International trade in healthcare
International trades in services
Cross-border
trade
Consumption
abroad
Commercial
presence
8 success factors for medical tourism
Competitive price
Tourist appeal
Market economics Developed political
and legal institutions
Local R &D Human capital
Confluence of western and
traditional medicine
International trades in services
Cross-border
trade
Consumption
abroad
Commercial
presence
Cross border revenue (US$ million)
Service 2000 2005
Customer-interaction center 60 2250 Medical transcription 28 800 Financial and accounting services 50 375 Medical billing and collection 3 75 Medical claims processing 13 30 Pre-press and digital pre-media 45 200 Geographic information system - 50
Distance learning 60 150
Human resources services - 115 Litigation support services 3 27
International trades in services
Cross-border
trade
Consumption
abroad
Commercial
presence
Foreign investment in healthcare
Country
Situation
India
•
No caps on direct foreign investment
•
90% German ownership of 200-bed hospital in
New Delhi
•
100% ownership of orthopedic clinic in Mumbai
•
All providers must be registered by councils
Malaysia
Foreign share <30%
President Regulation No.36/2010, Investment
Negative List
Pharmaceutical industry Maximum 75% foreign shareholding Hospital management and health
assistance services (health aid and patient evacuation in emergency situations);
Specialist/sub-specialist hospital service (200 beds); Health care providers (mental rehabilitation, specialist medical, dental, laboratory and medical clinics)
Maximum 67% foreign shareholding
Calibration testing, health and medical equipment rental, maintenance and
repair services; Acupuncture and nursing services (outside Medan and Surabaya)
President Regulation No.36/2010, Investment
Negative List
Nursing services in Medan and Surabaya Maximum 51% foreign shareholding Pharmaceutical drug producer and
wholesaler
Requires a special license from the Minister of Health
Traditional medicine producer and business industry; Pharmaceutical
including raw material, wholesaler, and drug store/pharmacy; Health care
providers (hospitals, health research center, health service facility,
ambulance,etc.); Health professionals (e.g. specialist doctor, etc.)
Foreign Investment in healthcare
Parkway Holding (Singapore)
Malaysia Others
Pantai Holding (Malaysia)
Singapore Other
International trades in services
Cross-border
trade
Consumption
abroad
Commercial
presence
Doctors and nurses trained abroad working in OECD
countries*
Countries Doctor trained abroad Nurses trained abroad
Number Percentage Number Percentage Australia 11,122 21 NA NA Canada 13,620 23 19,061 6
Finland 1,003 9 140 0
France 11,269 6 NA NA
Germany 17,318 6 26,284 3
Ireland NA NA 8,758 14
New Zealand 2,832 34 10,616 21
Portugal 1,258 4 NA NA
UK 69,813 33 65,000 10
USA 213,331 27 99,456 5
The cost of training one
doctor in Australia =
AU$280,000
The cost of recruiting a
foreign doctor to
Percentage of doctor trained working in OECD
countries
(Docquier & Bhargava, 2006)
African doctors working abroad*
Country Total doctors in home country
Doctors working in 8 OECD countries
Number Percentage
Angola 881 168 19
Cameroon 3,124 109 3
Ethiopia 1,936 335 17
Ghana 3,240 926 29
Mozambique 514 22 4
Nigeria 34,923 4,261 12
South Africa 32,973 12,136 37
Uganda 1,918 316 16
Tanzania 822 46 6
Zimbabwe 2,086 237 11
Total 82,417 18,556 23
Global distribution of health workforce (doctors,
nurses, midwives) shortage*
WHO Region Number of countries In countries with shortage
Total With shortage
Total stock Shortage Percentage increase required Africa 46 36 590,198 817,992 139 Americas 35 5 93,603 37,886 40 South-East
Asia
11 6 2,332,054 1,164,001 50
Europe 52 0 NA NA NA
Eastern
Mediterranean
21 7 312,613 306,031 98
Western Pacific
27 3 27,260 32,560 119
There are 5 times more
Indian neurosurgeons in
Passing rates of Indonesia nurses
Year Country Number of applied nurses
Number of nurses passed
Passing rate (%)
1996 United Emirate Arab (UEA)
120 11 9.1
1997 UEA 123 17 13.8
1998 UEA
The Netherlands
600
1999 UEA 300 50 16.6
2000 UEA Kuwait
2001 Kuwait 768 210 27.3
2002 Kuwait UK
2004 Saudi Arabia 120 58 48.3
Each migrating
African professional
Why African health workers migrate?*
Proportion of foreign* doctors in Malaysia in 2005**
Medical officers
Local Foreign
Specialists
Local Foreign
Proportion of foreign doctors among all doctors
registered in Singapore in 2008*
Local Foreign
Where would cardiac surgeons prefer to work?
MOPH
(National Chest Hospital)
Teaching hospitals
(Chulalongkorn and Siriraj)
International hospital
(Bangkok General hospital)
Annual number of heart surgery 900 800-1200 200-250 Number of active cardiac
surgeon
4-5 8-9 7
Year work load per surgeon 200 100-134 28-35 Total monthly income (Baht) < 100.000 (reg
salary plus incentive per case (7200 Baht)
200.000 (reg salary and other
incentives)
400.000
(40.000-60.000 Baht per
surgery)
The impact of Thai medical tourism
•
Extra 100 000 patients seeking treatment in
Thailand
•
Internal brain drain of up to 700 doctors
•
Exacerbated shortages of medical professionals,
especially in the public sector and in rural areas.
Pros vs cons of medical tourism
Pros
Cons
Doctors who would migrate
incentivized to stay
Doctors lured away from public
facilities and remote areas
Advanced technology and
equipments available to local
patients
Only accessible to those who
can afford -> widen gap
More revenues
Accrued to foreign/private
investors
Quality of healthcare abroad
•
Insufficient management of complications and lack of
post-operative care (Terzi et al 2008)
•
Problems with continuity of care (Birch et al 2004)
Complications post cosmetic tourism*
Operation undertaken
0 5 10 15 Breast surgery
Abdominoplasty Facial rejuvenation Liposuction
Type of complication
0 2 4 6 8
Dehiscence/…
Poor cosmesis Implant rupture Contracture Bowel perforation Nerve palsy
Plastic surgery abroad websites
•
37% - no information on adverstised
procedures
•
10% - mentioned possibility of complications
Medical tourism websites
•
11.9% - mentioned risk of procedures
•
21.5% - mentioned possibility of complications
•
35% - mentioned post-op complications
Average medical practice payout (US$)*
Thailand Mexico USA
Millio
n
USD
