International trade in healthcare
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
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
TOTAL 192 57 3,355,728 2,358,470 70
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 600 300 143 60 23.8 20.0
1999 UEA 300 50 16.6
2000 UEA Kuwait 315 726 6 241 19.0 28.9
2001 Kuwait 768 210 27.3
2002 Kuwait UK 754 19 241 4 32.1 21.1
2003 - - -
-2004 Saudi Arabia 120 58 48.3
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$)*
0 50000 100000 150000 200000 250000 300000 350000Thailand Mexico USA
Major risks of medical tourism
Patient safety
Cross-border
spread of
diseases
Donor &
surrogate
safety
Public health
system
Addressing medical tourism risks
Increase patient
safety
Improve Disease
surveillance &
control
Promote ethical
practices
Protect domestic
public health
system
International trades in services
Cross-border
trade
Consumption
abroad
Commercial
presence
