 140(8), 999-1005. Recuperado en 23 de abril de 2015, de http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-9887201200080000.... 10.4067/S0034-98872012000800005 Retrieved from http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872012000800005

Margaret Chirgwin Replied at 4:35 AM, 6 May 2015

Doris - the term "selective eugenic abortion" is at least in the UK context very morally loaded - would I choose to abort my child in-utero or live with a dying child for some months? I do not know and I believe none of us really know what we would choose until it happens to us - I do know that those who have experience this kind of thing also often change their position after the fact - a terribly difficult situation for all concerned and not one to be judged. There is also the possibility that the genetics of the Cuban population and the Chile population are sufficiently different to explain how one country can get a lower infant mortality than another with the same pre-natal service.

I think we should not continue the debate about Cuba - it is not helpful I think in the discussion of medical tourism.

International recognition of data quality is complicated - data is not as robust as we would like it any where - I know that when I start scratching at data it often proves very poor. WHO/PAHO are unfortunately not as politically neutral in their behaviour as I would like but lets hope that they find Cuba's data quality acceptable. For Medical Tourism data quality and truthful reporting is going to be important and I am not sure how we will be able to verify for any private organisation that they are reporting fully and transparently - inspection is a very flawed way to try to verify if the picture painted by an organisation is true and meets required standards. We may need to think of more open information methods for Medical Tourism - perhaps it is posting on line, available to all, the outcomes of all their procedures???? Might also ask for all users of a provider to be asked to provide on line feedback on may be a small number of areas of their experience. Choosing private medical institutions is not something we do in the UK - we are trying to make info available about public providers and encourage some level of choice based on the data but the data is slippery. I am sure others will probably have some examples of good practice that could be promoted internationally?

Margaret

Amado Alejandro Baez Replied at 7:02 AM, 6 May 2015

About Value Based Medical Tourism


Transparency is a much needed element in healthcare in general. Cost and outcomes data needs to be available for patients to make intellgent decisions. Value-Based Medical Tourism is another term we have been pushing. Cost, quality and outcomes data is needed, benchmarking is key. This is a global business and there needs to be a compararve framework where with transparency there is evidence of system, country, provider and procedure outcomes.
We propose a global value-based Medical Tourisn platform that will foster positive sum competition, improved outcomes (both clinical and economic) and better care.

https://hbr.org/2013/09/value-based-health-care-is-inevitable-and-thats-good/

Amado Alejandro Baez Replied at 2:06 PM, 8 May 2015

About Value Based Medical Tourism



Transparency is a much needed element in healthcare in general. Cost and outcomes data needs to be available for patients to make intelligent decisions. Value-Based Medical Tourism is another term we have been pushing. Cost, quality and outcomes data is needed, benchmarking is key. This is a global business and there needs to be a comparative framework where with transparency there is evidence of system, country, provider and procedure outcomes.
We propose a global value-based Medical Tourism platform that will foster positive sum competition, improved outcomes (both clinical and economic) and better care.


https://hbr.org/2013/09/value-based-health-care-is-inevitable-and-thats-good/

Joe Niemczura, RN, MS Replied at 8:27 AM, 15 May 2015

Lots of stuff to digest here. I think David Citrin's writing is wonderful and well-thought out.

I'll be brief.

I'm finishing up a year here on leave from my University teaching job. I taught critical care skills here in Nepal, started in 2011. I've done 68 sessions now, with 1,900 nurses and docs trained in a course based on the Advanced Cardiac Life Support (ACLS) course of USA. (disclaimer: it's *not* the official course. Never was. Never will be).

If you decide to come to Nepal, do the following

a) leave the PowerPoint at home. The electricity won't work and the people will be too polite to tell you they don't understand.

b) don't just train ten of the "top movers and shakers" of Kathmandu docs and think you've "trained-the-trainers." They never turn around and transmit the knowledge or skill.

c) realize that Nepal is more than just Kathmandu.

d) don't present "cutting edge" techniques. Nepal is thirty years ( some day fifty) behind the times. If you are a pulmonologist and you want to talk about derivative values for obscure lung mechanics, it will not advance the standard in a country where the nurses do not know how to clean the bag-valve-mask device between patients. I once attended an international conference here that went out of it's way to attract nurses attendees, then a speaker spent an hour discussing the surgical technique of shaving a mitral valve.

e0 I already read some PR pieces which frankly seem designed to position this or that Global health Group in the process of obtaining the USAID grants that will inevitable come down the pike. This is worrisome. I've never seen some of these groups here. and - I get around.

forgive me for being a curmudgeon today....

chryssoula botsi Replied at 3:49 PM, 16 May 2015

Ι could not agree more with Joe. Not everything is suitable for everybody. the different cultures the different situations really define the way Health Services are delivered. working with poluations wholive in a different era in a very different way than ours, is very important.we should adapt to the circumstances with respect to the people. Even in my country a lot of Money is given to produce leaflets for the migrants on TB or HIV but a big proporton cannot read..

Amado Alejandro Baez Replied at 9:23 AM, 18 May 2015

About Medical Tourism with Social Responsibility

I very much enjoy all your posts, thank you. In the Dominican Rep we have looked at various models for a Medical Tourism platform. From fully independent Medical Free Zones to dedicated "International Services" within a local services platform.
I now see that Medical Tourism to be sustainable and of high impact, it needs to have a strong social quota. The idea is to have MT inject funds to the Healthcare system, promote quality care based on international standards, transparency, access to medical technologies, so that this MT "layer" actually allows and fosters better care to everyone, specially locals. We have are calling Medical Tourism with Social Responsibility.

Amado Alejandro Baez Replied at 9:43 AM, 18 May 2015

Thank you so very much to all who followed and contributed to our forum. I am summarizing the findings of this amazing exchange:

Summary

1. Medical Tourism is the care component of a broader concept now called "Global Healthcare"- This includes international research, medical education and patient care services and disaster/ medical missions.
2. Within the context of patient care services, we have the Medical Tourism component (defined a traveling for medical care), and extensively elaborated on in this forum the Humanitarian/ Disaster component of "volunteer convergence/ disaster tourism" and international missions.
3.The need to further measure impact of these efforts was outlined on this discussion, as well as the much needed regulatory framework to standardize these global medical efforts, we propose a "Value-Based" bench-marking approach to effectively address quality/ outcomes and costs.
4. The business side of this industry needs to be coupled with a social quota, what we are describing as Medical Tourism with a Social Responsibility, where local developing systems can grow based on the economic contributions of a Medical Tourism offer.

Please stay tuned for our next discussion on the Ethical Aspects of Global Healthcare

Amado Alejandro Baez, MD, MSc, MPH, FAAEM, FCCP, FCCM
Director
Centers for Global Health and International Medicine

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