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International trade in healthcare
Yodi Mahendradhata
International trades in services
Cross-border trade
Consumption abroad
Commercial presence
Natural presence
8 success factors for medical tourism
Competitive price
Tourist appeal
Market economicsDeveloped political
and legal institutions
Local R &DHuman capital
Confluence of western and traditional medicine
Developed physical infrastructure
International trades in services
Cross-border trade
Consumption abroad
Commercial presence
Natural presence
US$ 4 billion industry
Teleradiology
Telepathology
Teleconsultation
Telepharmacy
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
TOTAL 264 4072
International trades in services
Cross-border trade
Consumption abroad
Commercial presence
Natural 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%
Thailand Foreign share <50%
Foreign investment in healthcare in Indonesia?
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)
Maximum 49% foreign shareholding
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.)
Requires 100% domestic capital
Foreign investment in Indonesian hospitals 1993-1999
Foreign Investment in healthcare
Parkway Holding (Singapore)
Malaysia
Others
Pantai Holding (Malaysia)
Singapore
Other
* Source: Leng CH (2010)
International trades in services
Cross-border trade
Consumption abroad
Commercial presence
Natural 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
*Source: WHO (2006)
The cost of training one doctor in Australia =
AU$280,000
The cost of recruiting a foreign doctor to
Australia = AU$30,000
Percentage of doctor trained working in OECD countries (Docquier & Bhargava, 2006)
Malaysia
12.8%
Philippines
9.7%
Singapore
10.2%
Thailand
3.3%
African doctors working abroad*Country Total doctors in
home countryDoctors working in 8 OECD countries
Number Percentage
Angola 881 168 19
Cameroon 3,124 109 3
Ethiopia 1,936 335 17
Ghana 3,240 926 29
Mozambique 514 22 4
Nigeria 34,923 4,261 12
South Africa 32,973 12,136 37
Uganda 1,918 316 16
Tanzania 822 46 6
Zimbabwe 2,086 237 11
Total 82,417 18,556 23
*Source: WHO (2006)
Countries with critical shortage of health workforce (doctors, nurses, midwives)
Global distribution of health workforce (doctors, nurses, midwives) shortage*
WHO Region Number of countries In countries with shortage
Total With shortage
Total stock Shortage Percentage increase required
Africa 46 36 590,198 817,992 139
Americas 35 5 93,603 37,886 40
South-East Asia
11 6 2,332,054 1,164,001 50
Europe 52 0 NA NA NA
Eastern Mediterranean
21 7 312,613 306,031 98
WesternPacific
27 3 27,260 32,560 119
TOTAL 192 57 3,355,728 2,358,470 70
*Source: WHO (2006)
There are 5 times more Indian neurosurgeons in
USA than in India
Passing rates of Indonesia nurses
Year Country Number of applied nurses
Number of nurses passed
Passing rate (%)
1996 United Emirate Arab (UEA)
120 11 9.1
1997 UEA 123 17 13.8
1998 UEAThe Netherlands
600300
14360
23.820.0
1999 UEA 300 50 16.6
2000 UEAKuwait
315726
6241
19.028.9
2001 Kuwait 768 210 27.3
2002 KuwaitUK
75419
2414
32.121.1
2003 - - - -
2004 Saudi Arabia 120 58 48.3
2005 Saudi Arabia 179 107 59.7
Each migrating African professional
costs the country US$ 184,000
Why African health workers migrate?*
*Source: WHO (2006)
Proportion of foreign* doctors in Malaysia in 2005**
Medical officers
Local
Foreign
Specialists
Local
Foreign
*Origins: India, Myanmar, Pakistan, Indonesia, Bangladesh, Sri Lanka and Egypt**Source:: Leng CH (2010)
Proportion of foreign doctors among all doctors registered in Singapore in 2008*
Local
Foreign
* Source:: Leng CH (2010)
Where would cardiac surgeons prefer to work?
MOPH (National Chest Hospital)
Teaching hospitals (Chulalongkornand 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 (regsalary plus incentive per case (7200 Baht)
200.000 (regsalary and other incentives)
400.000 (40.000-60.000 Baht per surgery)
* Exchange rate: US$ 1 = 38 Baht
Risks of medical tourism?
Health workforce migration
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.
• Recruitment of 10,000 doctors to keep up with needs and demand
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
Resource allocation diversion
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)
• Post-discharge experience (Boffin et al 2005)
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
*Ref: Miyagi et al 2011
Plastic surgery abroad websites
• 37% - no information on adverstised procedures
• 10% - mentioned possibility of complications
• 4% - mentioned aftercare and follow up form post-op complications
Medical tourism websites
• 11.9% - mentioned risk of procedures
• 21.5% - mentioned possibility of complications
• 35% - mentioned post-op complications
• 9.8% - legal recourse
Average medical practice payout (US$)*
0
50000
100000
150000
200000
250000
300000
350000
Thailand Mexico USA
Mill
ion
USD
*Cortez 2012
Womb for rent?
Surrogacy in US: $70.000
Surrogacy in India: $12.000
Major risks of medical tourism
Patient safetyCross-border
spread of diseases
Donor & surrogate
safety
Public health system impacts
Addressing medical tourism risks
Increase patient safety
Improve Disease surveillance &
control
Promote ethical practices
Protect domestic public health
system
Develop better data
International trades in services
Cross-border trade
Consumption abroad
Commercial presence
Natural presence